Corrective Action Plans

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2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Tak...
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Taken: The accounting department had a significant turnover during 2022 which cause reporting errors go unreviewed. Since 2023, the appropriate accounting team has been assembled and proper policies, procedures, authorization, segregation of duties and reviews have been put in place so that going forward this will not be an issue. All reporting is now being reviewed prior to submission so that reporting requirements including proper period and proper information is reported correctly. We have proactively reached out to the PRF Reporting Help Desk to correct the reporting and communicated the noted reporting corrections needed. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organiz...
2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organizations’ signature approval on the documentation received and the fee calculated and provided to the applicant. All applications should contain support for the individual’s income level or documentation of no income, and the determination of the resulting fee. Action Taken: This finding was repeated in 2022. Since this was a repeat finding, an internal audit was performed on all 2023 approved sliding fee applications to ensure compliance with our policy. Any corrective actions to the 2023 application were address and the facility’s sliding fee scale was modified to reflect proper authorization and proper segregation of duties going forward. Going forward, all sliding fee scale applications are now reviewed and authorized by the Manager of Revenue Cycle. Future auditing procedures have been put in place to review applications and adjusted, if needed, in a timely manner between now and the end of the year. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
Finding 4162 (2022-004)
Significant Deficiency 2022
Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly ...
Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Corrective Action: Policies and procedures will be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Implementation Date: Ongoing
Finding 4161 (2022-003)
Significant Deficiency 2022
Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development ...
Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development Block Grant program is completed. Corrective Action: Township is working towards implementing reporting process to meet the 90 day filing deadline for CDGB Annual Performance and Evaluation Report. Implementation Date: Ongoing
Finding 4160 (2022-002)
Significant Deficiency 2022
Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be ch...
Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing
Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to d...
Finding 2022-003: Data Collection Form and Single Audit Reporting Package Finding: The Organization did not comply with the required submission date of the data collection form and reporting package to the FAC for the fiscal year ended December 31, 2022. Corrective Action: Prepare reports prior to due dates in case there is a computer issue. If a report is late, request an exception/extension in writing to file with report. Contact: Evelyn Vargas, Grants Compliance Manager Expected Completion Date: 11/30/2023 If you have any questions, please contact Evelyn Vargas at 713-472-0753 or by email at evargas@tbotw.org.
Finding 4038 (2022-002)
Significant Deficiency 2022
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no di...
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System ensure that remaining statement balance for uninsured testing is not balance billed to the patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. All balances remaining after HRSA payments will be reviewed and adjusted to zero. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023
View Audit 6359 Questioned Costs: $1
Finding 4037 (2022-001)
Significant Deficiency 2022
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding...
Program Name: COVID-19 HRSA Uninsured Program – Federal Assistance Listing Number 93.461 Recommendation: We recommend that the System review the submissions to HRSA to ensure that the patients they requested reimbursement for were in fact uninsured. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We understand the finding. In future submissions, the System will review all patients to ensure that are uninsured. Name(s) of the contact person(s) responsible for corrective action: Adam McConnell, Chief Financial Officer Planned completion date for corrective action plan: December 31, 2023
View Audit 6359 Questioned Costs: $1
Finding 3992 (2022-004)
Significant Deficiency 2022
Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.
Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.
Finding 3979 (2022-001)
Significant Deficiency 2022
U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the U...
U.S. DEPARTMENT OF HOMELAND SECURITY KANSAS ADJUANT GENERAL 2022-001: Disaster Grants – Public Assistance CFDA No. 97.036 Grant period: Year Ended December 31, 2022 Condition and Context: The County does not have a complete set of written cash management policies and procedures as required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Criteria: The Uniform Guidance requires Non-Federal entities other than States, including those operating Federal programs as subrecipients of States, to follow the cash management standards set out at 2 CFR section 200.305. The County must have a complete set of written cash management policies, which conform to applicable Federal statutes and the cash management requirements identified in 2 CFR part 200. Cause: The County was unaware of the written cash management policy requirements required by the Uniform Guidance. Effect: An important component of internal controls is the existence of operating policies and procedures and that they are clearly understood and communicated. Without clear written policies and procedures, there is a higher risk of noncompliance with program requirements. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.
The City of Delmont Governing Board is the contact for the corrective action plan for this finding. Because of the size of the City of Delmont, the City cannot support the internal controls needed to properly segregate duties. The City Council Members and Finance Office employees are aware of the ...
The City of Delmont Governing Board is the contact for the corrective action plan for this finding. Because of the size of the City of Delmont, the City cannot support the internal controls needed to properly segregate duties. The City Council Members and Finance Office employees are aware of the problem. We will be working on some different policies and controls that will help minimize the future risk. This will be an ongoing process that will include input from the State Auditor's Office, talking to other municipalities and utilizing the council members in some of the financial controls.
The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.
The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned Costs.
Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsib...
Finding Numbers 2022-005 and 2022-006 Planned Corrective Action: Management plans to offer additional trainings, reminders to the Financial Screening Department, and institute a quarterly audit of completed applications to ensure compliance. Anticipated Completion Date: December 31, 2023 Responsible Contact Persons: Jillian Hudspeth, CEO Christopher Bernardi, CFO
Management understands that according to CFR 200.430(i), charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. The records must be supported by a system of internal controls which provides reasonable assurance that the charges are accur...
Management understands that according to CFR 200.430(i), charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. The records must be supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Hood River County is currently working toward stronger internal controls, education of staff, and a more intense review process. It is expected that these changes will take time. The new Grants Committee is meeting monthly to keep grant management in the forefront of all those concerned.
1. Effective December 1, 2023, the President & CEO will implement a sound reporting process to ensure compliance with its reporting requirements. 2.As part of the reporting process, timelines and target dates will be implemented and additional communication within the CNC team will be established fo...
1. Effective December 1, 2023, the President & CEO will implement a sound reporting process to ensure compliance with its reporting requirements. 2.As part of the reporting process, timelines and target dates will be implemented and additional communication within the CNC team will be established for all personnel to be aware of the deadlines and the importance of meeting the deadlines. The President & CEO and other department heads can monitor that the Organization is on pace to meet its various reporting deadlines including the submission of the Data Collection to the FAC website by the deadline established by the Uniform Guidance. It is anticipated that this additional oversight and communication can occur right away, but the deadlines for various information and reports required by the grantors occur monthly with the goal of submitting reports by the deadlines for 2023-2024 awards going forward. Management will need to monitor continuously to make sure that the Organization is making progress and meeting its reporting deadlines. Successful implementation would indicate that the Organization meets all its reporting deadlines going forward starting with the 2023-2024 awards and submitting its Data Collection and Audit Reporting Package nine months after year-end which would be September 30, 2024.
Segregation of duties will always be difficult in a small district.  The District hired an additional office assistant in fiscal year 2022 and will continue to review control procedures to obtain the maximum internal control possible under the circumstances.
Segregation of duties will always be difficult in a small district.  The District hired an additional office assistant in fiscal year 2022 and will continue to review control procedures to obtain the maximum internal control possible under the circumstances.
We will continue to monitor our internal control procedures and make changes where possible.
We will continue to monitor our internal control procedures and make changes where possible.
The District has implemented a grants manual during fiscal year 2023. Additional efforts are expected to ensure grant budgets are amended in an appropriate timeframe. Management will evaluate additional enhancements to policies and procedures. Due to the timing of the current year audit, the Distric...
The District has implemented a grants manual during fiscal year 2023. Additional efforts are expected to ensure grant budgets are amended in an appropriate timeframe. Management will evaluate additional enhancements to policies and procedures. Due to the timing of the current year audit, the District expects implementation overall and implementation with the June 30, 2024 year end.
Action Taken: NICAA has parted ways with previous auditors, O’Connor & Brooks. NICAA has contracted with WIPFLI to standardize our internal controls and financial reporting. WIPFLI follows the Generally Accepted Accounting Principles (GAAP) standards more closely than previous auditors. In 2024, N...
Action Taken: NICAA has parted ways with previous auditors, O’Connor & Brooks. NICAA has contracted with WIPFLI to standardize our internal controls and financial reporting. WIPFLI follows the Generally Accepted Accounting Principles (GAAP) standards more closely than previous auditors. In 2024, NICAA will be working with WIPFLI to update internal controls and financial recording policies and procedures. Management and the Board of Directors will remain involved in the financial affairs of Northwestern Illinois Community Action Agency by providing oversight and independent review of financial reporting and accounting procedures.
Finding 3501 (2022-004)
Significant Deficiency 2022
The clerk is preparing and reporting COVID-19 funds and will work with the supervisor and treasurer to ensure correct reporting in the future. To be implemented in the next reporting cycle April 2024.
The clerk is preparing and reporting COVID-19 funds and will work with the supervisor and treasurer to ensure correct reporting in the future. To be implemented in the next reporting cycle April 2024.
• Condition: During testing of required financial reports and invoices, we noted differences in the amounts of expenses reported to grantors compared to actual expenses incurred during those periods. • Response Response MHA relies on our accounting representative to ensure that the invoices submitte...
• Condition: During testing of required financial reports and invoices, we noted differences in the amounts of expenses reported to grantors compared to actual expenses incurred during those periods. • Response Response MHA relies on our accounting representative to ensure that the invoices submitted to the accountant each week are added to the appropriate GL account to ensure the cost report reflects the correct amounts being reported to the grantors match the actual expenses incurred. • Planned Corrective Action: Again, monthly meetings reviewing the cost reports and GL together will reduce mistakes like this from MHA and the Accounting Rep. moving forward. MHA and the Accounting Rep will review the expenses being submitted for reimbursement together to ensure expenses incurred match the expenses being reported to the grantor.
In accordance with federal audit protocols, our organization underwent a rigorous evaluation administered by Jessica Sayles, CPA, representing the prestigious firm Houldsworth, Russo, and Co. for fiscal year 2021-2022. Specifically, the audit was conducted with a focus on our utilization of funds al...
In accordance with federal audit protocols, our organization underwent a rigorous evaluation administered by Jessica Sayles, CPA, representing the prestigious firm Houldsworth, Russo, and Co. for fiscal year 2021-2022. Specifically, the audit was conducted with a focus on our utilization of funds allocated under the ARP grant. This comprehensive audit revealed two distinct facets deserving of meticulous attention. Firstly, we are pleased to report that the examination of our direct expenditures under the ARP grant has yielded an impeccable record of financial stewardship. No anomalies, deficiencies, or discrepancies were identified in the management of these direct expenses. This outcome reaffirms our unwavering commitment to fiscal diligence in the administration of public funds. However, the audit did unveil an issue of significance, pertaining to our handling of indirect expenses and fringe rates. Ms. Jessica Sayles, discerned that our organization had inadvertently transgressed established regulations governing allowable indirect cost rates, particularly in relation to payroll and other miscellaneous expenses. This misapplication resulted in the disbursement of funds beyond the thresholds specified under the Uniform Guidance framework, consequently necessitating reimbursement to federal agencies. This disclosure is an acknowledgment of the audit findings and represents our steadfast commitment to forthrightness, transparency, and responsible financial management. We deeply respect the critical importance of precision and adherence to federal guidelines in matters of fiscal accountability, and we are dedicated to addressing these issues with utmost professionalism. Issue 1: Material Adjustments to the Financial Statements We acknowledge the discovery of material current and prior period adjustments necessary to ensure that our financial statements are fairly stated in accordance with generally accepted accounting principles (GAAP). We understand the importance of accurate financial reporting and have already taken steps to address this concern. Our response to this issue includes: Comprehensive Review: We have initiated a thorough review of our accounting records to identify the root causes of these material adjustments. This process includes examining internal controls and financial reporting procedures. Rectification Plan: A plan has been developed to rectify these adjustments promptly, with a focus on maintaining compliance with GAAP. This includes improved monitoring, internal auditing, and reporting protocols. Training and Development: Our finance and accounting team have undergone additional training and development to strengthen their understanding of financial reporting standards, and GAAP compliance. Issue 2: Uniform Guidance - Allowable Indirect Cost Rates We acknowledge the findings related to the misapplication of allowable indirect cost rates for payroll and other expenses. We deeply regret the misunderstanding that led to this issue and take full responsibility for it. To address this matter, we have initiated the following actions: Immediate Compliance: We have already taken steps to ensure that allowable indirect cost rates are correctly applied in accordance with Uniform Guidance. This includes a review of all grant expenditures and related indirect costs. Training and Education: We are committed to improving our management's understanding of allowable indirect cost rates. Specialized training sessions will be conducted to clarify the proper application of these rates to prevent such errors in the future. Reconciliation and Repayment: We have worked closely with federal agencies, who opted for a refundable advance, to reconcile the amounts overdrawn on federal requests for reimbursements and promptly addressed any amounts due as a result of the misapplication of indirect cost rates. We recognize the gravity of these findings and are actively working to ensure that such misapplications will not recur in the future. In tandem with this, we commit to working diligently alongside Ms. Sayles and her esteemed team to expeditiously rectify these concerns and establish a robust framework for accurate financial reporting in our future endeavors. This organization remains firmly committed to upholding the highest standards of integrity, accountability, and compliance in its financial operations. We extend our appreciation to your department for your dedication to ensuring responsible fiscal oversight and the judicious allocation of federal resources. Should you require additional information or wish to engage in a more detailed discussion of these matters, we are readily available for dialogue. Andrea L. Gregg Chief Executive Officer High Sierra AHEC 639 Isbell Road, Suite 290 Reno, NV 89509 (775) 507-4022 andrea@highsierraahec.org
Recommendation: The Association should ensure source documentation is maintained for all costs and elements of a cost calculation reimbursed by federal awards. Explanation or disagreement with audit finding: There is no disagreement with the audit finding from responsible officials that two out of ...
Recommendation: The Association should ensure source documentation is maintained for all costs and elements of a cost calculation reimbursed by federal awards. Explanation or disagreement with audit finding: There is no disagreement with the audit finding from responsible officials that two out of forty wage rate authorization forms requested were not located. Other documentation was submitted that supported the wage rates, including results of a salary survey performed by an HR consulting company. Actions taken in response to finding: In response to the finding, the Association generated detailed pay rate change history reports from the payroll system for these two employees and took a random sample of pay history for three other employees. Nothing unusual was identifiable. The Association will ensure source documentation is maintained for all federal award cost reimbursements by taking the following actions: • At least two Association leadership staff members will review all payroll changes and save documentation in secure, electronic personnel files and payroll processing files. • An improved human resources information and payroll system with more robust time tracking, reporting and document storage features is being implemented. • Detailed requirements for payroll changes will be added to revised finance and human resources policies and procedures (currently under revision). Name(s) or the contact person(s) responsible for correction action: Laura Dale, Director of Finance Bob Marsalli, CEO Planned completion date for corrective action plan: January, 2024
Agree with the finding. We will implement the segregation of duties matrix as part of SOPs. We will ensure that authorization and review of cash draws of fedral funds are done by some one other than the individual who initiates and records the transaction . We have implemented the same and Dr EIli (...
Agree with the finding. We will implement the segregation of duties matrix as part of SOPs. We will ensure that authorization and review of cash draws of fedral funds are done by some one other than the individual who initiates and records the transaction . We have implemented the same and Dr EIli (pi) is reviewing and approving the report before each withdrawal. The Finance Head ( Nafih) is withdrawing the fund .Anticipated Completion Date : 12/31/2022 Actual date of implementation :01/24/2023
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