Corrective Action Plans

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Finding 393273 (2022-003)
Significant Deficiency 2022
Significant Deficiency in Internal Control over Compliance and Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by The Organization as proof of oversight of expenditure of federal funds...
Significant Deficiency in Internal Control over Compliance and Compliance Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by The Organization as proof of oversight of expenditure of federal funds. CLA would recommend the use of an AP voucher, or similar, for each type of disbursement that leaves the Organization (check, EFT, credit card, etc.) to improve documentary evidence that costs are being reviewed and approved for appropriateness. There is no disagreement with the audit finding. Action taken in response to finding: Since Fall/Winter 2023, we have increased the emphasis and training for all staff on documenting evidence of approvals, including obtaining and retaining necessary documentation and proof of expenditure oversight for federal funds to ensure there is adequate evidence that costs are being reviewed and approved for appropriateness. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 4/1/2024
View Audit 303558 Questioned Costs: $1
Finding 392927 (2022-001)
Significant Deficiency 2022
1. Name of person responsible for the corrective action: Jane Sanchez & Ewell Sterner 2. Corrective Action Planned: In February 2024, the Organization engaged with Shirlee Victorio, VP Consulting Services, to assist Jane Sanchez and Ewell Sterner in establishing procedures related to grant reportin...
1. Name of person responsible for the corrective action: Jane Sanchez & Ewell Sterner 2. Corrective Action Planned: In February 2024, the Organization engaged with Shirlee Victorio, VP Consulting Services, to assist Jane Sanchez and Ewell Sterner in establishing procedures related to grant reporting. Ms. Victorio has an employment history of grant administration for the City of San Jose and the County of Santa Clara. Outstanding reporting requirements are being served and the process to administer grants activity, including formal documentation of processes and retention of supporting documents, and reporting is in process. 3. Anticipated Completion Date: March 31, 2024
Action Taken: Range Mental Health Center, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensur...
Action Taken: Range Mental Health Center, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensure reporting requirements are met.
Action Taken: Range Mental Health, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensure repor...
Action Taken: Range Mental Health, Inc. and Subsidiaries is in the process of developing internal controls to ensure timely and appropriate actions are made to ensure timely and accurate reporting as it relates to grant requirements. We are currently performing a review of all grants to ensure reporting requirements are met.
Action Taken: During 2023, Range Mental Health Center, Inc. and Subsidiaries had experienced turnover in key financial functions. In addition, we were notified that current independent audit firm would no longer be performing the 2023 financial and single audits. In response to this we have outsourc...
Action Taken: During 2023, Range Mental Health Center, Inc. and Subsidiaries had experienced turnover in key financial functions. In addition, we were notified that current independent audit firm would no longer be performing the 2023 financial and single audits. In response to this we have outsourced its CFO function. We have also engaged a new independent audit firm, as this was a first-year audit there was an acclimation period delaying many processes. As a result, we anticipate an improvement in timeliness of our financial records.
Finding: 2023-2 MESA's Accounting Manual has been amended to include the following language under the Division of Responsibilities: Operations Director reviews all incoming and outgoing invoices. Upon review and approval of an invoice, the Operations Director signs and dates the invoice, and prese...
Finding: 2023-2 MESA's Accounting Manual has been amended to include the following language under the Division of Responsibilities: Operations Director reviews all incoming and outgoing invoices. Upon review and approval of an invoice, the Operations Director signs and dates the invoice, and presents it to the Executive Director for review. The Executive Director reviews all invoices and signs and dates all invoices upon approval prior to payment.
DATE: March 4th, 2024 FROM: Anna Flores, Chief Financial Officer SUBJECT: Corrective Action Plan for Compliance and Control finding 2022-001 -- Refugee cash and Medical Assistance Program – Reporting Responsible Party – Anna L. Flores, Chief Financial Officer Corrective Action Plan: Implement additi...
DATE: March 4th, 2024 FROM: Anna Flores, Chief Financial Officer SUBJECT: Corrective Action Plan for Compliance and Control finding 2022-001 -- Refugee cash and Medical Assistance Program – Reporting Responsible Party – Anna L. Flores, Chief Financial Officer Corrective Action Plan: Implement additional month-end closing procedures that will facilitate the year-end closing process. The new procedures will ensure the timeliness of each month, which will in turn ensure the year-end close will be completed promptly. Regards, Anna Flores, CFO
Contact Person: Shameikia Smith, VP of Housing Services We agree with the finding. Clear documentation of eligibility requirements for each grant should be communicated with program personnel and should be verified for each applicant. In May of 2023, we implemented an internal auditing system to en...
Contact Person: Shameikia Smith, VP of Housing Services We agree with the finding. Clear documentation of eligibility requirements for each grant should be communicated with program personnel and should be verified for each applicant. In May of 2023, we implemented an internal auditing system to ensure compliance with grant/funding requirements, ensuring eligibility and eligible costs. 50 files are reviewed each month. Any deficiencies are required to be updated within two-weeks of the receipt of the report. As of 2024, there is stability in the staffing pattern and leadership of the Emergency Rental Assistance Program. In February of 2024, the Emergency Rental Assistance team is now combined with our Housing Services department. This change will help mitigate risk and increase compliance to 100%. Completion Date: Completion Date February 29, 2024
Finding 2022-002 Internal Controls over Allowable Costs ...
Finding 2022-002 Internal Controls over Allowable Costs The auditors recommend the following: 3. Management implement procedures to ensure all expenditures are properly reviewed and approved, and supporting documentation maintained in accordance with federal regulations. Context SDA was unable to produce backup for several invoice payments and evidence of one Time & Effort Certification for allocation to specific grants. Staffing Corrective Action SDA continues to have an outside accounting firm conduct a semi-annual review of financial statements and invoice documentation in advance of the official audit process. The addition of internal staff provides audit support needed to validate that the new systems, procedures and processes implemented by SDA to correct the 2022 audit findings. Process Corrective Action In 2023, SDA introduced training for managers on the requirement of Time & Effort Certification submission for all staff and contractors who are working on grant-funded projects. The updated process requires Mangers to approve a signed Time & Effort Certification with any invoice approval. The Director of Finance and Administration will rigorously enforce the SDA policy that all invoices, receipts, and Time and Effort Certifications must be submitted to receive payment for any work completed. Systems Corrective Action In mid-2023, SDA implemented a centralized and password protected e-filing system to hold all important records for all programs and every area of the business including finance, human resources, and administration. To further ensure that all payments made by the organization have appropriate invoice backup, Bill.com, an invoice and payables tracking system, was implemented fully in 2023 with an approval chain that houses evidence of all transactions.
View Audit 302802 Questioned Costs: $1
Reporting Financial, Internal Control Weakness and Noncompliance PRDOH accepts the finding, due to a misinterpretation on the waiver given by the FAC with regard to Hurricane Fiona, the PRDOH incurred in a delay for the contracting for the 2022 single audit. At this time the Department has acceler...
Reporting Financial, Internal Control Weakness and Noncompliance PRDOH accepts the finding, due to a misinterpretation on the waiver given by the FAC with regard to Hurricane Fiona, the PRDOH incurred in a delay for the contracting for the 2022 single audit. At this time the Department has accelerated the hiring process of the auditors for 2022 and 2023. The 2022 report is in the final stages for distribution and upload to the FAC. On the other hand, the 2023 report is in the field work stage. As per conversation with the auditors we are expecting to be ready by August 2024.
Maternal and Child Health Services Block Grants to the States Earmarking Material Weakness in Internal Control over Compliance The PRDOH partially agrees with the finding. The narrative of compliance with the requirement is presented annually in the report to the federal government. They are evide...
Maternal and Child Health Services Block Grants to the States Earmarking Material Weakness in Internal Control over Compliance The PRDOH partially agrees with the finding. The narrative of compliance with the requirement is presented annually in the report to the federal government. They are evidenced by the completed forms for budget and reported expenses that are submitted for the annual request for funds. The accounts between the programs have already been separated, so it shows the fulfillment of the Earmarking 30-30-10; Each is assigned 30% or more for required service and no more than 10% for the administration thereof. In the order hand the PRDOH has encountered challenges with the payroll to separate the percentage work for each grant however, this is shown on all the monitoring made by the federal government and all the reports send by the program. Also, with the new ERP from the Department of Treasury the new system will allow for that purpose, at this time the Department of treasury is currently working with the agency with the data conversation to migrate to the new system, this system is expected to be running by October 2024.
Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files During the month of August, the Office of Human Resources and Labor Relations was audited by the ADA. It is to this that we respond to the findings...
Payroll and Personnel Files Significant Deficiency in Internal Control over Payroll and Personnel Files - Accurate and Completeness of Personnel Files During the month of August, the Office of Human Resources and Labor Relations was audited by the ADA. It is to this that we respond to the findings indicated in the audit, as follows: Over the past few years we have developed an internal control, using a document entitled Check sheet, which contains the list of documents required for the appointment of employees and another for the audit of files. It contains three columns for the collation of documents required by the Analysts of the Appointments and Changes Section and ends with the collation of the Division Supervisor, before being referred to the Personnel Officers of our regions. This document has been modified according to needs, changes, procedures and new regulations. It is important to mention that many of our audited personnel records pertain to employees appointed in years where the required requirements or documents were minimal, and no evidence was required or maintained in the personnel file. Related to the academic preparation contained in the personnel files, they are documents required by the Recruitment and Selection Section and these respond to the minimum requirements and alternatives of the class, according to the Agency's Classification Plan. Each class specification sets minimum requirements for the position the candidate will hold. On the other hand, when the previously known Administration of Health Services Facilities (AFASS) closed in 1999, its employees went to the Department of Health with the file they had, whose procedures and processes were not uniform to those of our Agency. The Regions and Hospitals have delegated the verification of documents, to work on appointments and other personnel transactions, such as job reclassifications, promotions and others. This delegation brings the process of standardizing and authorizing DSP-29 by the Recruitment and Selection Section, to ensure that it is complied with as established in the Classification Plan. The agency is in the process of updating these documents as long as a change in the employee's job classification is applied. These are transactions that allow us to update the employees’ record to the new class they will occupy. In the case of Doping Test results, we mention that these are found in the Medical Record of each employee. By HIPPA law, these are not filed in the personnel file. Of the aspects pointed out in the audit, the Department of Health has developed greater review and audit measures by the analysts of our agency, before the defunct Quality Control Section, who watched over and audited the personnel files of the Regions, providing control and compliance with the documents required according to the Regulations and Standards that govern the Office of Human Resources and Labor Relations. The Office of Human Resources presented a work plan to implement an effective and efficient personnel file review procedure to comply with and improve the agency's personnel processes and transactions.
Finding 2022-002: Journal Entry Review and Segregation of Duties Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new f...
Finding 2022-002: Journal Entry Review and Segregation of Duties Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new funding without a corresponding increase in fiscal personnel has resulted in additional responsibilities placed on the Chief Financial Officer and Chief Operating Officer. The transition to remote working has also resulted in difficulties with handling electronic documentation and approvals.” However, a primary cause was the CFO’s decision to by-pass the outlined process and not submit the journal entries for review. To address these causes, IMPACT Community Action Partnership will follow a rectifying course of action. 1. Remove CFO that was responsible for reconciliations (complete) 2. Hire an interim Controller to assess and rectify all fiscal internal controls (complete) 3. Do not grant check signing capability to the controller (complete) 4. Develop a written fiscal procedure for the review of journal entries (complete) 5. Procure a more robust fiscal software that permits more efficient electronic record review. (April 30, 2024) Anticipated Completion Date: April 30, 2024
Finding 2022-001: Fiscal Internal Controls Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new funding without a corre...
Finding 2022-001: Fiscal Internal Controls Management’s Response: Management agrees with the finding. Contact Person Responsible for Corrective Action: Anne Bacon, CEO Corrective Action Plan: The auditor finding concludes that the cause of the finding is: “Rapid growth of new funding without a corresponding increase in fiscal personnel, combined with the late issuance of the September 30, 2021, audited financial statements resulted in significant delays in reconciliations and preparing for the September 30, 2022 audit.” In order to address these causes, IMPACT Community Action Partnership will follow a rectifying course of action. 1. Remove CFO that was responsible for reconciliations (complete) 2. Hire an interim Controller to assess and rectify all fiscal internal controls (complete) 3. Hire an interim accounting specialist to assure 2023 reconciliations are completed in a timelier manner (complete) 4. Procure a more robust fiscal software that will create efficiencies around reconciliations. (April 30, 2024) 5. Complete all monthly reconciliations by the 10th of the following month (April 10, 2024) Anticipated Completion Date: April 30, 2024
Finding 392319 (2022-001)
Significant Deficiency 2022
Odc
CA
Management’s Response and Corrective Action Plan: We have expanded the ability of MIP Fund Accounting to track grants separately when needed. We have now implemented both exclusive preparation of grant financial reports along with any budget submitted at the application and/or progress budgets when ...
Management’s Response and Corrective Action Plan: We have expanded the ability of MIP Fund Accounting to track grants separately when needed. We have now implemented both exclusive preparation of grant financial reports along with any budget submitted at the application and/or progress budgets when multi-year grants. We are now using a segment exclusive for each federal grant.
At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to h...
At the onset of the pandemic, certain employees were sent to work remotely. During this period of time, the Organization experienced larger than usual turnover, including the CFO position, which remained unfilled for a significant period of time. Due to these factors, many employees were forced to handle new responsibilities for the first time in a new remote setting, as the Organization worked diligently to continue operations. Since many of the shows were being cancelled or modified from their traditional format, smaller projects related to design buildout, maintenance, and advertising were taken on. Many of these projects involved smaller retail purchases for which documentation was not properly retained. The Organization acknowledges the findings and has since hired a new CFO and instituted policies and procedures surrounding documentation of all cash disbursements and expenditures of federal awards.
FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corre...
FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT Finding: 2022-003: Significant Deficiency in Internal Controls over Compliance – Reporting Name of Contact Person: Shema Jones CFO Catholic Community Service 1803 Glacier Highway Juneau, AK 99801 Controller reviews and corrects reports received which includes backup by the Staff Accountant, then CFO reviews reports created by Controller prior to submission. Proposed Completion Date: 6/30/23
Finding 392162 (2022-003)
Material Weakness 2022
Forth
OR
Material Weakness 2022-003 Finding - Cash Management (Invoices) – Material Weakness in Internal Control over Compliance. Reporting (Federal Form 425 & FSRS) – Material Non-Compliance and Weakness in Internal Control over Compliance. Condition / Context: It was noted during the audit that there wer...
Material Weakness 2022-003 Finding - Cash Management (Invoices) – Material Weakness in Internal Control over Compliance. Reporting (Federal Form 425 & FSRS) – Material Non-Compliance and Weakness in Internal Control over Compliance. Condition / Context: It was noted during the audit that there were insufficient internal controls over invoices submitted for cost reimbursement related to federal grants as invoices were created and approved by one individual. While the internal controls were insufficient, our sample of invoices did not contain errors or undocumented amounts. It was noted during the audit that there were insufficient internal controls over required federal financial reports as federal financial reports were created and approved by the one individual. While the internal controls were insufficient, our sample of federal financial reports did not contain errors or undocumented amounts. It was also noted that there were three first-tier subawards entered into during 2022 greater than $30,000 that were not reported to the Federal Funding Accountability and Transparency Act Subaward Reporting System. Recommendation: The Organization should establish written policies and procedures regarding federal financial reporting and invoicing for cost-reimbursement related to federal grants which include proper segregation of duties. Additionally, the Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Action Taken: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Senior Finance Manager in late 2022 and an Accounting Associate in early 2023 to allow for further segregation of duties. Effective 2023, the Senior Finance Manager prepares the invoices and financial reports related to federal grants for review and approval by the Director of Finance and Operations. Additionally, there are now static financial reports and supporting documentation to substantiate each billing invoice. We will update the financial policies and procedures to reflect these enhanced internal controls over reporting and invoicing by March 2024. Policies and procedures will be revised as needed to ensure the guide is current. Responsible Official: Gina Avalos-Limardo, Director of Finance & Operations Planned Completion Date: March 31, 2024
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will establish a debt service fund in accordance with the letter of conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will obtain required insurance coverage as noted in the Letter of Conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward including providing required financial information the USDA. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Has been implemented.
Finding 392054 (2022-002)
Significant Deficiency 2022
We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure...
We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure that all relevant documents and information required for the reports are readily accessible and properly maintained, minimizing delays caused by searching for necessary materials. We will institute a schedule for regular reviews and monitoring of the reporting process. This will involve conducting periodic assessments to identify any bottlenecks or potential issues that could lead to delays, allowing for proactive intervention and resolution. By implementing these measures, we aim to mitigate the risk of late filing of the audit report, thereby enhancing compliance with regulatory requirements and ensuring timely and accurate reporting.
Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.
Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.
Corrective action planned: Educate and/or replace employee responsible for preparing RD Form 442-3 – Balance Sheet for USDA reporting. Increase internal control with Chief Executive Officer review of financial reporting. Anticipated completion date: August 3, 2023 Contact person responsible for c...
Corrective action planned: Educate and/or replace employee responsible for preparing RD Form 442-3 – Balance Sheet for USDA reporting. Increase internal control with Chief Executive Officer review of financial reporting. Anticipated completion date: August 3, 2023 Contact person responsible for corrective action: Mia Amore Talon, Chief Financial Officer
Finding 2022-003 Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027 COVID – 19 Coronavirus State and Local Fiscal Recovery Funds. Pass-Through Award Numbers: Good Shepherd, pass-through Gregg County: SKM_C55822012711390 ...
Finding 2022-003 Identification of the federal program: Federal Grantor: United States Department of the Treasury Assistance Listing No.: 21.027 COVID – 19 Coronavirus State and Local Fiscal Recovery Funds. Pass-Through Award Numbers: Good Shepherd, pass-through Gregg County: SKM_C55822012711390 Trinity Mother Frances, Pass-through Smith County: Not available Santa Rosa, Pass-through the City of San Marcos: Not available Award Period of Performance: Good Shepherd, pass-through Gregg County, September 1, 2021 – November 30, 2021 Trinity Mother Frances, Pass-through Smith County, October 1, 2021 – November 30, 2021 Santa Rosa, Pass-through the City of San Marcos, March 03, 2021 through December 31, 2026 Corrective Action Planned: Management concurs with the finding and is in the process of performing a full audit of all expenditures reported to the respective pass-through agency. Upon completion of that review, we will seek guidance from the respective pass-through agency as to the appropriate corrective action. Responsible party: Lee Sonne, Vice President of Finance and Controller, jointly with the Melissa Crenwelge-Nedbalek Accounting Director responsible for Grant Reporting Implementation Date: Full audit of reported expenditures has begun in each ministry. Ultimate resolution is dependent on timing and results of meetings with the respective pass-thru agencies, but we expect to have procedures completed by June 30, 2024 to request the meeting with the pass-thru agencies.
View Audit 300148 Questioned Costs: $1
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