Corrective Action Plans

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Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Wea...
Department of Health and Human Services Federal Financial Assistance Listing #93.697 COVID-19 Testing and Mitigation for Rural Health Clinics Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Period of Performance Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The Health System’s expense tracking spreadsheet, which identified the expenses claimed under the federal program as allowable costs included three expenses which were subsequent to December 31, 2022, and therefore, outside the period of performance. Although invoices were approved for payment, only one invoice included documentation relating to specific approval as allowable costs related to the grant. Likewise, the Health System’s expense tracking spreadsheet did not include a documented secondary review and approval by someone other than the preparer. Responsible Individuals: Diana Swindler, CFO Corrective Action Plan: Tri Valley Health System will implement a control process which includes an independent review and approval of the expense tracking spreadsheet which identifies the expenses claimed under the federal program as allowable costs and retain documentation of the review process. The expenses referenced as being outside of the period of performance were costs to a vendor whom was contracted/engaged prior to the period of performance. Due to supply chain/vendor demand issues, the work was completed subsequent to the period of performance. It was our understanding that these are eligible expenses under the program, as the work and payment was delayed due to supply chain/vendor demand issues. However, if necessary, we have identified other qualifying expenditures incurred within the period of performance we can submit which will satisfy allowable costs claimed for the period of performance. Anticipated Completion Date: 01/31/2024
View Audit 10349 Questioned Costs: $1
Finding 2023-005 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We experienced a system glitch resulting in records that remained in validation tables and did not move to the process reporting tables which prevented proper reporting of work hours pe...
Finding 2023-005 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We experienced a system glitch resulting in records that remained in validation tables and did not move to the process reporting tables which prevented proper reporting of work hours performed. The system did not generate the required certification reports to allow the selected employee to certify their effort. We are reviewing our processes to implement an automated comparison reports of individual employees paid from federal grants and the system generated effort certification report to ensure that the system generates the required effort report to allow the employee to properly certify their effort. We will also ensure that all employees approve/certify actual time worked allotted to federal funds within our time and attendance system to provide another level of certification. This report will be produced quarterly to ensure that system errors are corrected before the required semiannual effort reporting requirement. Anticipated Completion Date: March 1, 2024
View Audit 10337 Questioned Costs: $1
Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the age...
Finding 2023-001 Name of Responsible Individual: Tonya Kilpatrick, AVP Finance and Compliance Corrective Action: We agree. The expenditures were reported on the schedule of expenditures for federal awards subsequent to the period of performance end date. These funds were not charged to the agency and are considered cost share for the grant as the work on the grant continued past the grant end date. We will review our grant close-out procedures to ensure that grants are closed out in a timely manner based on the grant end date preventing subsequent charges to the grant award. Anticipated Completion Date: March 1, 2024
View Audit 10337 Questioned Costs: $1
Finding 7849 (2023-001)
Significant Deficiency 2023
The Blood Bank added review and approval processes to ensure only allowable charged are included in the MTDC subject to the indirect cost rate.
The Blood Bank added review and approval processes to ensure only allowable charged are included in the MTDC subject to the indirect cost rate.
View Audit 10207 Questioned Costs: $1
Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made...
Executive Director of Finance: Management agrees with this finding. The school district converted to a new financial ERP system as of July 1, 2023. The new ERP system flags any duplicate invoice numbers that maybe entered. The Accounts Payable (A/P) staff will verify if payment has already been made. On occasion, payment requests do not have an invoice number. To prevent duplicate payments, the Accounts Payable staff require original invoices and uses a system generated invoice number, or a will use a manual entry numbering convention to prevent duplicate invoice numbers. The invoice data is entered by an Accounts Payable specialist and reviewed by the Accounts Payable Manager. On occasion, A/P must request corrected invoices from vendors who try and reuse invoice numbers. The A/P Manager reviews invoice numbers during the check run for accuracy. Purchasing and A/P will also periodically review the vendor database for duplicate vendors. For construction projects that list a pay application number instead of an invoice number, A/P will implement a consistent invoice numbering convention to avoid duplicate payments. The A/P specialists will also review the PO payment history prior to processing. Responsible party(ies) for corrective action(s): Accounts Payable Manager Corrective action(s) timeline: December 1, 2023
View Audit 10190 Questioned Costs: $1
Management’s Response – Corrective Action Plan: When using federal funds to compensate employees, Child & Family Resources (CFR) acknowledges that the internal controls need to reasonably assure that the charges are accurate, allowable and properly allocated. The records should support the distribut...
Management’s Response – Corrective Action Plan: When using federal funds to compensate employees, Child & Family Resources (CFR) acknowledges that the internal controls need to reasonably assure that the charges are accurate, allowable and properly allocated. The records should support the distribution of the employee’s salary or wages among the specific activities charged. CFR uses a third party payroll company (Paycom) for payroll and time and attendance reporting. The payroll allocations are tracked based on percentages approved by the funding source or by employee entries on their timesheet reflecting the grant they are working on. For direct service employees that are allocated to various federal grants, CFR will include the following information on the budget narrative that will outline the specific employee, their time allocation and need. The Federal Program will be able to review and approve the amount of time these employees will spend under their specific grant rendering the allocation as an allowable expense. The language to be included within the budget narrative outlining this allocation is as follows: Labor Costs (Special Considerations): Compensation to members of the non-profit institution, trustees, directors, associates, officers and immediate family thereof: (Name of employee with breakdown of time to be spent on contract) Explanation of why this cost is necessary for the (Program’s) Operations: What is the total cost to the agency? Is the cost a less-than-arms-length transaction? Contact Person: The Grants & Contracts Coordinator (Scott Fauland) will complete the budget narratives for the federal funding agencies and include the above language within them in order to receive approval from the contracting agency. Completion Date CFR will submit the Special Considerations request to the current federal contracts awarded for Fiscal Year 2024 by December 2023 for approval. On new federal contracts, this language will be included on the budget narratives submitted from the original submission. This will be implemented for new contracts starting December 1, 2023.
View Audit 10163 Questioned Costs: $1
Condition: The District submitted claims for meal reimbursements that were higher than the meals actually served. Plan: Management will review and implement procedures to ensure the reports used for daily counts match the reports used for submitting the claim to ISBE. Anticipated Date of Completion:...
Condition: The District submitted claims for meal reimbursements that were higher than the meals actually served. Plan: Management will review and implement procedures to ensure the reports used for daily counts match the reports used for submitting the claim to ISBE. Anticipated Date of Completion: 6/30/2024 Name of Contact Person: Annie Mulvaney, Assistant Superintendent Management Response: N/A
View Audit 10160 Questioned Costs: $1
The HUD Form 9839 has been prepared and sent for signature of the Project Owner. Once it is received back it will be signed by the Management Agent and forwarded to our HUD Asset Manager.
The HUD Form 9839 has been prepared and sent for signature of the Project Owner. Once it is received back it will be signed by the Management Agent and forwarded to our HUD Asset Manager.
View Audit 10143 Questioned Costs: $1
Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jorge Cano, Director of Food Service Anticipated Completion Date: January 1, 2024 Planned Corrective Action: The District plans to en...
Finding Number: 2023‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jorge Cano, Director of Food Service Anticipated Completion Date: January 1, 2024 Planned Corrective Action: The District plans to ensure that all program costs are allowable and in adherence  to  applicable  federal  requirements.  This  includes  submitting  Capital  Expenditure  Pre‐Approval Request Forms to ADE for approval prior to purchasing equipment items that are not listed on ADE’s approved equipment list.
View Audit 9955 Questioned Costs: $1
Corrective Action Plan Transition the St. Dominic payroll to be processed centrally at the System in accordance with all System's processes and procedures. Anticipated Completion Date January 1, 2022 Name of Contact Person for Corrective Action Amanda Hymel, Corporate Controller
Corrective Action Plan Transition the St. Dominic payroll to be processed centrally at the System in accordance with all System's processes and procedures. Anticipated Completion Date January 1, 2022 Name of Contact Person for Corrective Action Amanda Hymel, Corporate Controller
View Audit 9933 Questioned Costs: $1
U.S Department of Education 2023-002 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District puts in place the proper procedures for sufficiently documenting all procurements and methodology used. Explanation of disagreement with audit finding...
U.S Department of Education 2023-002 Special Education Cluster – Assistance Listing No. 84.027 and 84.173 Recommendation: CLA recommends the District puts in place the proper procedures for sufficiently documenting all procurements and methodology used. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work to revise its procedures as necessary to ensure that all procurements which are charged to federal programs are fully documented, including support for noncompetitive proposals. Name(s) of the contact person(s) responsible for corrective action: Marie Schrul, Executive Director of Finance Planned completion date for corrective action plan: January 31, 2024
View Audit 9887 Questioned Costs: $1
Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Noncompliance Finding/Significant Deficiency; Activities Allowed or Unallowed Compliance Requirement Corrective Action Plan: The Medical Center will impleme...
Identification: 93.498 United States Department of Health and Human Services, Provider Relief Fund and American Rescue Plan Rural Distribution; Noncompliance Finding/Significant Deficiency; Activities Allowed or Unallowed Compliance Requirement Corrective Action Plan: The Medical Center will implement procedures to ensure that future reporting of federal expenditures are reduced by an amount that other sources have reimbursed or are obligated to reimburse using actual Medicare cost report percentages to compute the amount that has been previously reimbursed by Medicare. Anticipated Completion Date: The Medical Center intends to implement this immediately which will apply to any future reporting periods.
View Audit 9771 Questioned Costs: $1
Management agrees with the finding. The funds will be reimbursed in the amount of $61,646.
Management agrees with the finding. The funds will be reimbursed in the amount of $61,646.
View Audit 9649 Questioned Costs: $1
Finding Synopsis: District submitted to the state for reimbursement costs that were not applicable to specific grants in the District's expenditure reports. Action Steps: Management will develop and implement procedures to ensure that reimbursement requests and supporting documentation are reviewed ...
Finding Synopsis: District submitted to the state for reimbursement costs that were not applicable to specific grants in the District's expenditure reports. Action Steps: Management will develop and implement procedures to ensure that reimbursement requests and supporting documentation are reviewed by a second person. Contact Person: Jeff O’Connell Assistant Superintendent of Business Services 630-529-4500 Anticipated Completion Date: 06/30/2024
View Audit 9587 Questioned Costs: $1
Recommendation: There were inadequate controls over payments for goods and services. Payments were made in advance of the services being performed and were based on estimates. The School Board should adhere to their policies and procedures to ensure that all payments are made after services are per...
Recommendation: There were inadequate controls over payments for goods and services. Payments were made in advance of the services being performed and were based on estimates. The School Board should adhere to their policies and procedures to ensure that all payments are made after services are performed and based on actual costs. Corrective Action Plan: LPSS followed guidance provided by the Louisiana Department of Education (LDOE) on a conference call that occurred on February 17, 2023, to issue final payments based on enrollment counts of children in April 2023 for the months of April, May and June 2023. This recommendation was provided to encourage LPSS to quickly request funds from their department. During the financial audit, the external auditors cited LPSS for not having documentation to substantiate certain payments that were based on LDOE’s guidance. Since then, additional training has already occurred on how to interact with unfounded guidance and how to review and interpret certain documents for payment processing. Regardless of LDOE recommendations in relation to this program, payments will not be made in advance of services rendered, and payments will not be based on estimates. Staff will strictly adhere to contractual guidelines and stipulations, purchasing policies and procedures.
View Audit 9532 Questioned Costs: $1
Finding No. 2023-004: Financial Aid Administration – Control Deficiency Federal Agency: U.S. Department of Education AL Number and Title: 84.063P – Federal Pell Grant Program 84.268 – Federal Direct Student Loans Questioned Costs: $25 Responsible Individual: Calvin Black, Financial Aid Manager, Hawa...
Finding No. 2023-004: Financial Aid Administration – Control Deficiency Federal Agency: U.S. Department of Education AL Number and Title: 84.063P – Federal Pell Grant Program 84.268 – Federal Direct Student Loans Questioned Costs: $25 Responsible Individual: Calvin Black, Financial Aid Manager, Hawaiʿi Community College Date Action Taken: On-going Return of Title IV Funds R2T4 was calculated incorrectly due to inadequate staffing and lack of personnel training. R2T4 has been recalculated for the identified student, and Hawaiʿi CC is working to hire vacant positions and resolve ongoing staffing issues. The UH Community College Central Financial Aid Office is also working to develop/finalize written R2T4 procedures. Enrollment Reporting Exit materials were sent late due to inadequate staffing and ongoing staff absences. Hawaiʿi CC is working to hire vacant positions and resolve ongoing staffing issues.
View Audit 9418 Questioned Costs: $1
Finding 7095 (2023-001)
Significant Deficiency 2023
Audit Finding #: 2023-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Home Energy Assistance (LIHEAP) Federal Assistance Listing (CFDA#): 93.568 Description: During the audited year July 2022 – June 2023, Access paid benefits for an indi...
Audit Finding #: 2023-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Home Energy Assistance (LIHEAP) Federal Assistance Listing (CFDA#): 93.568 Description: During the audited year July 2022 – June 2023, Access paid benefits for an individual whose income was over the threshold of 60% of the CT state median income. The income was documented but ultimately incorrectly calculated. Four other individual household’s basic benefit levels were incorrectly classified as non-vulnerable instead of vulnerable and should have received $50 more in their basic benefit. Statement of Concurrence: Access management concurs with the audit finding: Corrective Action: Access has put in place written procedures as follows: ○ Access will review and revise its training orientation for the next fiscal year. and will provide additional training support and resources to staff to ensure that all LIHEAP applications are certified in an accurate manner. ○ Access will review and improve its file audit process to create a master log of all files reviewed and also note any major findings so a timely response can be made. ○ Access will communicate to the LIHEAP approved software company and CT Department of Social Services suggestions about how to build in better controls regarding categorically eligible households.
View Audit 9137 Questioned Costs: $1
We have a limited number of competent contractors working in our area but will attempt to obtain more price quotes. In cases where we do not receive an adequate number of price quotes, we will document our reason for awarding the contract and document the cost analysis to determine reasonableness o...
We have a limited number of competent contractors working in our area but will attempt to obtain more price quotes. In cases where we do not receive an adequate number of price quotes, we will document our reason for awarding the contract and document the cost analysis to determine reasonableness of the costs.
View Audit 8933 Questioned Costs: $1
Landesa will revise its internal controls on subrecipient financial and programmatic monitoring by clarifying required documentation and recordkeeping procedures for all subrecipients on federal awards and the supervisory review process on compliance with subrecipient reporting requirements in the S...
Landesa will revise its internal controls on subrecipient financial and programmatic monitoring by clarifying required documentation and recordkeeping procedures for all subrecipients on federal awards and the supervisory review process on compliance with subrecipient reporting requirements in the Subrecipient Monitoring Policy and the Engaging Third Parties guidance. Landesa will also clarify the procedures and appropriate timelines for resolving instances of significant non-compliance with the terms and conditions of a subaward by a subrecipient on federal awards. In the event a subrecipient does not comply with programmatic and financial reporting requirements, Landesa will seek resolution in a timely manner to either correct instances of non-compliance of subrecipient or terminate subaward if there is a failure to correct on part of the subrecipient. Landesa will provide training on revisions to the policy to all relevant staff by March 2024. The Director of Program Effectiveness will monitor staff implementation of the revised policy and procedures to ensure compliance with the revised policy. Director, Program Effectiveness and Anticipated completion date: March 2024
View Audit 8892 Questioned Costs: $1
Landesa has revised it's cash management policy to base cash requests from the United States Treasury on a lookback of one month to determine that total cash on hand is a negative amount, and a disbursement request can be triggered. Advances, if any will be kept to a maximum period of 3 days, per U...
Landesa has revised it's cash management policy to base cash requests from the United States Treasury on a lookback of one month to determine that total cash on hand is a negative amount, and a disbursement request can be triggered. Advances, if any will be kept to a maximum period of 3 days, per US regulations. Contact person: Director of Finance and Anticipated completion date: November 2023
View Audit 8892 Questioned Costs: $1
This finding is a result of a) staff changes that occurred throughout the year without an adequate training and transition strategy, b) a lack of sufficiently detailed written procedures, and c) a lack of resources to adequately review staff work and provide feedback. Status/timeline: This is among...
This finding is a result of a) staff changes that occurred throughout the year without an adequate training and transition strategy, b) a lack of sufficiently detailed written procedures, and c) a lack of resources to adequately review staff work and provide feedback. Status/timeline: This is amongst the first areas that will be addressed by our fee accountant. Enhanced policies and procedures to be written within 30 days of fee accountant start date. The Directof Finance and Accounting along with the fee accountant will help ensure procedures are being followed with proper supporting documentation provided for each draw.
View Audit 8885 Questioned Costs: $1
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recomme...
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to review a sample of the new files entering the program to determine if files were prepared and processed in accordance with internal policies and compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The compliance officer will ensure that at least 3 of the 15 files selected for review each month are new intakes to determine if files were prepared and processed in accordance with internal policies and compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Regla Exavier and Ruchelle Hobbs Planned completion date for corrective action plan: January 1, 2024.
View Audit 8875 Questioned Costs: $1
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recomme...
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to review a sample of the files that have been recertified each month, to determine if the tenant files were prepared in accordance with internal policies and until the compliance deficiencies have been corrected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The compliance officer will review at least 15 files monthly and 30 SEMAP files annually to determine if the participant files were prepared in accordance with internal policies and follow up until the compliance deficiencies have been corrected. The HCVP Director will ensure that HCV staff has corrected all files within 10 days of receipt. Name(s) of the contact person(s) responsible for corrective action: Regla Exavier and Ruchelle Hobbs Planned completion date for corrective action plan: No later than 1/1/2024
View Audit 8875 Questioned Costs: $1
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recomme...
Federal agency: U.S. Department of Housing and Urban Development Federal program title: Housing Choice Voucher Program ALN Number: 14.871 & 14.879 Award Period: April 1, 2022 through March 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Recommendation: We recommend management should designate one person to oversee the inspection process to ensure that all inspections are being performed in a timely manner. Furthermore, management should ensure no HAP payments are issued for units that have not passed HQS housing inspections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The HCV Director will utilize MONDAY.com to monitor and trac abatement and family failed inspections. The compliance officer will review PIC on a monthly bases to ensure all inspection 50058 has been submitted and accepted by HUD, as well as reporting late HQS inspections. Name(s) of the contact person(s) responsible for corrective action: Ruchelle Hobbs, Regla Exavier Planned completion date for corrective action plan: no later than 1st quarter 2024.
View Audit 8875 Questioned Costs: $1
Deficiency Identified: Federal Award Findings and Questioned Costs: Question Costs – Charges in Excess of Costs Incurred Response to Questioned Costs: We concur with the question costs. Corrective Action Plan (Action taken to correct specific deficiency identified): We have made applicable credits...
Deficiency Identified: Federal Award Findings and Questioned Costs: Question Costs – Charges in Excess of Costs Incurred Response to Questioned Costs: We concur with the question costs. Corrective Action Plan (Action taken to correct specific deficiency identified): We have made applicable credits to respective Federal programs for the questioned costs. Preventative Action Plan: (Action taken to prevent the reoccurrence of this problem in the future): In the future, we plan to recalculate Worker’s Compensation expense quarterly and make adjustments as needed and we plan to allocate State Unemployment Tax quarterly based upon direct labor hours. Responsible Personnel: Tina Bonner, Controller Projected Completion Date: December 31, 2023
View Audit 8855 Questioned Costs: $1
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