Corrective Action Plans

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2022-002 Finding - : Noncompliance and Significant Deficiency in Internal Control over Compliance - Allowable Costs. Criteria: Costs attributable to common or joint use of facilities or services by Head Start programs and other programs must be fairly allocated among the various programs that utiliz...
2022-002 Finding - : Noncompliance and Significant Deficiency in Internal Control over Compliance - Allowable Costs. Criteria: Costs attributable to common or joint use of facilities or services by Head Start programs and other programs must be fairly allocated among the various programs that utilize such services (42 USC 9839(c)). Context and Cause: Expenditures should be charged to the proper programs and allocated in accordance with the cost allocation plan. Questioned Costs: $6,357 – resulted in likely questioned costs greater than $25,000. Cause: Turnover of accounting personnel and lack of documentation and understanding of the allocation process with the Organization resulted in costs being incorrectly allocated between programs. Action Taken: Cost Allocation Plans have been thoroughly reviewed by executive director and finance director to verify and correct methodology and calculations in new approved cost allocation plan. Views of responsible official: Management concurs with the audit findings.
View Audit 303434 Questioned Costs: $1
Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing expenditures. The organization will significantly increase the practice of including sufficient supporting records to report gr...
Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing expenditures. The organization will significantly increase the practice of including sufficient supporting records to report grant expenses for reimbursement. Completed before January 2024.
View Audit 302849 Questioned Costs: $1
Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing expenditures. The organization will significantly increase the practice of including a subclass to track and report grant expen...
Response: The organization agrees with the finding. There were gaps in information flow due to staff turnover. The organization already has a process in place for reviewing expenditures. The organization will significantly increase the practice of including a subclass to track and report grant expenses for reimbursement. Completed before January 2024.
View Audit 302849 Questioned Costs: $1
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
Finding 392094 (2022-002)
Significant Deficiency 2022
Since the ERAP grant was a new COVID-related grant that was fast-tracked by the Government to provide immediate assistance in the midst of the pandemic, neither the Grantor, nor the Grantee, provided clear templates for reporting to the Organization as a Subgrantee. This forced the organization to c...
Since the ERAP grant was a new COVID-related grant that was fast-tracked by the Government to provide immediate assistance in the midst of the pandemic, neither the Grantor, nor the Grantee, provided clear templates for reporting to the Organization as a Subgrantee. This forced the organization to create its own templates, in which the unprotected spreadsheet formulas became corrupt, and were not consistent from month to month--largely due to changing interpretations of requirements for what could be claimed as a reimbursement. It is noted, that neither the organization, nor the primary Grantee caught the spreadsheet miscalculations -- in order to reconcile the accounts in a timely manner. The Organization made a change in Executive Directors a month after the Grant closed (April 2022), and a week before the fiscal year end (June 28, 2022). As part of understanding the process of grant reimbursements in the past, the current Executive Director created a Financial Reimbursement Policy for submitting grant reimbursements going forward into FY23. With this change, the Organization has stronger controls in place to catch any errors in financial reporting. This policy was reviewed by the Board of Directors in October 2022, to ensure procedures are in place in which non-protected spreadsheet formulas are double checked for accuracy, all receipts are reviewed and entered by at least two persons, and reimbursements are reconciled with corresponding requests in cooperation with a third-party accountant. In addition, due to work slowdowns that occurred during the COVID crisis, it created a long time lapse in waiting for reimbursement deposits from requests through the Grantee and Grantor. In many cases, reimbursements were not deposited until months after the request. Unfortunately, at the time, there was no mechanism in place to track these expenses for reconciliation. This too has been corrected in the new Reimbursement Policy change that includes a new grant reimbursement tracker in place going forward. While current Management recognizes the above failure to reconcile these discrepancies at the time, in review, the miscalculations on the submitted spreadsheets actually underestimate the expenses incurred compared to what was requested for reimbursement. Over the course of the grant the Organization actually under invoiced for its expenses. Since the grant was closed, the new Director, did not find these discrepancies until the audit and the organization understands this loss cannot be recouped.
View Audit 302227 Questioned Costs: $1
Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.
Management's Response: We concur with the recommendation, and the corrective action will be implemented as of March 6, 2024.
View Audit 301535 Questioned Costs: $1
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1,...
Management concurs with the audit finding. Capital Region Medical Center has sufficient unreimbursed lost revenues to replace the unallowable expenses reported. Capital Region Medical Center federal grant processes will begin to follow the University of Missouri grant policies beginning January 1, 2024.
View Audit 301078 Questioned Costs: $1
Finding 390130 (2022-004)
Significant Deficiency 2022
1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of susp...
1. The Center will retain evidence of competitive bidding, unless an emergency or other situation precluding the delay of competitive bidding has arisen (in which case, the Center will retain the evidence and rationale justifying the sole source contract). The Center will retain verification of suspension and debarment for all potential contract service providers. The Center notes that one of the contracts selected for testing arose during an emergency situation (flooding). 2. CFO will ensure that all invoices and supporting documentation are retained. ED and/or Director of Legal Services (depending on amount of expenditure, both may be required) will approve electronic payments in Bill.com. Approval of expenses paid with paper checks will be indicated by signature of checks after reviewing accompanying support.
View Audit 301014 Questioned Costs: $1
Finding 390129 (2022-003)
Significant Deficiency 2022
Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payro...
Personnel costs will be charged to the program based on actual time recorded in the organization’s case management software. Hours will be audited quarterly to ensure accuracy and completeness. The Center notes that the grantor, the State Bar of California, never requested the Center to charge payroll expenses to the program based on actual time documents, nor had they ever noted this discrepancy during their periodic audits of the program.
View Audit 301014 Questioned Costs: $1
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
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: ...
Finding 2022-001 Federal Program Information Federal Agency: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Award Period of Performance: July 1, 2020 to June 30, 2022 Corrective Action Planned: Management agrees that certain expenses to the COVID department were not reviewed and approved at the order entry level in specific cases. Although evidence of review was not retained for every charge to the COVID department, we believe the appropriateness of the charge was reasonable. Additionally, based on monthly review of departmental expenses and full-time equivalent (FTE) analysis at the facility level, we believe that these expenditures are subject to the appropriate level of review to identify unexpected variances. As it relates to the COVID Activity Code, this code was created as a means to track certain COVID hours worked, but was not configured to calculate the amounts associated with those hours, resulting in the need to make reasonable estimates. Even using the base pay rate at the time the hours were incurred would not have been accurate since it would omit adjustments for shift differentials, weekend hours, and overtime. We performed internal analyses and reviewed the results of samples selected by the auditors and concluded that the risk of a material overcharge to the program was minimal. Further, we have almost $40 million of unused lost revenues after our final PRF submission for Period 5, such that any questioned costs would easily be covered by other eligible uses of PRF funds. We have reviewed our processes related to the retention of expense documentation to improve audit evidence should this program ever be awarded in future periods. Responsible party: Lee Sonne, Vice President of Finance and Controller Implementation Date: Procedures were reviewed and analysis completed along with the Period 5 portal filing in September 2023.
View Audit 300148 Questioned Costs: $1
2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who...
2022-004 Period of Performance U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board implement internal controls and policies to ensure that supporting documentation is maintained for all transactions, and that a member of management who is knowledgeable of the period of performance is reviewing and approving all transactions prior to payment. Action Taken: For each accounting procedure, internal controls have been put in place. The Board’s payroll processing goes through three levels of approval before it is processed. The expenditures process goes through three levels of approval before the bill is paid. The Board is verifying that each report or process is approved by at least three levels of approval and within a timely manner. Expenditure checks are issued every two weeks. The approval of these checks is also approved by an officer of the Board of Directors. Any out of the ordinary practices have both the approval of the Executive Director and an officer of the Board of Directors. With the past issues of this Board, the Board added an internal control for the sake of period of performance, for reports that are submitted to Workforce WV. In addition, these reports will be reviewed and approved by one of the managers of the Board within the time the report is due.
View Audit 299381 Questioned Costs: $1
2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that a...
2022-002 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment, and that adequate supporting documentation for all federal program charges is maintained. Action Taken: The Board is taking adequate action to review and approve all charges to the federal programs. The Board’s steps have been reviewed with Workforce WV and has been approved our procedures. Supporting documentation is kept both in physical and electronic forms. Each check the Board distributes has an approved purchase order attached, (if applicable), invoice, or if it is a monthly recurring charge, statement or bill attached and once the bill is entered into our system and the bill is paid, the check has the Executive Director’s initials and date showing it is approved in our accounting system. Also, if the expenditures are questionable, we will receive approval before submission of the bill from our liaison in the Workforce WV office.
View Audit 299381 Questioned Costs: $1
Corrective Action Plan: The nursing home payroll staff compiled a list of staff beginning in March 2020, where there was a workforce-related actual expense to prevent, prepare for or respond to coronavirus during the reporting period. To complete the Provider Relief Fund expenses for Payroll/General...
Corrective Action Plan: The nursing home payroll staff compiled a list of staff beginning in March 2020, where there was a workforce-related actual expense to prevent, prepare for or respond to coronavirus during the reporting period. To complete the Provider Relief Fund expenses for Payroll/General and Administrative Expenses, this extensive payroll expense list needed to be sorted & tabulated to meet the PRF report. In the process, a portion of 5 weeks of covid expense were included twice causing double expense, an additional $41,046.24. This was a clerical error by the Director of Finance. To correct this issue moving forward, a secondary reviewer needs to inspect the compilation of payroll expenses and formulas in the spreadsheet before submitting. Due to the excessive amount of lost revenues in all reporting periods, the reporting of expenses was not needed, but reported for historical information. The Director of Finance called the HRSA helpdesk on 2/5/2024 as soon as this error was noted. HRSA replied that unless CCNH receives a letter, they will not reopen this reporting period and they will not reopen a reporting period for an outside auditor finding. Name of Responsible Person: Carrie Klebe Anticipated Implementation Date of Corrective Action: The above actions will take effect immediately.
View Audit 298844 Questioned Costs: $1
Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Act...
Finding 2022-002 – Head Start Cluster - Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Brenda Overton Contact Phone Number: 574.393.5866 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: We will ensure all vouchers are reviewed by a secondary individual, all supporting backup is maintained for each claim, and all payroll amounts agree to approved contracts. Anticipated Completion Date: April 2024
View Audit 298779 Questioned Costs: $1
Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension, and Debarment Material Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: Procurement policies under Unifor...
Department of Treasury Federal Financial Assistance Listing/ALN 21.027 COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Procurement, Suspension, and Debarment Material Noncompliance and Material Weakness in Internal Control over Compliance Finding Summary: Procurement policies under Uniform Guidance were not followed when obtaining bids for two contracts. Responsible Individuals: Robben Luhning and Susan Koesterman. Corrective Action Plan: Procurement policy is currently under review. As permission was received from granting agency to use current internal controls, the policy update was not prioritized by management. Anticipated Completion: December 31, 2024.
View Audit 298678 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers and Mainstream Vouchers Programs to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Amy Barts, Director of Housing, is responsible for implementing this corrective action by December 31, 2023.
View Audit 298608 Questioned Costs: $1
Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Amy Barts, Director of Housing, is respons...
Views of responsible officials and planned corrective action: The Authority agrees with the finding and will increase oversight on the maintenance of the waiting list and process of housing applicants to better monitor adequacy with compliance requirements. Amy Barts, Director of Housing, is responsible for implementing this corrective action by December 31, 2023.
View Audit 298608 Questioned Costs: $1
Management will review its process for requesting reimbursements and reconciling same to the ledger.
Management will review its process for requesting reimbursements and reconciling same to the ledger.
View Audit 298333 Questioned Costs: $1
Significant Deficiency in Internal Control Over Compliance and Noncompliance – A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Recommendation: The auditor recommended FSA implement procedures for all employees who have payroll claimed under federal programs to maintain de...
Significant Deficiency in Internal Control Over Compliance and Noncompliance – A. Activities Allowed or Unallowed and B. Allowable Costs/Cost Principles Recommendation: The auditor recommended FSA implement procedures for all employees who have payroll claimed under federal programs to maintain detailed timecards or time studies to support hours worked under each federal program. Planned Corrective Actions: Family Service Association of Howard County, Inc. (FSA) will implement procedures and maintain time cards and time studies for employees who have payroll claimed under the federal programs to be in compliance of federal grants beginning April 2024.
View Audit 297675 Questioned Costs: $1
New financial grant accountant has been assigned to work with departments to ensure proper accounting of expenditures.
New financial grant accountant has been assigned to work with departments to ensure proper accounting of expenditures.
View Audit 297486 Questioned Costs: $1
Finding 384184 (2022-006)
Significant Deficiency 2022
Finding number: 2022-006 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was pre...
Finding number: 2022-006 Federal agency: U.S. Department of Education Programs: Student Financial Assistance Cluster Assistance listing #: 84.268 Award year: 2022 Corrective Action Plan: College Unbound hired two new positions, a Controller and a Bursar, who both started on 10/2/23 (the role was previously filled by a single temporary employee). Part of the Controller’s scope of work is a monthly review of all uncashed checks. Beginning March 2024, the Controller initiated a new process for outstanding checks issued to students. After monthly bank reconciliation, the list of outstanding checks will be forwarded to our Director of Employee Success and Student Accounts to follow up with the students and rectify the issues. In addition, College Unbound is undertaking a project to encourage students to receive credit balance refunds through ACH, as opposed to paper check, whenever possible. The ACH process will increase accuracy, security, and speed of delivery. Additionally, for students still opting to receive paper checks, College Unbound has initiated Positive Pay through the bank. Timeline for Implementation of Corrective Action Plan: Ongoing. Fully implemented by the end of FY24. Contact Person: Diana Perdomo, CFO
View Audit 297283 Questioned Costs: $1
Finding 383856 (2022-006)
Significant Deficiency 2022
Community Partners acknowledges that while subrecipient monitoring was performed for federal subrecipients by hiring third party CPAs, the monitoring was based on randomly selected samples and a risk assessment was not included in the monitoring plan. Current leadership has enhanced the subrecipient...
Community Partners acknowledges that while subrecipient monitoring was performed for federal subrecipients by hiring third party CPAs, the monitoring was based on randomly selected samples and a risk assessment was not included in the monitoring plan. Current leadership has enhanced the subrecipient monitoring plan by ensuring that risk assessments are incorporated into any future subrecipient monitoring. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.
View Audit 296891 Questioned Costs: $1
Finding 383855 (2022-005)
Significant Deficiency 2022
Community Partners acknowledges that payroll costs did not consistently have sufficient documentation to support the hours charged to the program. Prior leadership did not establish clear guidelines for staff and program personnel to emphasize the time and effort requirements of federal awards. Curr...
Community Partners acknowledges that payroll costs did not consistently have sufficient documentation to support the hours charged to the program. Prior leadership did not establish clear guidelines for staff and program personnel to emphasize the time and effort requirements of federal awards. Current management has implemented guidelines and review procedures to ensure that compliance staff verify that hours charged to programs are appropriately supported. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.
View Audit 296891 Questioned Costs: $1
Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expendit...
Community Partners acknowledges that documentation to support expenditures was not consistently kept across all federal grants. Current leadership has addressed this issue by implementing documentation standards across all federal grants. Furthermore, through the implementation of NetSuite, expenditures will be fully supported and approved by staff before posting. The person responsible for the corrective action detailed above will be Joyce Williams, Chief Financial and Operations Officer, (213) 346‐3202. We anticipate corrective action will be completed by June 30, 2024.
View Audit 296891 Questioned Costs: $1
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