Corrective Action Plans

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Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financ...
Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its reporting policy and implemented the changes. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within th...
Lack of Documentation Related to Reporting Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implement
Missing Documentation to Support Payroll Authorizations Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample sele...
Missing Documentation to Support Payroll Authorizations Condition: The Organization could not provide one salary authorization form for sample selection of 40 employees under ALN #93.224 and 93.527 Health Care Center. The Organization could not provide one salary authorization form for sample selection of eight employees under ALN #93.498 COVID-19 Provider Relief Fund. Corrective Action Planned: The Organization continues to engage the consulting services of a professional certified accounting firm. The Organization has hired a new Chief Financial Officer, as of March 2022, as well as additional supporting staff within the finance department. The Organization will implement additional review procedures related to the salary authorization forms to verify accuracy of the information and review our procedures related to retention of documentation. The Organization will consider implementing additional procedures associated with employees agreeing to the salary as well as specifically identifying the revenue sources (e.g. specific grants, local funds, etc.) when applicable. The Organization implemented this corrective action during fiscal year 2023. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a n...
Use of Budgeted Versus Actual Costs for Reimbursements Condition: The Organization made drawdowns after month-end based on budgeted period expenses rather than actual salary expenses to support the amounts being requested for reimbursement. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization has reviewed and updated its grant drawdown procedures to included only actual cost and for the request to be reviewed and approved by someone other than the preparer prior to submission. The corrective action for this finding has been approved and implemented by the Organization. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identi...
Lack of Internal Controls Over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Organization’s policies for the sliding fee scale were recently updated during fiscal year 2022, by management, based on findings during the monitoring by HRSA performed in 2022, but management will consider discussing potential improvements to their policy with the grantor to potentially update it to allow for certain exceptions. The Organization will also consider discussing the agreement with the local school district in more detail with the grantor to either structure their policies to allow for these visits to have different requirements or to see if the grantor would be willing to provide a waiver with regards to theses visits not being technically in compliance with other regular clinic visits. The planned corrective action for this finding is currently in the process of development, approval, and implementation. The Organization expects to have the corrective action implemented by July 1, 2024. The Organization will continue to engage the consulting services of the professional certified accounting firm to assist in this process through completion. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: July 1, 2024
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.
View Audit 304032 Questioned Costs: $1
The Roosevelt Fire District was late in filing their Single Audit for the Fiscal Year Ending 12/31/21 due to limitations caused from COVID. We are a small office with part-­time staff and fully volunteer fire & ambulance service.
The Roosevelt Fire District was late in filing their Single Audit for the Fiscal Year Ending 12/31/21 due to limitations caused from COVID. We are a small office with part-­time staff and fully volunteer fire & ambulance service.
National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 and Research and Development Cluster – Assistance Listing No. 15.608 and 15.945 Recommendation: We recommend management incorporate review control procedures to ensure the 10 percent de minimis r...
National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 and Research and Development Cluster – Assistance Listing No. 15.608 and 15.945 Recommendation: We recommend management incorporate review control procedures to ensure the 10 percent de minimis rate is properly applied in accordance with UG and ensure appropriate costs are charged to the awards consistent with their federally approved budgets. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Upon conducting the FY21 audit TAS was informed that the inclusion of the Biological Expertise line item on federal budgets (approx. 7.5% additional uplift) was not allowable as it was currently being calculated. TAS is allowed a 10% de minimus rate on noted FY21 Federal awards some of which also included a Biological Expertise line item that is budgeted as an hourly rate. TAS had been calculating uplift amounts owed by simply adding the Biological Expertise (7.5%) to the de minimus rate (10%) for a total uplift of 17.5%. This was done at the direction and approval of our federal partners. However, due to Biological Expertise being entered in the federal and approved budgets as an hourly line item and not a percentage TAS was considered out of compliance by using this method of calculation. Moving forward TAS will be billing the de minimus rate (10%) as a percentage and will calculate the Biological Expertise line item as an hourly rate. Name(s) of the contact person(s) responsible for corrective action: Kim Lopez, Director of Finance & Operations Planned completion date for corrective action plan: effective immediately / in progress
Finding 2021-003 Cash Management Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We ag...
Finding 2021-003 Cash Management Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We agree with the auditor's comments and actions stated in the recommendation. CMSDC will update its policies and procedures to include procedures for reconciling expenditures to cash drawdowns monthly. Contact Person: Jose Robles Michelena, Executive Vice President Anticipated Completion Date: In efforts to improve and prevent the above finding CMSDC engaged a new accounting firm as of September of 2021 and they also brought in new leadership in April of 2022.
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type...
2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type of Finding: • Material Weakness in Internal Control over Compliance • Other Matters (Modified Opinion) Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: CLA was unable to verify if the Family Practice is in compliance with period of performance. Questioned costs: Unknown Context: During our review expenditures for period of performance we noted expenditures were not supported by adequate records and documentation to facilitate testing. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to identify expenses and the date incurred are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is ...
2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure documentation and records are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls.. Furthermore, a controller has been hired to prepare the reports and oversee cash management activities. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: March 11, 2024
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024
We contacted our auditors upon receipt of the notice of rejection. The audit engagement was then revised to include the additional components needed under the Uniform Guidance for nonfederal entities, and the audit results will be reported as required to the Federal Audit Clearinghouse. No further a...
We contacted our auditors upon receipt of the notice of rejection. The audit engagement was then revised to include the additional components needed under the Uniform Guidance for nonfederal entities, and the audit results will be reported as required to the Federal Audit Clearinghouse. No further action should be needed.
The Clinic has taken this recommendation into consideration and has created a policy and procedure for completing and submitting the Clinic's annual audit report to the Federal Audit Clearinghouse. Resolving finding 2021-003 is expected for the 2023 audit.
The Clinic has taken this recommendation into consideration and has created a policy and procedure for completing and submitting the Clinic's annual audit report to the Federal Audit Clearinghouse. Resolving finding 2021-003 is expected for the 2023 audit.
We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure t...
We agree with the auditors' comments, and the following action will be taken to improve the situation. We have adjusted the Organization’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the Organization’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.
View Audit 302371 Questioned Costs: $1
Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts ...
Condition and Context: The System did not complete the PRF Period 1 reporting in accordance with the U.S. Department of Health and Human Services guidance. The System did not enter the correct amounts from its data supporting lost revenues for all quarters; it also did not enter the correct amounts from its data supporting eligible expenditures. The adjustments needed within the PRF reports to correct the errors decreased year over year lost revenues from $21,664,944 to $11,771,346 and decreased eligible expenditures from $7,527,194 to $4,334,813, on total distributions of PRF funding of $14,972,846. In summary, the data supporting amounts for lost revenues and eligible expenses totals $16,104,159 on total distributions of PRF funding of $14,972,846 in this reporting period. Corrective Action Plan: System management agrees with the finding and has updated its lost revenue calculation. Management attempted to update lost revenue amounts with filing of its Period 4 reports; however, additional data entry errors were made. Management has worked extensively over the past two years to monitor the changing guidelines surrounding the various programs designed to respond to the COVID-19 pandemic. Management has furthered this effort by attending continuing professional education on this topic and reading available guidance to ensure that the final recordkeeping maintained by the System follows the guidance as established by HRSA.
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were revi...
2021-001 – Internal Controls over Allowable Costs Individual Responsible for Corrective Action Plan: J. Neal Bolton, Director of Revenue Management & Budget Shemaine Rose, Controller Anticipated Completion Date: Completed Management notes that all expenses charged to the federal program were reviewed by the Vice President of Human Resources and the Finance Team, with guidance obtained from independent consultants, however, the documentation of the review was not retained. Management also notes that all expenses were deemed to be appropriately charged to the federal program. In order to ensure documentation is retained evidencing approval of costs, the Authority will require physical sign off on all invoices or electronic approval of all costs charged to the federal program.
Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost reve...
Finding Number: 2021-005 Condition: - The System received targeted distributions for Bucyrus Community Hospital. A period one portal submission was completed, but no allowable expenses or lost revenues were reported within the Bucyrus Community Hospital report. All allowable expenses and lost revenues were reported on the first period portal submission for Galion Community Hospital, another hospital of the Avita Health System. Planned Corrective Action: The portal submission could not be modified by the time we identified the reporting issue. As such, no corrective report was completed, however management will implement procedures to ensure reporting requirements are adequately reviewed for all federal funding. Contact person responsible for corrective action: Eric Draime, Vice President/CFO Anticipated Completion Date: June 30, 2024
Condition: HealthSource did not have controls in place to ensure the inputs in their Covid related expense spreadsheet that was used to input the amount of 'Other PRF Expenses' reported in the portal submissions agreed to source documentation. Planned Corrective Action: All future submissions will b...
Condition: HealthSource did not have controls in place to ensure the inputs in their Covid related expense spreadsheet that was used to input the amount of 'Other PRF Expenses' reported in the portal submissions agreed to source documentation. Planned Corrective Action: All future submissions will be reviewed with the CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thorough...
Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place ov...
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid revenue and expenses will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
Finding 384265 (2021-006)
Significant Deficiency 2021
Finding Reference Number: SA 2021-006 Timely Reporting and Return of Unspent Grant Advance AL Number: 21.019 Assistance Listing Title: COVID-19 – Coronavirus Relief Fund Federal Agency: Department of Treasury Pass Through Entity: Yolo County, California Department of Finance Federal Award Ide...
Finding Reference Number: SA 2021-006 Timely Reporting and Return of Unspent Grant Advance AL Number: 21.019 Assistance Listing Title: COVID-19 – Coronavirus Relief Fund Federal Agency: Department of Treasury Pass Through Entity: Yolo County, California Department of Finance Federal Award Identification Number: Unavailable (Yolo County) and 607 (California Department of Finance) • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Kelly Stachowicz, Assistant City Manager • Corrective Action Plan: City notified Yolo County of unspent funds in January 2021. City returned unspent funds to Yolo County in January ($222) and March ($27,617) of 2021, with reporting submitted to County in March of 2021. For future short-notice and unexpected grants provided to the City, the City will designate a lead staff person with bandwidth to manage said grant and clarify timelines with the granting agency. • Anticipated Completion Date: Completed in March 2021.
Finding 375511 (2021-002)
Significant Deficiency 2021
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been impl...
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been implemented in which the bank and credit card statements are reconciled to C@P’s General Ledger. These procedures were evaluated to effectiveness as part of the 2022 Single Audit. Andrew Squires, Finance Director, is responsible for the implementation of these procedures. The procedures were implemented in February of 2022 and have been followed since then. If the Department of the Treasury has questions regarding this plan, please contact Andrew at Andy.Squires@church-at-the-park.org.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536 Questioned Costs: $1
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