Corrective Action Plans

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Finding 8202 (2022-006)
Significant Deficiency 2022
Finding Number: 2022-006 Finding Title: Activities Allowed and Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Brian Ophus, Social Services Director Corrective Action Planned: Staff alloca...
Finding Number: 2022-006 Finding Title: Activities Allowed and Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Brian Ophus, Social Services Director Corrective Action Planned: Staff allocations have been re calculated per DHS guidelines in the new County Payroll system. Anticipated Completion Date: November 1, 2023
Finding 8165 (2022-004)
Material Weakness 2022
FINDING 2022-004 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors. Anticipated Completion Dat...
FINDING 2022-004 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors. Anticipated Completion Date: The internal control monitoring and checks and balances will be implemented immediately and continue going forward.
Finding 8164 (2022-003)
Material Weakness 2022
FINDING 2022-003 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors and have updated our polici...
FINDING 2022-003 Craig Wright (765)747-4828 Views of Responsible Official: We concur with the findings. Description of Corrective Action Plan: Correcting the audit findings is ongoing. The city has implemented monitoring procedures to review and prevent reoccurring errors and have updated our policies and procedures. Anticipated Completion Date: The internal control monitoring and checks and balances will be implemented immediately and continue going forward.
Finding 2022-005: Sliding Fee Condition Wipfli reviewed 40 sliding fee charges to test if the amount charged, was calculated properly based on the patients’ income level and in compliance with Outreach Community Health Center's’ sliding fee policy. Wipfli noted that 7 of the charges were not properl...
Finding 2022-005: Sliding Fee Condition Wipfli reviewed 40 sliding fee charges to test if the amount charged, was calculated properly based on the patients’ income level and in compliance with Outreach Community Health Center's’ sliding fee policy. Wipfli noted that 7 of the charges were not properly determined based on patients family size and income level, in addition Wipfli noted that 6 files did not contain approval of the sliding fee calculation. Corrective Action Plan Re-education on proper completion of FPL fields provided to entire PSR staff 8/23/2023. Implementation of automated income calculation module within OCHIN Epic added 8/2023 OCHC created and filled Patient Financial Counselor position 11/27/2023 to monitor and update incomplete Sliding Fee Applications and audit quarterly for compliance. Person(s) Responsible PSR Manager – Lisa Mullins Director Revenue Cycle – Jennifer Leino Chief Financial Officer – Julia Harris Robinson Timing for Implementation 12/1/2023
Finding 8053 (2022-001)
Material Weakness 2022
Corrective Action Plan 2023: Alvis, Inc. recognizes that significant turnover in accounting operations and financial reporting teams resulted in a material number of adjustments, proposed by our accounting firm, in order to complete the 2022 audit. To properly address this matter, Jacqueline Neal ha...
Corrective Action Plan 2023: Alvis, Inc. recognizes that significant turnover in accounting operations and financial reporting teams resulted in a material number of adjustments, proposed by our accounting firm, in order to complete the 2022 audit. To properly address this matter, Jacqueline Neal has been tasked with improving upon the corrective actions which began in 2023 in order to comprehensively address this gap: 1) Fill vacant positions and redefine job responsibilities; 2) Implement an accounting workflow automation solution; 3} Hold internal trainings to increase our Finance Team's technical accounting knowledge and operational efficiencies. Fill vacancies and redefine job responsibilities: 1. The first order of business was to hire a seasoned payroll employee to handle all functions of payroll processing and recording related journal entries. This role was hired in September 2023. This was followed with an Accounting Manager and accounts payable coordinator hires in April 2023, which has resulted in critical accrual accounts being recorded and reconciled accurately and timely. 2. The team then redefined jobs and responsibilities of each team member, resulting in much greater communication and understanding around required job functions. This has resulted in substantial growth in our teamwork and collaboration. 3. The entire month-end close process was redefined with new expectations and tracking. This has resulted in the closing of the monthly books within 15 days after month end. Automation of month-end close workflows and centralization of reconciliations: 4. The Finance team implemented an automated accounting workflow software (FloQast or FQ) in April 2023. FQ allows the Team to streamline recurring tasks, checklists, and centralized documentation to increase the accuracy of our Close Data. For example, the system provides the team with a centralized view of the reconciliation status of each account with balance comparisons to the general ledger, preparers, reviewer, and signoff dates. Additionally, FQ sends automatic notifications when reconciliations are due, items are ready for review, or if the platform detects an unexpected out of balance condition. Internal accounting trainings 5. The team is in the process of creating an ongoing monthly hindsight meeting to review the previous month end process. This will be used to identify opportunities and training needs of the team. 6. The team plans to continue our quarterly lunch and learns which began in July 2023. •
The Authority has integrated EP Harrisonburg Owner, L.L.C into the financial operations of the Authority. The Authority has added additional internal controls to ensure the finance department is adequately informed of all development activities for correct classification and inclusion for financial ...
The Authority has integrated EP Harrisonburg Owner, L.L.C into the financial operations of the Authority. The Authority has added additional internal controls to ensure the finance department is adequately informed of all development activities for correct classification and inclusion for financial reporting.
Corrective action plan The Organization is currently implementing a procedure to strengthen written policies and procedures to evidence its compliance with Federal Programs. Name (s) of person (s) responsible for corrective action Ms. Mabel Román, YMCA Executive Director YMCA Finance Director Antici...
Corrective action plan The Organization is currently implementing a procedure to strengthen written policies and procedures to evidence its compliance with Federal Programs. Name (s) of person (s) responsible for corrective action Ms. Mabel Román, YMCA Executive Director YMCA Finance Director Anticipated completion date January 2024
Corrective action plan The accounting department obtained access to the billing system and share folder used by the program manager to bill the Department of Housing and Urban Development agency. YMCA develop a plan to increase the human resources supervision in all operational areas of the entity, ...
Corrective action plan The accounting department obtained access to the billing system and share folder used by the program manager to bill the Department of Housing and Urban Development agency. YMCA develop a plan to increase the human resources supervision in all operational areas of the entity, increase the outsourcing support and management recruitment is in process to increase internal control measures and supervision in the financial and accounting areas. Name (s) of person (s) responsible for corrective action Ms. Mabel Román, YMCA Executive Director YMCA Finance Director Anticipated completion date December 2023
Finding 7971 (2022-002)
Significant Deficiency 2022
Finding Number: 2022-002 Finding Title: Eligibility Program: Temporary Assistance for Needy Families (AL No. 93.558) Name of Contact Person Responsible for Corrective Action: Rhonda Porter, Director and Karen Syverson, Supervisor Corrective Action Planned: All five cases found to have errors are bei...
Finding Number: 2022-002 Finding Title: Eligibility Program: Temporary Assistance for Needy Families (AL No. 93.558) Name of Contact Person Responsible for Corrective Action: Rhonda Porter, Director and Karen Syverson, Supervisor Corrective Action Planned: All five cases found to have errors are being reviewed and will be corrected as appropriate. All case errors will be reviewed with staff who are involved in administering this program. Case file reviews will continue to occur, and any errors found will continue to be reviewed with staff and training provided. Anticipated Completion Date: The five cases found in error will be corrected by December 31, 2023. Family Team will review these errors on Dec. 14, 2023. Case file reviews will continue monthly.
The Town of Clinton/School Department will follow grants closeout procedures, consequently, the district will monitor closely all grants spending throughout each grant cycle. For both state-administered and direct grants, regardless of the period of availability, the District must liquidate all obl...
The Town of Clinton/School Department will follow grants closeout procedures, consequently, the district will monitor closely all grants spending throughout each grant cycle. For both state-administered and direct grants, regardless of the period of availability, the District must liquidate all obligations incurred under the award not later than 90 days after the end of the funding period unless an extension is authorized. These procedures have been updated in the Financial Procedures Manual (pages 226-230 under Section G - Timely Obligation of Funds)
2022-004 – Classification of Consumer Goals – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditor recommends LIFE strengthen policies and procedures over the classification of consumer goals to ensure that the goals in the ILS and DRS systems match and are recorde...
2022-004 – Classification of Consumer Goals – Significant Deficiency in Internal Controls over Compliance Recommendation: The auditor recommends LIFE strengthen policies and procedures over the classification of consumer goals to ensure that the goals in the ILS and DRS systems match and are recorded in the correct categories as defined by ILS Program Standards 5.6.1 Revision 19-1. Action Taken: LIFE Management will: • Conduct a comprehensive review of existing policies/procedures related to the classification of Consumer goals. • Outline the steps for correctly classifying Consumer goals in line with Program Standards. • Conduct mandatory training sessions for all relevant staff on the classification of Consumer goals to ensure understanding and compliance. • Working with the Purchased Services staff, review the goal status of each Consumer at closure, including comparing goals on both data collection systems. • Conduct monthly quality assurance checks and internal audits to ensure the correct classification of Consumer goals. Due Date of Completion: November 30, 2023 Responsible Official: Director of Programs
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Highline School District No. 401 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal R...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Highline School District No. 401 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal wage requirements. Name, address, and telephone of District contact person: Andrew Burgess, Controller 15675 Ambaum Blvd SW Burien, WA 98166 (206) 631-3201 Corrective action the auditee plans to take in response to the finding: For Federally funded public works contracts, the district will collect and review all weekly certified payroll reports from contractors and subcontractors to confirm laborers were paid proper prevailing wages Further, the district will ensure that staff (both current and future) that oversee and monitor the distribution and use of Federal funds are trained and made aware of this requirement, and the differences between prevailing wage requirements at the state versus the Federal level. Anticipated date to complete the corrective action: August 31, 2024
Finding 7857 (2022-002)
Significant Deficiency 2022
U.S. Department of Housing and Urban Development CFDA # 14.239 HOME Investment Partnerships Program Applicable Federal Award Number and Year – 2022 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization does not retain documentation that supports the...
U.S. Department of Housing and Urban Development CFDA # 14.239 HOME Investment Partnerships Program Applicable Federal Award Number and Year – 2022 Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: The Organization does not retain documentation that supports the internal controls in place over the review of the annual certifications for the HOME units. Responsible Individuals: Steve Kuehneman, Executive Director and Jacki Kurchinski, Director of Property Management and Operations Corrective Action Plan: Management agrees with the finding. The Organization added steps to the annual certification process to document the approval of the annual certifications of HOME units. Anticipated Completion Date: 2024
Finding 2022-003 When orders are generated in Ceres a ship date is established. Occasionally, due to weather, agency staffing, or other issues, the anticipated distribution date will have to change. There are also situations where disruptions in the computer system may require a different date in t...
Finding 2022-003 When orders are generated in Ceres a ship date is established. Occasionally, due to weather, agency staffing, or other issues, the anticipated distribution date will have to change. There are also situations where disruptions in the computer system may require a different date in the system when is available. GHFB takes several measures in making sure the records are secured and stored in an area known by several employees so that once a record is completed it can be filed and inventory integrity is maintained. Person responsible: Norman Stafford...10/1/23 completion date
Finding 2022-002 Golden Harvest Food Bank (GHFB) does not generate the Bill of Lading (BOL) for product being delivered. The USDA instructs vendors to include several numbers to be annotated on the BOL for reporting reasons. These numbers start with 1000, 2000, 3000, 4000, and 5000. There are occas...
Finding 2022-002 Golden Harvest Food Bank (GHFB) does not generate the Bill of Lading (BOL) for product being delivered. The USDA instructs vendors to include several numbers to be annotated on the BOL for reporting reasons. These numbers start with 1000, 2000, 3000, 4000, and 5000. There are occasions where some of these numbers are not included on the accompanying BOL when delivered. GHFB personnel look for any of the above numbers to insure items are TEFAP. As required, GHFB is required to report the receipt of the TEFAP items to the appropriate state entity that manages the TEFAP program. This report requests the 4000 and the 5000 numbers. If either one of those numbers is not on the BOL, the omission is annotated in this report. In addition to these numbers GHFB also maintains a listing of TEFAP products due in the first 15 days of the month and TEFAP products due in the second half of each month. GHFB believes all BOL have been signed by our personnel. Going forward all BOLs will be signed by both the individual who receives the product as well as the warehouse or inventory manager. Person responsible: Norman Stafford...10/1/23 completion date
U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s internal controls were not designed to properl...
U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s internal controls were not designed to properly ensure a review over program expenditures occurred that expenses being incurred and the basis for ultimate reimbursement were incurred within the grant award’s period of performance. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will implement controls that address whether expenses incurred have a basis for reimbursement and are incurred within the period of performance. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: March 2024
U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s existing controls over federal award reporting...
U.S. Department of the Treasury Passed through State of Arizona, Maricopa County (Maricopa County), Federal Financial Assistance Listing #21.027, PE386182260A4 2022 Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation’s existing controls over federal award reporting did not identify and correct that reports submitted to the grantor were submitted with inaccurate information and that the supporting documentation used to prepare the reports were utilizing budgeted expensed amounts rather than actual. Furthermore, the budgeted expensed amounts from the supporting documentation that were the basis for the amounts to report, did not agree with the ultimate amount reported. Management’s Response and Corrective Action Plan: Televerde Foundation has experienced significant growth from inception in March 2020 to fiscal year ended December 31, 2022. We have grown from contributions and grants of $83 thousand and $50 thousand, respectively, in March 2020 to contributions and grants of $236 thousand and $978 thousand, respectively, as of December 31, 2022. During this same period, Televerde Foundation went from 3 employees to 21 employees and experienced significant turnover in finance staff including 2 CFO’s, 2 Controllers, and four staff accountants. The growth combined with lack of a consistent finance team is the primary cause of this deficiency. To address the deficiency, management will perform the actions below. Management will leverage our general ledger to retain documentation for approval and review of expenditures. We will utilize actual amounts for expenditures and in circumstances where budgeted amounts are needed, we will perform a true-up on a quarterly basis. Management will perform quarterly reviews over financial reporting. Responsible Individuals: Michelle Cirocco, Executive Director Anticipated Completion Date: July 2023
Corrective Action Plan: The District will ensure its Schedule of Expenditures of Federal Awards is complete and expenditures are properly reported.
Corrective Action Plan: The District will ensure its Schedule of Expenditures of Federal Awards is complete and expenditures are properly reported.
Corrective Action: The lack of timeliness in payouts to SSVF subrecipients was largely due to the transition CAPO underwent in fiscal providers in 2022, and to a lack of sufficient internal staff to adequately manage the SSVF program’s growing fiscal requirements. The amount of SSVF funding CAPO pa...
Corrective Action: The lack of timeliness in payouts to SSVF subrecipients was largely due to the transition CAPO underwent in fiscal providers in 2022, and to a lack of sufficient internal staff to adequately manage the SSVF program’s growing fiscal requirements. The amount of SSVF funding CAPO passes through has increased significantly since 2021, and existing staffing was insufficient to assure timely tracking of draws and payments. Since moving to SMJ and hiring a Finance Manager, CAPO has improved the fiscal management of this grant considerably. CAPO is also hiring an Account Specialist to be assigned directly to SSVF invoicing and accounting needs. They will be charged to the VA grant and will work with the SSVF Program Manager and CAPO’s Finance Manager to process invoices, draw funds, and issue payments. Person Responsible: Janet Allanach, Rose Bradshaw, SSVF Program Manager; Shane Melton, Finance Manager. Timing for Implementation: Partially complete/In progress until December 31st, 2023, completion.
Corrective Action: CAPO was unable to locate Board minutes from FY 22 that indicate any increase in compensation for Janet Merrell (prior Executive Director through May 2022). We have been informed by the Board that the last increase was likely prior to 2020, as she had requested additional time of...
Corrective Action: CAPO was unable to locate Board minutes from FY 22 that indicate any increase in compensation for Janet Merrell (prior Executive Director through May 2022). We have been informed by the Board that the last increase was likely prior to 2020, as she had requested additional time off in lieu of additional salary increases. The last record of an evaluation is in the minutes from a Board meeting in August of 2020. Discussion of compensation would have occurred during an Executive Session and would be in the possession of the Secretary at the time and not in CAPO files. Currently, Executive session notes are kept by the Treasurer and will be carefully retained for and accessible to future audits. Person Responsible: CAPO Board of Directors Timing for Implementation: Complete
Corrective Action: Immediately after coming on board in May of 2022, the new Executive Director took action to move CAPO’s fiscal services contract from the current provider to a new accounting firm in Portland, Oregon – Susan Matlack Jones and Associates (SMJ) – as of July 1, 2022. SMJ works with ...
Corrective Action: Immediately after coming on board in May of 2022, the new Executive Director took action to move CAPO’s fiscal services contract from the current provider to a new accounting firm in Portland, Oregon – Susan Matlack Jones and Associates (SMJ) – as of July 1, 2022. SMJ works with several Community Action agencies in Oregon and their expertise is specifically in nonprofit accounting. They worked to resolve accounting issues from the latter half of FY 22 for the purposes of the audit and currently produce timely, accurate financial statements for CAPO management and Board review. As of October 2023, CAPO has also hired an in-house Finance Manager with experience in Community Action and federal fund accounting. Person Responsible: Janet Allanach, CAPO Executive Director Timing for Implementation: Complete as of July 1, 2022.
The district continues to find solutions to help segregate duties with our minimally staffed central office (business manager, HR director & nutrition direct). This year we modified duties of our building secretaries due to being short staffed. This eliminated an additional check & balance measure a...
The district continues to find solutions to help segregate duties with our minimally staffed central office (business manager, HR director & nutrition direct). This year we modified duties of our building secretaries due to being short staffed. This eliminated an additional check & balance measure added a few years ago of the secretary entering receipts into WebLink. The building secretaries continue to write deposit slips & post payment to our student information system. The district’s business manager & HR director will work with board members on the finance & negotiations committee to develop a plan to add more checks & balances to our current operation. We will use the segregation of duties handbook to help with this process.
We will continue to review procedures and re-align duties to obtain the maximum internal control possible.
We will continue to review procedures and re-align duties to obtain the maximum internal control possible.
DEPARTMENT OF AGRICULTURE. Market Access Program and Agricultural Trade Promotion Program Assistance Listing Number: 10.601 & 10.618. Recommendation: We recommend the Organization ensure the completion of the controls within their policies to ensure an adequate review process is in place prior to ca...
DEPARTMENT OF AGRICULTURE. Market Access Program and Agricultural Trade Promotion Program Assistance Listing Number: 10.601 & 10.618. Recommendation: We recommend the Organization ensure the completion of the controls within their policies to ensure an adequate review process is in place prior to cash disbursement payments and claims submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Food Export-Northeast, under the direction of the new Executive Director /CEO, has undergone a significant restructuring effective July 2023. This restructure has resulted in the installation of a Chief Financial Officer, reporting directly to the Executive Director/CEO. Similar “C-suite” positions now exist in Operations, Programs, and Communications. This has significantly increased the scope and ability for oversight and internal control. Internal policies and procedures are currently under review; any changes to policies and procedures will be made as needed/identified. Increased monitoring and enforcement of existing internal control measures has already resulted in improved completeness and accuracy of financial reporting. In September 2023, the Food Export staff met with FAS staff to review procedures and policies, including meetings with Management to review and evaluate controls. The feedback from those meetings will be incorporated into any updates on procedure. Names of the contact person(s) responsible for corrective action: Brendan Wilson, Food Export Executive Director/CEO; Michelle Rogowski, Chief Operating Officer, Laura England, Deputy Director/Chief Communications Officer; Robert Lowe, CPA, Chief Financial Officer; Teresa Miller, Chief Program and Partnership Officer. Planned completion date for corrective action plan: December 31, 2023. If the U.S. Department of Agriculture has questions regarding this plan, please call Laura England at (215) 599-9738 or contact via email at lengland@foodexport.org.
Action Taken: The Home will review and incorporate internal controls related to the written approval requirement to obtain written approval from the Office of Refugee Resettlement for the acquisition, construction or purchase of major capital improvements.
Action Taken: The Home will review and incorporate internal controls related to the written approval requirement to obtain written approval from the Office of Refugee Resettlement for the acquisition, construction or purchase of major capital improvements.
View Audit 9623 Questioned Costs: $1
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