Corrective Action Plans

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Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend ...
Corrective Action Plan: As part of the audit planning for 2024, Atrium Health CMHA management will ensure that the internal controls within the SFA IT Systems are documented and tested, or compensating controls implemented. Proposed Completion Date: In November of 2024, management would intend to incorporate and complete this IT systems controls testing into the planning phase of the December 31, 2024 reporting period audit.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Taken: NFFCMH plans to implement changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed, and to reconcile and true up any budget estimates on a consistent basis.
Action Taken: NFFCMH now performs and documents verification on all vendors and subcontractors. This practice has been implemented prior to the completion of the FY2023 Audit
Action Taken: NFFCMH now performs and documents verification on all vendors and subcontractors. This practice has been implemented prior to the completion of the FY2023 Audit
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These...
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with our external consultant, our Council auditors and our external auditor to reperform and review the base year and subsequent year calculations of revenue, using financial information in our final audit reports. These corrected calculations of lost revenue have been clearly documented and will be reported going forward. We will continue to work to ensure that all controls for grants be documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolv...
Action Plan: Upon learning of this finding during the FY2022 audit, we worked with the Neighborhoods Department to ensure wage rate requirement compliance was prioritized going forward. Considering this finding was presented near the completion of the FY2023 year, we expect this finding to be resolved in FY2024. We will continue to work with our departments to ensure that all controls for grants are documented with written procedures. The procedures will include the title of the positions responsible for each control (preparation, review, reconciliation, etc.) and will require that the performance of the controls be documented in a clear, reperformable manner including the name of each responsible individual, the specific control they performed over compliance for the grant and the date(s) the controls were performed. Contact Names responsible for the plan – Marcia Saulo Anticipated completion date of the plan – September 30, 2024
Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2023-003 (a)...
Name of Auditee: Rochester Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2023 CAP Prepared by: Shawn Burr, Executive Director Phone: (585) 697-6184 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2023-003 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation, please see below for action taken. (b) Action taken - HQS inspections of Shelter Plus Care properties will be performed on an annual basis. (c) Planned implementation date of corrective action - Completed by September 30, 2024.
The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by som...
The City agrees with the recommendation to strengthen internal controls over grant reporting processes. To enhance accountability and accuracy, grant reports authored by the designated grant recipient, who is the City employee tasked with managing the grant activity, will now undergo a review by someone else in the City independent of the report preparation. This review will focus on ensuring the reports are complete, accurate, and fully compliant with all stipulated grant requirements.
Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report...
Corrective Actions Taken or Planned: Create procedures by type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2024
Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent ...
Expenditures submitted for the Alabama Medicaid Administrative Claiming program included expenditures supported by federal funds and undocumented costs. Contact: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2024 claim.
View Audit 310807 Questioned Costs: $1
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority implement processes to ensure HUD-50058 submissions are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend the Authority implement processes to ensure HUD-50058 submissions are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Beginning in March 2023, the PBCHA implemented the completion of all reexaminations within its Yardi resident portal. Reexaminations within Yardi provide online workflows that maximize efficiency, streamline compliance, reduce errors and increase reporting accuracy. The PBCHA will implement processes to ensure that HUD 50058 submissions are uploaded in accordance with HUD regulations. The PBCHA will utilize available dashboards and reports to improve monitoring and oversight to ensure compliance. Name(s) of the contact person(s) responsible for corrective action: Cheryl Lewis Planned completion date for corrective action plan: 12/31/2024
Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated...
Management agrees with the recommendations. We are revising our Award Management policies to ensure the closeout procedures are clear and comply with this recommendation. We will ensure that all relevant teams are part of the closeout planning process to ensure expenses are planned for and allocated correctly within the period of performance. We also established a Grants Compliance Team that will be responsible for the compliance oversight of awards from inception to closeout.
FINDING 2023-003: Late Audit Submission Response: We were unaware that we had to complete a federal audit for FY 2023. We will confirm with the auditor in future years to make sure we are not late.
FINDING 2023-003: Late Audit Submission Response: We were unaware that we had to complete a federal audit for FY 2023. We will confirm with the auditor in future years to make sure we are not late.
The submission of purchase requisitions within the ERP system is reviewed and monitored by accounts payable staff. Requisitions are now reviewed and approved by the Program supervisor and the Accounts Payable section manager. Proper documentation is required prior to the approval of all requisitions...
The submission of purchase requisitions within the ERP system is reviewed and monitored by accounts payable staff. Requisitions are now reviewed and approved by the Program supervisor and the Accounts Payable section manager. Proper documentation is required prior to the approval of all requisitions and such documentation must match the requisition in vendor name, address, amount, invoice number and appropriate program code. Staff have been trained on the use of the purchase requisition system and briefed on the necessary documentation standards.
View Audit 310726 Questioned Costs: $1
Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.6 of the USDA's Loan Guarantee Agreement stipulates that the borrower must maintain certain financial reporting covenants, such as debt servic...
Federal Program: Community Facilities Loans and Grants Cluster: Community Facilities Loans and Grants Assistance Listing Number: 10.766 Criteria: Section 4.6 of the USDA's Loan Guarantee Agreement stipulates that the borrower must maintain certain financial reporting covenants, such as debt service coverage ratio of at least 1.25, days cash on hand in excess of 65 days, and obtaining an audited fiscal year-end financial statement audited by independent certified public accountants withing one hundred ten days subsequent to year end. Additionally, section 4(d) of the Community Facilities Loan Resolution Agreement stipulates that the Hospital will establish and maintain a bookkeeping or separate bank account for the debt reserve funds. As of September 30, 2023 the Hospital had not maintained a separate account at the bank with sufficient funds, nor was a separate general ledger account established. Condition and Context: The Hospital did not maintain a days cash on hand in excess of 65 days, as of September 30, 2023. Additionally, the Hospital failed to maintain a separate account at the bank with sufficient funds, nor was a separate general ledger account established. The Hospital's audited financial statements as of September 30, 2023 were issued subsequent to one hundred ten days following September 30, 2023. Corrective Action Planned: Management has contacted the financial institutions and the United States Department of Agriculture, for waivers of debt covenants to prevent triggering an event of default. Additionally, management has reviewed and modified its internal controls to ensure monitoring of ongoing compliance. Name of Contact Person Responsible for Corrective Action: Amy Downey, Chief Financial Officer, 200 Hospital Drive, Spencer, WV 25276 Anticipated Completion Date: June 27, 2024
Finding #2023-002 Continuum of Care Program Views of Responsible Officials and Planned Corrective Action The Authority will review its accounting processes to accurately record and provide complete reports as required by the U.S. Housing and Urban Development (HUD), by the recommendations from HUD’s...
Finding #2023-002 Continuum of Care Program Views of Responsible Officials and Planned Corrective Action The Authority will review its accounting processes to accurately record and provide complete reports as required by the U.S. Housing and Urban Development (HUD), by the recommendations from HUD’s technical assistance, and by the updated Uniform Guidance requirements to report matching requirements. Responsible accounting and planning personnel will be trained on updated Uniform Guidance. Responsible Party: Frances Danieli, Controller and Katherine Taitano, Chief Planner Anticipated Date of Completion: Ongoing effort and as training is made available
View Audit 310613 Questioned Costs: $1
Finding 2023-001 – Reporting – Federal Funding Accountability and Transparency Act (FFATA) Federal Program Information: Federal Agency: United States Agency for International Development Assistance Listing: 98.001 - USAID Foreign Assistance for Programs Overseas 98.U04 – USAID Foreign Assistance for...
Finding 2023-001 – Reporting – Federal Funding Accountability and Transparency Act (FFATA) Federal Program Information: Federal Agency: United States Agency for International Development Assistance Listing: 98.001 - USAID Foreign Assistance for Programs Overseas 98.U04 – USAID Foreign Assistance for Economic Growth Federal Award Identification Number: 98.001 - 7200AA19CA00002; 72066418CA00001; 72044020CA00002; 72049218CA00008; 72066418CA00001; 7200AA18CA00011; 72066322CA00005. 98.U04 - 72026320C00005 Award Year: FY 2022 – 2023 Corrective Action Plan: FHI 360 will implement a corrective action plan comprised of the following actions: 1.) additional global communications and meetings with key management teams; 2.) targeted and detailed training on FFATA requirements and completion of the FSRS template via an e-module; and 3.) implement an additional review through a small, centralized team both to identify prospective transactions and perform a final review of data quality prior to data entry in FSRS. Person(s) Responsible: Director, Contract Management Services Chief Operating Officer Completion Date: July 31, 2024
Finding 403480 (2023-012)
Significant Deficiency 2023
EARMARKING – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County implements a policy requiring a review of the administrative expenditures as reported on the quarterly DWP reports. Explanation of disagreement with audit finding: There is no disagreement with ...
EARMARKING – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County implements a policy requiring a review of the administrative expenditures as reported on the quarterly DWP reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement a review policy to ensure they are following compliance requirements for administrative expenditure reporting. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2024
Finding 403476 (2023-009)
Significant Deficiency 2023
EARMARKING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County reviews their policies and federal requirements to ensure all costs are reported under the correct category. Explanation of disagreement with audit finding: There is no disagreem...
EARMARKING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County reviews their policies and federal requirements to ensure all costs are reported under the correct category. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their policies and federal requirements related to earmarking to ensure compliance requirements are met. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024
Finding 403469 (2023-011)
Significant Deficiency 2023
SPECIAL PROVISIONS – STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: It is recommended that income documentation be reviewed for each eligible case file to ensure the information matches MAXIS. Explanation of disagreement with audit f...
SPECIAL PROVISIONS – STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: It is recommended that income documentation be reviewed for each eligible case file to ensure the information matches MAXIS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work on training new staff on requirements. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2024
Findings and Questioned Costs Relating to Federal Awards: Late Single Audit Submission, Reporting Management submitted Single Audit reports up to fiscal year 2023. To address the root cause for this finding, management performed the following actions: • Management audit contracts are followed up dir...
Findings and Questioned Costs Relating to Federal Awards: Late Single Audit Submission, Reporting Management submitted Single Audit reports up to fiscal year 2023. To address the root cause for this finding, management performed the following actions: • Management audit contracts are followed up directly by CFO to ensure timely execution to ensure audits are timely completed and planned. • Management enhancements to the finance function, such as accounting closing checklists, accounting closing meetings and reconciliation processes, among other actions, should improve the timing of audit results. Additional resources (consultants) were hired to assist in the audit process to ensure external auditors have information on a timely basis. In order to ascertain that basic and recurrent information requested by auditors is ready, management prepared an updated list of information normally requested and prepared a OneDrive (cloud backup storage) where all information will be archived and ready to be delivered to the auditors as requested. This should provide the efficiency and agility to response to auditors in a timely manner. Management successfully completed late Single Audit submissions with this 2023 Single Audit Report. With this filing, DDEC is up to date in its regulatory reports. Furthermore, with the process enhancements and improved controls implemented, DDEC expects to continue filing on or before filing due dates.
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report...
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTION Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include timely issuance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2025 RESPONSIBLE PERSON Jamille Muriente, CFO, Marjuli, David Mateo, Contract Coordinator Officer
The Department of Behavioral Health (DBH) agrees with the findings. DBH will work to ensure that the time management/payroll system accurately shows where an employee’s cost is being charged. An employee was not charged to the grant even though they were noted as key personnel (100% to be charged t...
The Department of Behavioral Health (DBH) agrees with the findings. DBH will work to ensure that the time management/payroll system accurately shows where an employee’s cost is being charged. An employee was not charged to the grant even though they were noted as key personnel (100% to be charged to the grant). DBH will work with the OCFO to make sure Peoplesoft can assign attributes that can be reported to show that they were charged to the grant. In addition, DBH will review with program staff the process to have a “Letter of Temporary Detail” noting when an employee is assigned to work on the grant so that their time can be charged to the grant. DBH will have the grants management system configured so that the PDF of the Letter of Temporary Detail can be attached to the grant file. Contact - PeopleSoft Set-up: Adran Reid, DBH Agency Fiscal Officer and Michael Neff, DBH Chief Operating Officer, Letter of Temporary Detail: Sharon Hunt, State Opioid Treatment Authority , Grants Management System Configuration: Michael Neff, DBH Chief Operating Officer Estimated Completion Date - Grants Management System, Uploading Documents to Grant File: January 1, 2025 See Corrective Action Plan for chart/table
The Department of Behavioral Health (DBH) agrees with the findings. Eligibility of Subrecipients: Training will take place for Fiscal Services Staff to ensure that screening for eligibility for the program takes place. The requirement for screening will be added as a required data element so screen...
The Department of Behavioral Health (DBH) agrees with the findings. Eligibility of Subrecipients: Training will take place for Fiscal Services Staff to ensure that screening for eligibility for the program takes place. The requirement for screening will be added as a required data element so screening can be monitored in the grants management system. Earmarking Requirements for Subrecipients: ICR will be set up based on allowable costs from the NOA in grants management system. Training will be conducted for Fiscal and Program Monitors so that they are aware of how ICR is determined and calculated. Monitoring of Subrecipients: DBH will conduct training to ensure that Fiscal and Program Monitors understand the requirements of on-going documentation to identify risk and compliance to the program. DBH will have the monitoring form created in the new grants management system so that failure to complete the documentation will trigger a system alert with an escalation process to ensure compliance. Contact - Eligibility of Subrecipients: Anthony Baffour, Director, Fiscal Services, Earmarking Requirements for Subrecipients: Sharon Hunt, State Opioid Treatment Authority and Anthony Baffour, Director, Fiscal Services, Monitoring of Subrecipients: Sharon Hunt, State Opioid Treatment Authority and Anthony Baffour, Director, Fiscal Services See Corrective Action Plan for chart/table Estimated Completion Date - Staffing Training: August 1, 2024, Grants Management System: January 1, 2025 See Corrective Action Plan for chart/table
The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to su...
The Department of Behavioral Health (DBH) concurs with the finding. The Accounting Supervisor will require additional documentation upon the presentation of requests for reimbursement for all federal grants prior to submitting the request in the federal system. The accountant will be required to submit supporting documentation reflecting the summary and detailed personal and non-personal service expenditures. Contact - Adran Reid, DBH Agency Fiscal Officer Estimated Completion Date - July 1, 2024 See Corrective Action Plan for chart/table
View Audit 310468 Questioned Costs: $1
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior D...
The Economic Security Administration (ESA) concurs with this finding. As a corrective action, ESA will provide refresher training and reinforce oversight controls to ensure caseworkers and supervisors are processing applications within federally required timeframes. Contact - Melisa Byrd, Senior Deputy Director and Medicaid Director Estimated Completion Date - June 18, 2024 See Corrective Action Plan for chart/table
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