Corrective Action Plans

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Anticipated Contact Finding: 2022-002 Agency: Lebanon County Commission on D&A Abuse Person/Title: James Donmoyer, Administrator of Lebanon County Commission on D&A Abuse Finding Title: Segregation of Duties over Reporting Corrective Action: The Department was in need of additional accounting...
Anticipated Contact Finding: 2022-002 Agency: Lebanon County Commission on D&A Abuse Person/Title: James Donmoyer, Administrator of Lebanon County Commission on D&A Abuse Finding Title: Segregation of Duties over Reporting Corrective Action: The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward. Completion Date: December 2023
Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...
Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance
View Audit 364627 Questioned Costs: $1
Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee's financial statement. It is the responsibility of the auditee's management to design and implement internal controls that provide reasonable assurance over the completeness and accuracy of th...
Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee's financial statement. It is the responsibility of the auditee's management to design and implement internal controls that provide reasonable assurance over the completeness and accuracy of the SEFA. The SEFA is the basis for the auditor's identification of major programs. Condition: The City's initial SEFA provided for the audit was incomplete and contained inaccurate program expenditure amounts. In particular, there were multiple federal programs that were not identified, or had inaccurate amounts reported, on the initial SEFA for the year under audit: ALN 16.554 National Criminal History Improvement Program (NCHIP) ALN 20.600 State and Community Highway Safety ALN 66.458 Capitalization Grants for Clean Water State Revolving Funds ALN 93.568 Low-Income Home Energy Assistance ALN 97.044 Assistance to Firefighters Grant ALN 97.067 Homeland Security Grant Program Cause: The City does not have a method to accurately track the related expenditures for reporting. Effect or Potential Effect: A Uniform Guidance compliance audit is based on the premise that management must comply with federal statutes, regulations and the terms and conditions of the federal awards it received. Without identifying the funds as federal, the auditee may not have complied with those requirements. In addition, there is increased risk regarding the accurate reporting of grant expenditures and noncompliance with policies and procedures surrounding the recording of federal awards. Questioned Costs: None Context: The City was aware of the requirement to prepare a SEFA prior to the audit; however, they were not able to accumulate the appropriate records to correctly identify the source of funding for all ongoing projects. In addition, management was unable to accurately determine the amounts to be reported on the SEFA in accordance with 2 CFR §200.502. The adjustments to the SEFA amounted to an increase in Total Federal Expenditures reported of $892,160. Repeat Finding: This is a repeat finding; it was previously finding 2021-006 and 2021-007. Recommendation: We recommend the City develop and implement procedures to ensure that information related to all federal awards is accumulated to assist in the preparation of the SEFA. In addition, we recommend management of the City verify the completeness and accuracy of the amounts reported on the SEFA. Response: The City agrees with the finding, and will develop a method for accurately tracking federal expenditures. Anticipated Completed Date: June 30, 2025 Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance City of Cortland, 25 Court Street, Cortland, NY 13045 (607) 758-8373
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
View Audit 361721 Questioned Costs: $1
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Finding Reference Number: MW2022-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behi...
Finding Reference Number: MW2022-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting audits for fiscal years (FY) 2022 and 2023. Management has made clearing this backlog its highest priority. The schedule is to complete and file the FY 2022 audit package in mid-2025, the FY 2023 package by fall 2025, and the FY 2024 package by the end of calendar-year 2025, at which point CUAHSI expects to return to on-time Federal Audit Clearinghouse filings. Recent upgrades to the accounting system, the hiring of in-house finance staff, and revised closing procedures are designed to streamline and accelerate future audit preparation so that all subsequent audits are filed by the required deadlines. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: 2025-12-31
Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program incom...
Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
2022-002 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Fi...
2022-002 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Finance Department will maintain detailed records of all payments made, deposits received, and the reimbursement and transfer processes. This approach ensures that all reports are completed in a timely manner. To strengthen internal control over accounts, disbursements, and fund entries, the LRA’s Finance Department will hire additional personnel. These new team members are responsible for updating and managing accounting records. Together, they have established a strict timeline for completing important tasks to ensure a clear and concise flow of funds. The workloads will be divided among the team, with specific responsibilities assigned for Accounts Receivable, Accounts Payable, Bank Reconciliation, and Bookkeeping. Some responsibilities are interlinked, allowing team members to support one another in the event of absence or the need for assistance and providing documents to the external audits for the Single Audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025
The Organization became behind on audits and is in the process of cathing up. The Chief Executive Officer will implement a procedures that makes sure that the federal clearinghouse form will be uploaded on a timely basis. This will be implemented with the June 30, 2024 audit.
The Organization became behind on audits and is in the process of cathing up. The Chief Executive Officer will implement a procedures that makes sure that the federal clearinghouse form will be uploaded on a timely basis. This will be implemented with the June 30, 2024 audit.
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced m...
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced monitoring tools and documentation standards will be completed by June 30, 2025
Finding 2022-103 - Allocation of Forest Reserve Funds (Repeat Finding) (Material Weakness, Compliance Finding) CFDA Number: 10.665 Cluster Title: Forest Service Schools and Roads Cluster Program Title: Schools and Roads – Grants to States Federal Agency: U.S. Department of Agriculture Award Year: 20...
Finding 2022-103 - Allocation of Forest Reserve Funds (Repeat Finding) (Material Weakness, Compliance Finding) CFDA Number: 10.665 Cluster Title: Forest Service Schools and Roads Cluster Program Title: Schools and Roads – Grants to States Federal Agency: U.S. Department of Agriculture Award Year: 2021 Award Number: None Compliance Requirement: Special Tests and Provisions Question Costs: None Condition and context: Forest reserve monies for Apache County were not properly disbursed for the benefit of public schools and public roads in accordance with A.R.S. 11-497. The County instead disbursed the entire annual allocation of $644,597 to public school districts. This finding is similar to prior year finding 2021-103. Recommendation: We recommend that the County stop violating state statute and distribute forest reserve monies in a manner that benefits both public schools and public roads as required by A.R.S. 11-497. Contact Name: Ryan Patterson, County Manager Corrective Action Planned: Prior to the close of fiscal year 2025, the County Manager will review the needs the County’s roads and schools and make a recommendation to the board on an appropriate allocation of the forest reserve funds. Anticipated Completion Date: The County intends for these items to be completely corrected in its fiscal year 2025 Single Audit Report submission.
Finding 2022-102 - Reporting (Material Weakness, Compliance Finding) Assistance Listing Number: 21.027 Cluster Title: N/A Program Titles: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: U.S. Department of theTreasury Award Year: 2021 Award Number: None Compliance Requirement: Report...
Finding 2022-102 - Reporting (Material Weakness, Compliance Finding) Assistance Listing Number: 21.027 Cluster Title: N/A Program Titles: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: U.S. Department of theTreasury Award Year: 2021 Award Number: None Compliance Requirement: Reporting Question Costs: None Condition and context: The cumulative expenditure amount reported on the annual report did not agree to the underlying accounting records for the grant. The County reported that $12,363,513 was spent as of yearend. However, the accounting records showed expenditures totaling $4,597,076. Recommendation: The County should establish policies and procedures to ensure that the amounts reported are accurate and agree to the underlying accounting records. Contact Name: Ryan Patterson, County Manager Corrective Action Planned: The identified finding was caused by miscommunication between County personnel concerning revenue replacement funds. To circumvent this situation from happening in the future, the County has developed and implemented policies and procedures which require the reconciliation or reported amounts on the federal reports to the underlying trial balances. Finally, the County did fully expend all allowable revenue replacement funds in fiscal year 2023.Anticipated Completion Date: The County intends for these items to be completely corrected in its fiscal year 2023 Single Audit Report submission.
Finding 2022-101 – Single Audit Reporting Package Not Files Timely (Repeat Finding) (Material Weakness, Compliance Finding) Assistance Listing Number: 21.027 Cluster Title: N/A Program Titles: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: U.S. Department of the Treasury Award Year...
Finding 2022-101 – Single Audit Reporting Package Not Files Timely (Repeat Finding) (Material Weakness, Compliance Finding) Assistance Listing Number: 21.027 Cluster Title: N/A Program Titles: Coronavirus State and Local Fiscal Recovery Fund Federal Agency: U.S. Department of the Treasury Award Year: 2021 Award Number: None Compliance Requirement: Reporting Question Costs: None Condition and context: The County’s single audit reporting package for the fiscal year ended June 30, 2022, was not submitted to the Federal Audit Clearinghouse within nine months after the County’s yearend. This finding is similar to prior year finding 2021- 101. Recommendation: We recommend that the County evaluate its resources necessary to complete the year-end closing and financial reporting process and consider the need to devote additional resources to the financial reporting process. Doing so will improve the timeliness of the County’s submittal to the Federal Audit Clearinghouse. Contact Name: Ryan Patterson, County Manager Corrective Action Planned: Additional policies and procedures will be implemented to facilitate and improve the financial reporting process. Anticipated Completion Date: March 31, 2026. The County intends to submit its fiscal year 2025 Single Audit Report by the statutory deadline of March 31,2026.
United of Marion County, Inc. experienced staff turnover during the ERA 1 & ERA2 which may have contributed to data not being regularly reconciled to the third-party grant tracking system. The United Way of Marion County, Inc has hired a full-time accounting professional to improve internal controls...
United of Marion County, Inc. experienced staff turnover during the ERA 1 & ERA2 which may have contributed to data not being regularly reconciled to the third-party grant tracking system. The United Way of Marion County, Inc has hired a full-time accounting professional to improve internal controls. Management as the time utilized the resources available to ensure residents received timely housing assistance.
Neighborhood Medical Center does have a formal process in place to ensure that the amount requested for payroll complies with the annual salary limitations required by HRSA. We were in the middle of moving from Quick Books to Work Force Go payroll system during this time. It appears that the perce...
Neighborhood Medical Center does have a formal process in place to ensure that the amount requested for payroll complies with the annual salary limitations required by HRSA. We were in the middle of moving from Quick Books to Work Force Go payroll system during this time. It appears that the percentage used to help us ensure this does not occur was omitted. It has been reviewd, and the information is in place to ensure the error will not occur again.
View Audit 358122 Questioned Costs: $1
Taylor Regional Hospital, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2022. The finding from the March 31, 2022 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule...
Taylor Regional Hospital, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2022. The finding from the March 31, 2022 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAM AUDIT FINDING Material Weakness (2022-001) Recommendation: We recommend the Hospital design and implement controls, including levels of review, to ensure accuracy and completion of the Hospital's Schedule. Planned Corrective Action: The 2022 Schedule was restated to reflect the two federal grants that were originally omitted. The Hospital will design and implement controls over financial reporting to ensure all grants are properly included on the Schedule in accordance with reporting requirements. Jonathon L. Green Chief Executive Officer
Finding No. 2022-008: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time to the related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and mai...
Finding No. 2022-008: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time to the related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and maintained in the shared file for immediate availability and reference.
View Audit 357068 Questioned Costs: $1
Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...
Finding No. 2022-007: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% Federal poverty level (FPL) with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the FPL. Patients whose incomes are above 100% or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of nondiscrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.
View Audit 357068 Questioned Costs: $1
Finding No. 2022-006: Inadequate System to Ensure Timely Filing and Review of Required Reports As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas the timely filing and review of required reports (e.g., Federal F...
Finding No. 2022-006: Inadequate System to Ensure Timely Filing and Review of Required Reports As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas the timely filing and review of required reports (e.g., Federal Financial Report (FFRs)) are now expected to be filed according to the prescribed deadline(s).
Finding 2022-005: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically des...
Finding 2022-005: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically designated to cover payroll costs, this process now includes the following: • A drawdown allocation schedule for the employee’s making up the amount requested • A budget breakdown by department for the amounts making up the drawdown request • A supporting schedule and related invoices for amounts to be reimbursed (e.g., malpractice insurance, etc.) • A completed Standard Form (SF) 270 that tracks the applicable grant amounts previously drawdown that also specifies the amount to be currently drawn.
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: The Council will develop FFATA reporting policies and procedures to submit subaward information through FSRS to ensure compliance with FFATA requirements. Proposed Completion Date: June 30, 2025
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: The Council will develop FFATA reporting policies and procedures to submit subaward information through FSRS to ensure compliance with FFATA requirements. Proposed Completion Date: June 30, 2025
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments have been filled to ensure that the Council follows internal control policies over grant reporting. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution...
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Due to miscommunication and turnover of accounting personnel, a misunderstanding arose regarding the collateralization of the Council’s general checking account to which federal awards are deposited. The financial institution utilizes a repurchase agreement by which the daily remaining collected balance in the checking account is invested by the bank, acting as agent of the Council. Securities purchased are exclusively obligations of the U.S. government and/or its agencies, or municipal bonds rated A or better. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over payroll transactions. Proposed Completion Date: Complete as of June 30, 2024
Name of Contact: Brian Henry, Executive Director Corrective Action Plan: Vacant positions within the accounting and program departments will be filled to ensure that the Council follows internal control policies over payroll transactions. Proposed Completion Date: Complete as of June 30, 2024
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