Corrective Action Plans

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Finding 400604 (2022-005)
Significant Deficiency 2022
TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort r...
TCA Health will address the Allowable Costs and Activities first, by hiring additional accounting professionals both internally and as third- party consultants to support the grants management process in place at TCA. As part of that work, the third-party consultant will review the Time and Effort reporting policy and model. TCA currently feels that what the process that they utilized to allocate salary and wage expense to the grant related to this finding was allowable from a Uniform Grants Guidance perspective, however they were not compliant with their policy and will work to revise their policy to less restrictive (although still in compliance with the UGG). The iCFO will create greater monitoring of the month-end process as it relates to the allocation of payroll costs to be consistent with the personnel activity reports and the Health Center’s revised policy.
The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s c...
The COO at TCA Health will address Cash Management first, reviewing the policy and procedure to ensure it’s up to date with today’s best practices and modern standards. In doing so, TCA will review the organization chart to assess if the policy and procedure to match the personnel structure that’s currently in place. Changes will be made if necessary. Additionally, TCA has hired a third-party consulting firm that can assist with grant best practices.
Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve effi...
Audit Finding Reference: 2021-006 Cross Training of Staff and Review of Responsibilities Management’s View and Planned Corrective Action: Management does not agree with this deficiency. We do agree that Management is actively working on some changes as improvements are made each year to improve efficiency. Each position in the Business Office other than HR has been crossed trained with one-to-two other team members. Cross training throughout the business office was implemented in 2016 and has continued to exist. Each position has the ability to have someone step in case of emergency, elongated vacations and when/if someone resigns or is terminated. The positions are not covered in entirety, but the important items that must be dealt with can be and are accomplished. Examples are as such: Accounts Payable is covered by our Special Ed Bookkeeper, and other staff have the ability to review manifest once generated. Payroll has been covered by the Assistant Business Administrator when vacations or vacancies have existed, Grants can be covered by the Business Administrator when vacations or vacancies have existed. The Assistant Business Administrator is covered by the Business Administrator during vacations and vacancies. Each position continues to do their own assigned job duties and takes on the other tasks as necessary. The work may not get completed in the same timely fashion as if the actual staff member holding the position was there because they are also completing their own tasks, but the work does get accomplished. When there are multiple turnovers and/illness occurring at the sometime it makes it challenging even when cross training exists. Every year the Business Administrator reviews workloads and reassesses if changes should occur to help create efficiencies and create equivalent workload between all staff members. While some positions have more deadlines than others it can appear that their plates are larger than others, but frequently tasks are divided out throughout the team to help alleviate this. These discussions are brought forth to COLT, the Senior Leadership team at the SAU, and restructuring is finalized at that time. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date – Already occurs
View Audit 308621 Questioned Costs: $1
Finding No. 2022-001 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not ensure passing HQS inspections were performed during 2022. Corrective Action: Unit inspections are being done for 2023.
Finding No. 2022-001 - HUD HOME Investment Partnerships Program, Federal Assistance Listing Number #14.239 Statement of Condition: The owner did not ensure passing HQS inspections were performed during 2022. Corrective Action: Unit inspections are being done for 2023.
Finding 2022-001 Federal Program Funds Utilized for Non-Federal Programs Recommendation: The Authority should locate additional sources of non-federal funds or reduce costs sufficiently so that the program can have enough cash to cover ongoing operations. Explanation of disagreement with audit findi...
Finding 2022-001 Federal Program Funds Utilized for Non-Federal Programs Recommendation: The Authority should locate additional sources of non-federal funds or reduce costs sufficiently so that the program can have enough cash to cover ongoing operations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Taken: The Authority has reevaluated its cost allocation plan and restructured various departments to better align staffing. This process helps ensure the COCC and funds are being properly charged for actual costs incurred. The Authority is also redeveloping its entire portfolio. This process had been and will continue to bring in developer and management fees to the COCC. Name of Contact Person responsible for Corrective Action: Cia Cook, Deputy Executive Director & CFO Planned Date for Corrective Action plan: June 30, 2024
The Academy has put in place additional staff to monitor time and effort support, personal activity reporting, and certification processes around the Title I program.
The Academy has put in place additional staff to monitor time and effort support, personal activity reporting, and certification processes around the Title I program.
View Audit 308166 Questioned Costs: $1
Management will create a Reserve Account to be in compliance with the USDA Loan Agreement Anticipated Completion Date: Fiscal year 2024
Management will create a Reserve Account to be in compliance with the USDA Loan Agreement Anticipated Completion Date: Fiscal year 2024
2) Finding 2022-02 - The School failed to document proper approval of purchases prior to disbursement of federal funds. a. Implementation of plan of action - Management will review control policies to ensure that approvals of purchases are documented prior to disbursement of federal funds. b. Implem...
2) Finding 2022-02 - The School failed to document proper approval of purchases prior to disbursement of federal funds. a. Implementation of plan of action - Management will review control policies to ensure that approvals of purchases are documented prior to disbursement of federal funds. b. Implementation date - Anticipated completion June 30, 2024. c. Persons responsible for the implementation - The Board of Directors and Head of School.
FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October...
FINDING 2022-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: The County Health Department was required to submit data through the online portal, National Electronic Disease Surveillance System Base System, monthly beginning in October 2022. The submitted data included program specific metrics related to patient case management of certified Elevated Blood Lead Levels. A Case Manager managed all aspects of an individual patient’s care. Once a patient’s care was complete, the case was closed by the Case Manager in the online portal. Completed cases were compiled by the Clinical Manager into a data sheet, which was then submitted to the Manager of Administration. The Manager of Administration based on the compiled data sheet prepared and submitted a reimbursement request to the State without an oversight, review, or approval process to ensure the reimbursement request was complete and accurate. Recommendation: We recommended that management of the County design and implement a proper system of internal controls, including policies and procedures that would provide segregation of duties to ensure appropriate reviews, approvals, and oversight are taking place to ensure reports are complete and accurate.” Contact Person Responsible for Corrective Action: Concetta Sanfilippo Contact Phone Number and Email Address: 574.523.2101 csanfilippo@elkhartcounty.com Views of Responsible Officials: Option 2: “We disagree with part of the finding.” Explanation and Reason for Disagreement: The County already has an established process of review and evaluation. The Case Manager’s reports on work are reported to their superior, the Clinical Manager. The Clinical Manager reviews data, enters report data into the program portal as required. A spreadsheet with case start date, patient ID number, home address and payment is submitted to the Manager of Administration who acts as secondary review and completes the invoice and submits it to the State where an additional process of review is then executed before approval and federal funds are drawn. Once the invoice is submitted, the Manager of Administration makes two copies of the invoice and the spreadsheet, one copy is sent to the Clinical Manager and the other to the Auditors office. This is an excellent procedure for checking and balance. Description of Corrective Action Plan: The Elkhart County Health Department receives elevated blood lead levels from the State. The Lead Case Manager determines if criteria are met to initiate a case. They conduct a home visit and make appropriate referrals. The lead case manager enters case information into NBS. INDIANA STATE BOARD OF ACCOUNTS 38 Ongoing case management for children with elevated blood leads levels includes coordination of blood lead tests, education, and appropriate referrals. The Lead Case Manager submits a list of cases each month to the Clinical Manager that meet the criteria for submission for reimbursement. The criteria are a completed home visit, a completed nutrition assessment, a referral for developmental assessment and documentation in NBS. The Clinical Manager reviews the cases in NBS and compiles a list and submits the data sheet to the Fiscal Manager. The Fiscal Manager prepares the invoice and submits it along with documentation to the State and Timothy Conley for review and approval. The Elkhart County Health Department will continue to have collaborative compilation of data which will be reviewed by field specialists before being submitted to the Manager of Administration for invoice reimbursement. The data and records are reviewed by the Manager of Administration and the invoice total will be confirmed and documented with the Clinical Manager prior to being submitted to the State for review and approval. Confirmation emails of secondary review will be retained as documentation. The State must approve invoices with supporting documentation and is the external party requesting reimbursement with Federal funds once approved. A copy of supporting documentation is supplied to the Elkhart County Auditor’s Office to be retained on file and to be used for receipting records once reimbursement is received and deposited into its unique 8000 series fund. Anticipated Completion Date: August of 2023 (Note: Provide the projected date of completion of major tasks for the planned corrective actions.)
FINDING 2022-003􀯗 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting􀯗 Summary of Finding:􀯗􀯗 Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the Department of the Treasury (Treasury). The reporting periods, as wel...
FINDING 2022-003􀯗 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting􀯗 Summary of Finding:􀯗􀯗 Recipients are required to submit quarterly or annually Project and Expenditure (P&E) reports to the Department of the Treasury (Treasury). The reporting periods, as well as the respective due dates, are based upon type of recipient and its population, as well as the recipient's allocation amount. Information to be reported includes projects funded, expenditures, and contracts for the appropriate reporting period. The County was classified as a metropolitan county with a population below 250,000 residents that received an allocation of more than $10 million in Coronavirus State and Local Fiscal Recovery Funds (CSLFRF). Therefore, quarterly P&E Reports were due by January 31, 2022, and the last day of the month after the end of each quarter thereafter. The County submitted four quarterly P&E Reports during the audit period. The County’s process for the completion and submission of the P&E Reports was the Grant Administrator prepared the P&E Reports and the County Auditor reviewed them prior to submission; however, the control was not effective in detecting and preventing noncompliance. Two of the four quarterly reports submitted during the audit period were selected for testing. The County utilized the current period obligations field to document total obligations less current period expenditures. For the reports tested, the current period obligations, per the County’s interpretation of the field, were not supported by the County’s records. The following errors were noted: Quarter 2 P&E Report (April 1, 2022 - June 30, 2022) 􀄁 The Current Period Obligations for the Revenue Replacement project were overstated by $399,097. Quarter 3 P&E Report (July 1, 2022 - September 30, 2022) 􀄁 The Current Period Obligations for the Prairie Creek Water Run Water Line project were overstated by $67,773. 􀄁 The Current Period Obligations for the Parks Department - Latrine project were overstated by $25,758. 􀄁 The Current Period Obligations for the Foraker/Southwest project were overstated by $230,338. The lack of effective internal controls and noncompliance was a systemic issue during the audit period. Contact Person Responsible for Corrective Action: Patricia Pickens Contact Phone Number and Email Address: 574.535.6719 ppickens@elkhartcounty.com􀯗 􀯗 􀯗 INDIANA STATE BOARD OF ACCOUNTS 36 117 N. 2ND St Rm 203 Goshen, IN 46526 - 574-535-6719 􀀃 Views of Responsible Officials:􀯗􀯗 We disagree with the finding.􀯗􀯗 􀯗 Explanation and Reasons for Disagreement:􀯗􀯗 The finding does not accurately reflect the administration of the SLFRF program and fails to correctly identify key challenges that impacted the difference in data. There is a rigorous system of diligent records keeping, auditing expenditures, and internal controls including multiple points of review and approval for reporting ARPA funds. All expenditures are accounted for and maintained with supporting documentation. The auditing team can clearly demonstrate attention to detail in the tracking and reporting of all expenditures. They also have extensive record of on-going issues with the reporting portal including tickets and communications with Treasury support. They have identified issues with the portal that prevented the submission of reports or caused erroneous calculations/data.
The Municipality will take all the necessary administrative measures to address and correct this situation. I will instruct the Finance Department to submit all required financial information promptly to our financial consultatn and external auditors to meet the deadline for submitting the Single A...
The Municipality will take all the necessary administrative measures to address and correct this situation. I will instruct the Finance Department to submit all required financial information promptly to our financial consultatn and external auditors to meet the deadline for submitting the Single Audit Report for the year 2024. Expected completion date: March 30, 2025
Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensu...
Corrective Action: Coastal Harvest will begin tracking all inventory on hand by source, including receipts, distributions, waste/loss, and any other adjustments, and will perform periodic reconciliations of amounts recorded in the inventory system and amounts recognized in the general ledger to ensure accurate USDA food commodities inventory recordkeeping compliance. Further, Coastal Harvest will include specific inventory policies and procedure in the manual discussed in the corrective action for finding 2022-001. Anticipated Completion Date: June 30, 2024
View Audit 307582 Questioned Costs: $1
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
#10.760 Water and Waste Disposal Systems for Rural Communities Federal Grantor: U.S. Department of Agriculture Pass-through Agency Number: N/A Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over g...
#10.760 Water and Waste Disposal Systems for Rural Communities Federal Grantor: U.S. Department of Agriculture Pass-through Agency Number: N/A Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures offederal awards would be prevented or detected. Cause:The Village does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of expenditures of federal awards is high. Questioned Costs: None Recommendation: We recommend that the Village works on written policies and procedures over grants and grant expenditures. Grantee Response: The Village will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance. Contact Person: Lee Kucher Anticipated Completion: December 31, 2024
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In ...
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Cluster Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliations for the federal program. In addition, there was lack of review of the quarterly internal monitoring of the Hospital’s debt covenants. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: For the reserve fund reconciliations, a secondary review will be completed and documented. The Hospital will also ensure that the quarterly covenant calculations are completed and presented to the board for review with the financials. Anticipated Completion Date: 05/31/2024
Federal Agency Name: Department of Health and Human Services; Department of Agriculture Assistance Listing Number: #93.498; #10.766 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution; Community Facilities Loans and Grants Cluster Finding Summary: The Hospi...
Federal Agency Name: Department of Health and Human Services; Department of Agriculture Assistance Listing Number: #93.498; #10.766 Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution; Community Facilities Loans and Grants Cluster Finding Summary: The Hospital does not have an internal control system designed to allow for a complete and accurate Schedule being audited. We were requested to draft the Schedule. Responsible Individuals: Rick Korf, CFO Corrective Action Plan: We will continue to have our auditors assist with preparing the schedule of expenditures of federal awards (SEFA). Anticipated Completion Date: Ongoing
Auditor's Recommendation: We recommend the Entity follow their policy and procedures related to purchases. Action Taken: The Organization understands the importance of following current, written policies and procedures for both employees and members of management. Policies and procedures will be rev...
Auditor's Recommendation: We recommend the Entity follow their policy and procedures related to purchases. Action Taken: The Organization understands the importance of following current, written policies and procedures for both employees and members of management. Policies and procedures will be reviewed to ensure the appropriate approvals and signatures are obtained. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023
Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective du...
Auditor's Recommendation: We recommend the Entity implement adequate controls to ensure the accuracy of the information reported to the Grantor Agency in a timely manner. Action Taken: The Organization will create an electronic calendar with reminders for all reporting requirements and respective due dates. Responsible Official: John Clemons, Chief Financial Officer Timeline for Implementation: July 31, 2023
Finding 2022‐006 – Special Tests and Provisions Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not have adequate internal control policies in place to ensure...
Finding 2022‐006 – Special Tests and Provisions Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not have adequate internal control policies in place to ensure review and approval over the reserve funds, monitoring of all required debt covenants, proper funding of the reserve accounts, or to ensure that proper procedures are followed for obtaining USDA approval for any withdrawals from the debt service reserve funds. Responsible Individuals: Kelly Johnston, CFO Status: The Hospital enhance internal control policies to ensure formal documentation of reviews for the reserve fund reconciliations is retained, monitoring that the required debt covenants are monitored and reviewed, reserve funds are properly funded, and that there are proper procedures in place for obtaining USDA approval for any future withdrawals from the debt service reserve funds. Anticipated Completion Date: 6/30/2024
Finding 2022‐005 – Reporting Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not submit the quarterly reports for 2022 to the United States Department of Agri...
Finding 2022‐005 – Reporting Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Hospital did not submit the quarterly reports for 2022 to the United States Department of Agriculture and the interim financing lender and did not send the annual budget, financial statements, cost report, and debt service reserve calculation to the United States Department of Agriculture. Responsible Individuals: Kelly Johnston, CFO Status: Management will implement policies and procedures surrounding the reporting required under the United States Department of Agriculture loan program as well as provide the required reports on a timely basis to all respective parties. Anticipated Completion Date: 6/30/2024
Finding 2022‐004 – Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: United States Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 COVID‐19 Provider Relief Fu...
Finding 2022‐004 – Preparation of Schedule of Expenditures of Federal Awards Federal Agency Name: United States Department of Agriculture Department of Health and Human Services Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 COVID‐19 Provider Relief Fund and American Rescue Plan Rural Distribution Federal Assistance Listing #93.498 Finding Summary: Proper controls over financial reporting include the ability to prepare the schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule. The Hospital does not have an internal control system designed to provide for a complete and accurate Schedule being audited. We were requested to draft the Schedule. Responsible Individuals: Kelly Johnston, CFO Status: It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule and accompanying footnotes. We requested that our auditors, Eide Bailly LLP, prepare the Schedule and accompanying footnotes as a part of their annual audit. We have designated a member of management to review the drafted Schedule and accompanying footnotes. Anticipated Completion Date: Ongoing
Finding 397881 (2022-006)
Significant Deficiency 2022
College will put controls in place between Registrar and Financial Aid to ensure enrollment status of students
College will put controls in place between Registrar and Financial Aid to ensure enrollment status of students
View Audit 306623 Questioned Costs: $1
Finding 397880 (2022-005)
Significant Deficiency 2022
Administration adjusted job responsibilities of current staff and made process changes to work with third party financial aid servicer to validate federal awards prior to submission
Administration adjusted job responsibilities of current staff and made process changes to work with third party financial aid servicer to validate federal awards prior to submission
POF’s initial exposure to Single Audit compliance requirements has sharpened its focus on the need to purposefully identify and maintain corroborating evidence regarding its timely submission and acceptance by each of the respective funding sources. While POF believes that all these reporting requir...
POF’s initial exposure to Single Audit compliance requirements has sharpened its focus on the need to purposefully identify and maintain corroborating evidence regarding its timely submission and acceptance by each of the respective funding sources. While POF believes that all these reporting requirements were timely met and accepted by all funding sources, it did not consistently maintain either the report itself, or the related documentation such as copies of the emails sent or the associated read-receipts as evidence of these reports. Effective July 1, POF will routinely and consistently accumulate and organize these documents as well as ancillary evidence of their transmission to, receipt by, and acknowledgement of acceptance by the federal agency. As it deems necessary, POF will seek professional education and advice in implementing policies, practices, and procedures in addition to those already described herein.
As more fully described above, additional internal control procedures and practices will be implemented effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR and other regulatory requirements. More specifically, vendor inv...
As more fully described above, additional internal control procedures and practices will be implemented effective July 1, 2024, to ensure that underlying cost documentation is adequate, reasonable, and complete in accordance with 2 CFR and other regulatory requirements. More specifically, vendor invoices and the like will be scanned and electronically saved on QBO, as incurred. On the other hand, contractors were engaged to perform certain tasks and were not constrained by hours. If the subject service required on-site intervention by the contractor with a POF client at 3 AM, then the contractor was expected to and had agreed to deliver. The contractor would report any such encounters at the subsequent weekly meetings with certain contractors present. Consistent with IRS employer guidelines, POF did not supervise contractors or dictate work habits or work schedules. Instead, POF defined what each contractor was expected to do or deliver. It was incumbent upon the contractor to determine how best to accomplish the assigned and agreed upon duties defined in their jointly signed agreement. POF’s contractors were and are professionals with state credentials, degrees, or certifications which permit them to serve other NPOs or customers as independent contractors. In many cases, their work products were summarized during the previously mentioned POF weekly meetings and transmitted to Wright State University (now the Ohio State University) where the data were aggregated independently by these contracted third parties and made available to POF’s funders. Effective July 1, 2024, copies pf these weekly report summaries will be routinely saved to provide further evidence of POF’s monitoring of contractors’ activities and adherence to contract terms.
View Audit 306345 Questioned Costs: $1
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