Corrective Action Plans

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Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...
Item 2022.007 - Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures, that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance FEDERAL AWARDS FINDINGS AND QUESTIONED COSTS If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Cynthia Mitchell, CEO at 508-627-5797.
A financial consultant was engaged to prepare procedures, workflows and training for a culture of sustained readiness for all audit reports. The issue has been identified causing slow submission of the required clearinghouse filing. The audit itself will be timely going forward with the filing requi...
A financial consultant was engaged to prepare procedures, workflows and training for a culture of sustained readiness for all audit reports. The issue has been identified causing slow submission of the required clearinghouse filing. The audit itself will be timely going forward with the filing requirement date, less than two weeks, as the final date for the audit to be completed, reviewed by the board, responded to by management, and filed.
Condition and Context: As noted in finding 2022-002, ITCN had cash deficit in the amount of $35,398, while also reporting a total deferred revenue of $1,187,084 and a due to grantor agency of $269,375. At September 30, 2022, the WIC program is reporting deferred revenues of $289,963 while reflecting...
Condition and Context: As noted in finding 2022-002, ITCN had cash deficit in the amount of $35,398, while also reporting a total deferred revenue of $1,187,084 and a due to grantor agency of $269,375. At September 30, 2022, the WIC program is reporting deferred revenues of $289,963 while reflecting an amount loaned to other funds relating to these restricted sources totaling $60,455. Also, at September 30, 2022, the Child Care and Development Block Grant program is reporting deferred revenues of $198,541 while reflecting an amount loaned to other funds relating to these restricted sources totaling $828,529. As a result, ITCN is not in compliance with their contracts governing the use of these restricted funds. Recommendation: The auditors recommended that we implement the recommendations noted in finding 2022-002. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: ITCN has adopted the corrective actions under Finding 2022-002, with fiscal contractors monitoring compliance. The CFO provides monthly restricted fund reviews. MIP/Microix will add automated cash tracking and prohibit interfund borrowing. Staff training will reinforce cash management best practices. Anticipated Completion Date: The policy was adopted in March 2024. ITCN began to request for reconsideration, including supporting documentation, with grantor agencies with expected completion by December 31, 2025.
Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommenda...
Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommendation: The auditors recommended that ITCN implement the recommendations noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: This broad finding is being addressed by the corrective actions above. Fiscal contractors are providing quarterly compliance monitoring. ITCN’s Compliance Officer has initiated quarterly internal monitoring reviews. Migration to MIP/Microix will enhance reporting and compliance tracking. Training will ensure fiscal staff maintain compliance standards long-term. Anticipated Completion Date: The additional monitoring began in June 2024, with integration and staff training to be fully complete by June 2026.
Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreem...
Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that management reinforce the importance of its control to ensure costs are charged to federal awards within the period of performance with employees through on-going training. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCA has worked diligently to strengthen its accounting standards when it comes to Federal awards, including the centralization of reporting through its YESS shared services accounting systems and procedures. Operations personnel review the tenants of the grants up front in the process of executing each Federal grant. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: Complete
Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximiz...
Child Care and Development Block Grant– Assistance Listing No. 93.575 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations that are calculated in a consistent manner that ensure costs are applied uniformly to respective benefited activities, and that are reflective on employees’ time and effort records Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The YMCAs overhead structure differs from department to department, which makes it difficult to develop a common framework. And quite often the Federal or State agency is prescriptive when it publishes its grant guidelines. Though these grants are developed and submitted more centrally than in the past; nonetheless we will endeavor to develop a common listing of approved cost allocations. Name of the contact person responsible for corrective action: David Wyman Planned completion date for corrective action plan: December 2026
Finding 1175570 (2022-008)
Material Weakness 2022
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.
Finding 2022-012 Matching, Level of Effort and Earmarking Individual(s) Responsible: Cheryl DuBois, Head Start Director and Paula Vann, Grants Compliance Officer. Action: Make sure all reporting requirements are met. Maintain enrollment documentation and provide information upon request. Anticipated...
Finding 2022-012 Matching, Level of Effort and Earmarking Individual(s) Responsible: Cheryl DuBois, Head Start Director and Paula Vann, Grants Compliance Officer. Action: Make sure all reporting requirements are met. Maintain enrollment documentation and provide information upon request. Anticipated Completion Date: March 2026.
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to documen...
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to document that it had been approved by management to pay. During this period of 2022 we were on a manual accounts payable system. Invoices were approved before payment was made by email and the email was to be printed and attached. In September of 2022 we implemented a new ERP system. This system requires electronic approval by management for the invoice to be paid. Ferrick Jones, Controller, is responsible for ensuring this is remediated.
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action...
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
CMSU WILL SUBMIT YEARLY AUDITS WITHIN THE NIN MONTH REQUIREMENT UPON THE COMPLETION OF THE FISCAL YEAR
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in...
Recommendation: We recommend the College review the reporting requirements and implement procedures to ensure that all required reports are issued/posted in an accurate and timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Collaborative workflow was developed between Grant PI's and IS department personnel to ensure that all reports are posted to the website in a timely manner. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the cha...
Recommendation: We recommend the College enhance their controls around payroll disbursements to ensure employees are paid properly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College has recognized the challenge of hiring a Payroll Specialist. In September 2022, the College outsourced “Payroll” to Paycom. We continue to develop and communicate the unique needs of our College Payroll structure and Federal and private funding sources with Paycom and the College Human Resources to ensure that employees are paid properly. As such, the Business Office is undergoing a restructure and we have identified an internal candidate to take the lead on Payroll. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Reatha Tom, Accounts Payable Specialist, Michelle Ferron-Guppy, Director – Human Resources, and Zoy Zamudio-Lane, Human Resources Generalist Planned completion date for corrective action plan: September 30, 2024
Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are ...
Recommendation: We recommend the college implement policies and procedures to ensure all procurement documentation is complete and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Procurement policies are in place and trainings have been provided for Purchasing and Accounts Payable staff to ensure that all Procurement documentation is included in payment packets. Name of the contact person responsible for corrective action: Clarissa Salhus, Finance Manager, Duane VanderGriend, CFO Planned completion date for corrective action plan: Completed as of January 14, 2026
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the executive Director left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director, onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of he...
During 2020 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. Due to staffing shortages and restricted to access to apartments as a result of health concerns, our property manager was unable to perform Housing Quality Standards Inspections. The new Executive Director has contracted with a General Contractor to help assist our property manager with Housing Quality Standards Inspections. These inspections are conducted annually with detailed inspection logs for HVAC, Painting, Fire Safety, and major unit renovations maintained and tracked in our digital database. These logs are reviewed and updated on a quarterly basis to ensure timeliness in compliance and maintenance requests.
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This w...
HOMECorp will make use of Yardi Breeze Premier Affordable Property Management CRM feature which allows both HOMECorp and our tenants to track their program compliance, maintenance requests, leases, lease renewals and annual recertifications. This information will be saved/stored in the cloud. This was implemented on 05/01/23 through coordination of the Yardi Implementation Team and the executive director. During 2021 – 2022, HOMECorp’s management team was significantly impacted by COVID and despite PPP loan retention efforts we lost all our staff and transitioned our HUD Certified Housing Counselor to Property Manager. During this time, the Executive Director, left as well as two (2) interim Executive Directors, who responsibilities were general management. They lacked the training and experience in Affordable Housing Management to help our property manager to maintain our program compliance procedures. Since the new Executive Director onboarded in April 2023, the property manager has been trained on our policy and procedure for verifying tenant eligibility and calculating rent amounts in compliance with HOME program requirements, tenant intake, income verification, and rent calculations to ensure compliance with federal regulations. This is done in Yardi Affordable compliance worksheet. Quarterly periodic reviews and audits of tenant files and rent schedules are performed to ensure ongoing compliance.
The City will enhance compliance monitoring by updating monitoring checklists, ensuring required signatures are obtained, and documenting follow-up when borrower documentation (including occupancy certifications) is incomplete. A monitoring calendar will be used to ensure timely review of HOME loans...
The City will enhance compliance monitoring by updating monitoring checklists, ensuring required signatures are obtained, and documenting follow-up when borrower documentation (including occupancy certifications) is incomplete. A monitoring calendar will be used to ensure timely review of HOME loans and collection of required annual documentation. Staff will receive refresher training on HOME requirements.
Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one em...
Finding 2022-004: Activities Allowed and Unallowed, Allowable Costs (Compliance; Internal Controls Over Compliance) Response: For the audit period and subsequent audit periods (FY 2022-23 and partial 2023-24) The District will not be in compliance with this finding as duties were completed by one employee (accounts payable, payroll, balancing) and many records are not able to be located. For partial 2023-24 and 2024-25 records are now fully maintained and should be accessible for audit review. Training has been provided by the District’s Financial Consultant (payroll and accounts payable). The District Financial Consultant is reviewing payroll, processing tax and retirement payments, reviewing AP and correcting coding when necessary. The Consultant is also balancing reports and submitting monthly financial reports to the Board of Trustees.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Corrective Action Plan The documentation deficiencies identified were largely due to the absence of a dedicated internal Human Resources (HR) department and the absence of formalized HR procedures. During the audit period, HR services were outsourced to a third-party provider; however, the services ...
Corrective Action Plan The documentation deficiencies identified were largely due to the absence of a dedicated internal Human Resources (HR) department and the absence of formalized HR procedures. During the audit period, HR services were outsourced to a third-party provider; however, the services provided were not comprehensive nor su􀆯iciently tailored to the agency’s operational and compliance needs. Additionally, the scope and deliverables under that contract were not clearly defined, resulting in incomplete documentation practices and potential risk exposure.
Audit Finding: Finding 2022-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...
Audit Finding: Finding 2022-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately
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