Corrective Action Plans

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Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Shelby Mahoney, State Alliances Accounting Manager Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal fun...
Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Alliance Director Shelby Mahoney, State Alliances Accounting Manager Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024
Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds...
Individual Responsible for Corrective Action Plan: Lana Taylor, Alliance Director Shelby Mahoney, State Alliances Accounting Manager State Corrective Action: The Alliance will enhance its procedures and internal controls around cash management to ensure that time between receipt of federal funds and payment to its local clubs is minimized. The Alliance will also request notification of funding from the agency. Anticipated Completion Date: December 31, 2024
Corrective Action Plan: The Methodist College Registrar has been working with NSC to get the college relinked to the correct college in their system, which was fixed 11/2023. The registrar redeveloped database query to pull the old data that had been deleted by NSC due to FERPA and began sending acc...
Corrective Action Plan: The Methodist College Registrar has been working with NSC to get the college relinked to the correct college in their system, which was fixed 11/2023. The registrar redeveloped database query to pull the old data that had been deleted by NSC due to FERPA and began sending accurate file submissions to NSC in June 2024. Files generated and submitted under the College’s new processes are taking roughly one week to process from initial submission, through error correction, and finalization. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: End of 2024
Corrective Action Plan: In standing financial aid meetings, we will review Federal Loan limits and what our process/procedures are if a student is close to limits to insure, we don’t over award. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: 2024
Corrective Action Plan: In standing financial aid meetings, we will review Federal Loan limits and what our process/procedures are if a student is close to limits to insure, we don’t over award. Contact Person(s): Justina Kirchgessner Anticipated Completion Date: 2024
View Audit 323383 Questioned Costs: $1
Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and implemented procedures to ensure appropriate documentation of personnel costs is complete and accurate. The prior year's finding was corrected with the pay period ending...
Corrective Action Plan: SOR II grant leadership evaluated its process for preparing and reviewing time tracking for this award and implemented procedures to ensure appropriate documentation of personnel costs is complete and accurate. The prior year's finding was corrected with the pay period ending 9/23/2023, which resulted in this repeat finding for the year ended 12/31/2023. Hourly staff are clocking into the appropriate cost center and salaried staff are submitting hours to payroll to ensure the proper tracking of time. Contact Person(s): Heather Hintz/Kathy Dams Anticipated Completion Date: 10/1/2023
2023-005. Match Source Documentation United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: Source documentation was not maintained to support costs applied to the match. Recommendation: The Organization should maintain an accounting for all funds ...
2023-005. Match Source Documentation United States Department of Housing and Urban Development Continuum of Care Program ALN: 14.267 Condition: Source documentation was not maintained to support costs applied to the match. Recommendation: The Organization should maintain an accounting for all funds expended attributed to meeting the match requirement, as well as the source documentation. Corrective Action: The Organization will implement procedures to ensure accounting for funds expended, as well as source documentation, is maintained for costs attributed to meeting the match requirement. Responsible Contact Person(s): Dolores Kordon, Executive Director, will be responsible for resolving this matter. Anticipated Completion Date: December 31, 2024.
Views of Responsible Officials and Action Taken: FCE implemented new internal controls in the fourth quarter of 2023 and has continued to document all draw down requests, review thereof, and approvals.
Views of Responsible Officials and Action Taken: FCE implemented new internal controls in the fourth quarter of 2023 and has continued to document all draw down requests, review thereof, and approvals.
We understand how crucial it is to have strong policies and procedures in place. Here’s how we plan to move forward: 1. Review of Existing Policies and Procedures: We’re currently taking a close look at our existing policies and procedures to ensure they align with the Uniform Guidance. This will h...
We understand how crucial it is to have strong policies and procedures in place. Here’s how we plan to move forward: 1. Review of Existing Policies and Procedures: We’re currently taking a close look at our existing policies and procedures to ensure they align with the Uniform Guidance. This will help us identify any gaps and make necessary updates so that we’re fully compliant. 2. Development of New Policies: Alongside this review, we will create clear and comprehensive written policies in key areas, such as: • Cash Management: Setting up procedures that comply with 2 CFR 200.305 to ensure timely payments. eCFR :: 2 CFR 200.305 -- Federal payment. • Allowability of Costs: Crafting guidelines that follow Subpart E—Cost Principles, so we can confidently determine which expenses are allowable. https://www.ecfr.gov/current/title-48/chapter-7/subchapter-E/part-731/subpart-731.7/section-731.770. • Conflict of Interest: Establishing standards of conduct that address potential conflicts and promote transparency. • Equipment and Real Property Management: Developing policies for managing equipment acquired under federal awards in line with 2 CFR 200.313(b). eCFR :: 2 CFR 200.313 -- Equipment. • Procurement Procedures: Creating clear procurement guidelines that align with 2 CFR 200.318 through 200.326 to ensure fairness and oversight. eCFR :: 2 CFR 200.318 -- General procurement standards. 3. Training and Communication: The Finance Department will be responsible for training all staff involved in managing federal awards. Training sessions will ensure that everyone understands the requirements and their roles in maintaining compliance. This training will be completed by December 31, 2024. Personnel responsible: Eduardo Cedeno, Director of Finance Anticipated completion date: December 31, 2024
We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have imp...
We will implement a formal review over monthly payment vouchers submitted to HUD beginning with the September 2024 vouchers to be filed in October 2024. This corrective action is already being done and has been since our last audit. Since our corrective action plan issued in early 2024, we have implemented a process that all grant claims/payment vouchers are formerly reviewed and initialed by our Executive Director.
We will implement procedures to ensure that our policies and procedures requiring the maintenance of documentation and formal review to support earmarking for federal awards be followed consistently for all programs in October 2024.
We will implement procedures to ensure that our policies and procedures requiring the maintenance of documentation and formal review to support earmarking for federal awards be followed consistently for all programs in October 2024.
Finding Reference Number: 2023-001 Identification of the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing No.: 10.557 Name of responsible official: James Geraghty Vice Presi...
Finding Reference Number: 2023-001 Identification of the Federal Program: Grantor: United States Department of Agriculture Program Name: Special Supplemental Nutrition Program for Women, Infant, and Children Assistance Listing No.: 10.557 Name of responsible official: James Geraghty Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: September 12, 2024 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” Management was unable to provide evidence of a control being consistently performed to address the risk that the Health System may seek reimbursement for expenditures that are either out of contract period or are for non-permissible costs under the applicable contracts. Status Management concurred with the audit finding and has implemented a standardized review and approval process that will be performed prior to monthly vouchers being submitted for reimbursement, including verification of allowability of expenditures, and that all expenditures were incurred in the proper period. Evidence of the monthly review and approval will be retained.
Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and e...
Finding 2023-003 – Fiscal Management System (Material Weakness) Criteria: CFR Part 200.302.b Auditee Responsibilities includes the requirement that the financial management system of each non-Federal entity provide the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. Accurate, current, and complete disclosure of the financial results of each Federal award or program. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. The reimbursement reports were to be reviewed by the District Manager prior to submission. Approval of the reimbursement requests and supporting reports by the District Manager were often delayed. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper financial reporting. Lack of timely filing of reimbursement requests could result in overstating accounts receivable balances and critical revenues lost due to cutoff terms of the grant award. Questioned Cost: No Context: Delays in filing reimbursement claims and internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures resulted in lost revenues and delayed recognition of revenue, which required adjustments to correct the financial statements. Repeat of a Prior-Year Finding: Yes, Financial Statement Findings 2022-001 Recommendation: The District should establish a more simplified and effective process for the review and approval of GAAP basis reporting and grant reimbursement requests and grant reporting. As part of this process, supporting general ledger reports and supporting data should be subject to a qualified individual to review and approval on a timely basis. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District
Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20...
Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) CARES 5311 Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring accurate and timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper grant accounting, reporting, and reimbursement. Questioned Cost: No Context: Internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures created a potential for inaccurate, incomplete reporting. Repeat of a Prior-Year Finding: Yes, Findings and Questioned Costs 2022-003 Recommendation: The District should continue to improve grant accounting efforts, and establish a more simplified and effective process for the review and approval of grant accounting and reimbursement requests. Additional training of management should occur to ensure they fully understand all compliance regulations and have the skills to assist in designing and implementing effective controls. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. . Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District
Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Pro...
Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024
Identification on the Federal Program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: The School’s Office of Student Financial Services has instituted comprehensive processes a...
Identification on the Federal Program: Grantor: Department of Education Program Name: Federal Direct Student Loans Assistance Listing No.: 84.268 Views of responsible officials and planned corrective actions: The School’s Office of Student Financial Services has instituted comprehensive processes and controls to ensure a timely review and submission of the FISAP, in accordance with the U.S. Department of Education’s FISAP instructions. The specific procedures will be documented in the School’s manual. With these protocols in place, we will adhere to the regulations set forth by the U.S. Department of Education. Name of responsible official: LaVerne Walker Director of Student Financial Services laverne.walker@mssm.edu Projected completion date: - September 26, 2024: Completed implementation of FISAP completion and signature submission. - October 7, 2024: Complete revision to procedure manual
Management’s Response: Management will develop and install a journal voucher system which requires approval by a person other than the preparer.
Management’s Response: Management will develop and install a journal voucher system which requires approval by a person other than the preparer.
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memori...
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memorial Hospital Corporation’s (Grady) CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional management review of the SEFA to include the prior of any submission and to provide evidence of the related review Grady’s corrective action plan: Grady Memorial Hospital Corporation has implemented a new review policy for the submissions of PRF reports which also includes a new reporting and review procedure that are performed by the Controller and Tax & Technical Accounting Manager. GMHC will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained within the timeline it was signed. Contact person/s responsible for the correction action: Gina Smith, VP, Fiscal Service/Controller Anticipated Completion Date: Grady Memorial Hospital Corporation has implemented controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained.
Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 202...
Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed and approved by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024
Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establ...
Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024
Finding 500343 (2023-003)
Significant Deficiency 2023
Management of the City will work with their contractors, both the construction contractors and the engineering firms hired to oversee and monitor the construction projects, to ensure they understand the wage rate requirements that must be followed for federally funded construction projects. The City...
Management of the City will work with their contractors, both the construction contractors and the engineering firms hired to oversee and monitor the construction projects, to ensure they understand the wage rate requirements that must be followed for federally funded construction projects. The City will implement a periodic monitoring program where the City verifies the contracted engineering or compliance vendors are adhering to the City’s contractual requirements such as obtaining the weekly certified payrolls.
The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when retur...
The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when returning funds. The business office will use this report to make sure the appropriate amount is posted to the student's account.
View Audit 323097 Questioned Costs: $1
Management has reviewed the loan requirements and will ensure that excess cash will not be pulled from the Project except as allowed under the Section 232 guidelines and at annual or semi‐annual intervals. Additional training was provided to the cash director as of November 2023 and will ensure that...
Management has reviewed the loan requirements and will ensure that excess cash will not be pulled from the Project except as allowed under the Section 232 guidelines and at annual or semi‐annual intervals. Additional training was provided to the cash director as of November 2023 and will ensure that excess cash will not be pulled from the Project.
All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years...
All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years, allowing clients to be seen by a medical provider quickly. This practice ended in 2023. 30-day eligibility is no longer allowed.
2023-004: Underfunded Resident Security Deposit Account Condition: The Partnership’s resident security deposit account is under-funded by $2,442 during the year ended December 31, 2023. Management’s Corrective Actions: Management has since fully funded the security deposit account and established pr...
2023-004: Underfunded Resident Security Deposit Account Condition: The Partnership’s resident security deposit account is under-funded by $2,442 during the year ended December 31, 2023. Management’s Corrective Actions: Management has since fully funded the security deposit account and established procedures to ensure that the account is properly funded moving forward.
2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish...
2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish the policies and procedures for reviewing and approving reimbursement claims to ensure that the claims are properly prepared and submitted timely.
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