Corrective Action Plans

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FA 2022-001 Strengthen Controls over Expenditures Compliance Requirements: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncomplia...
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirements: Activities Allowed or Unallowed Allowable Costs/Cost Principles Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 – School Breakfast Program 10.555 – National School Lunch Program Federal Award Number: 225GA324N1199 (Year: 2022) Questioned Costs: $21,440.00 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District’s internal control procedures were not operating appropriately to ensure that the School District’s procurement procedures were followed. Corrective Action Plan: The Harris County SNP will review internal controls and apply correct procedures to all purchases made. Estimated Completion Date: June 30, 2024 Contact Person: Meghan L. Ceja Telephone: 706-628-4206 Email: ceja-m@harris.k12.ga.us
View Audit 296666 Questioned Costs: $1
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds.
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds.
View Audit 296291 Questioned Costs: $1
In the exploratory phase of applying for a new grant, the Executive Director will ascertain whether or not the source of funding is Federal. The Executive Director will be assisted in this responsibility by a professional accountant that has been retained from an accounting firm. Where any doubt e...
In the exploratory phase of applying for a new grant, the Executive Director will ascertain whether or not the source of funding is Federal. The Executive Director will be assisted in this responsibility by a professional accountant that has been retained from an accounting firm. Where any doubt exists, the funding partner will be contacted to confirm their perspective.
View Audit 296191 Questioned Costs: $1
The Academy will undertake the following actions to ensure compliance in this area: For the immediate future, the Academy will ensure that only eligible expenses are included in the overhead calculation and that other rules and limitations are adhered to. The Academy will then submit a revision to ...
The Academy will undertake the following actions to ensure compliance in this area: For the immediate future, the Academy will ensure that only eligible expenses are included in the overhead calculation and that other rules and limitations are adhered to. The Academy will then submit a revision to its ARPA agreement allowing it to increase its overhead rate to the 10% default rate. Lastly, the Academy will gather the information needed to apply for an individual rate based on its specific cost structure. The Executive Director will supervise the professional accountant in this effort.
View Audit 296191 Questioned Costs: $1
Formal timesheets will be prepared and approved consistent with the payroll cycle, documenting the time spent on Federal grants and on other areas. The professional accountant retained by the Academy will be tasked with this responsibility under the supervision of the Executive Director.
Formal timesheets will be prepared and approved consistent with the payroll cycle, documenting the time spent on Federal grants and on other areas. The professional accountant retained by the Academy will be tasked with this responsibility under the supervision of the Executive Director.
View Audit 296191 Questioned Costs: $1
In the future, Employment Connection will not make any variations from contractual requirements without our contract being formally amended by the recipient.
In the future, Employment Connection will not make any variations from contractual requirements without our contract being formally amended by the recipient.
View Audit 296001 Questioned Costs: $1
The Board of County Commissioners will work with all County Officials to go over all grants. The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants
The Board of County Commissioners will work with all County Officials to go over all grants. The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants
View Audit 295825 Questioned Costs: $1
FA 2022-001 Improve Controls over Employee Compensation Compliance Requirements: Activities Allowed or Unallowed Allowable Costs/Cost Principles Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding...
FA 2022-001 Improve Controls over Employee Compensation Compliance Requirements: Activities Allowed or Unallowed Allowable Costs/Cost Principles Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education AL Numbers and Titles: 10.553 – School Breakfast Program 10.555 – National School Lunch Program Federal Award Number: 225GA324N1199 (Year: 2022) Questioned Costs: $41,309.92 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the employee compensation process as it relates to the Child Nutrition Cluster. Corrective Action Plans: The Hancock County School District has updated the internal controls over the employee compensation process as it relates to the Child Nutrition Cluster and has corrected the employee codes for the director and former director to ensure that the correct employees are paid from CNC. Estimated Completion Date: June 30, 2024 Contact Person: Matthias Jones, Finance Director Telephone: (706) 444-5775 Ext. 125 Email: mjones@hancock.k12.ga.us
View Audit 295543 Questioned Costs: $1
Finding 380817 (2022-007)
Significant Deficiency 2022
Audit Finding Reference: 2022-007 Improve Procurement Procedures (Significant Deficiency) Planned Corrective Action: City’s Purchasing Department will work with School & City Personnel to educate staff regarding Federal Award procurement practices to avoid this finding in the future. Completion D...
Audit Finding Reference: 2022-007 Improve Procurement Procedures (Significant Deficiency) Planned Corrective Action: City’s Purchasing Department will work with School & City Personnel to educate staff regarding Federal Award procurement practices to avoid this finding in the future. Completion Date Kevin McHugh, City of Lynn School Business Manager Stephen T. Spencer, City of Lynn Comptroller December 31, 2024
View Audit 295538 Questioned Costs: $1
Finding 380815 (2022-004)
Significant Deficiency 2022
Audit Finding Reference: 2022-004 Maintain Employer’s Time and Effort Records (Significant Deficiency) Planned Corrective Action: The district began implementing the Time and Effort process during fiscal year 2016. We now collect signed Time and Effort sheets twice per year for all employees paid 1...
Audit Finding Reference: 2022-004 Maintain Employer’s Time and Effort Records (Significant Deficiency) Planned Corrective Action: The district began implementing the Time and Effort process during fiscal year 2016. We now collect signed Time and Effort sheets twice per year for all employees paid 100% by Federal Grants. For those employees that are paid partially from Federal Grants, we collect them on a monthly basis. We will increase our diligence to strive for 100% efficiency in the future for the Department of Education Grant. In response to the CDBG, Time and Effort records were not maintained for all applicable employees. Community Development implemented the monthly collection of signed time and effort sheets for all employees paid with Federal Grants (in partial or full) a number of year ago, and will increase its diligence to ensure this procedure is consistently followed going forward. Name of Contact Person and Completion Date Kevin McHugh, City of Lynn School Business Manager James Marsh, Executive Director Community Development December 31, 2024
View Audit 295538 Questioned Costs: $1
Condition: During the audit it was noted that in one instance wages submitted for reimbursement for one Club employee were more than gross wages that should have been assigned to the grant based on the amount of the paycheck. Plan: The Club plans to review the issue with its current procedures and r...
Condition: During the audit it was noted that in one instance wages submitted for reimbursement for one Club employee were more than gross wages that should have been assigned to the grant based on the amount of the paycheck. Plan: The Club plans to review the issue with its current procedures and revise them as necessary to provide better controls over the grant expenditure reporting process. Anticipated Date of Completion: As soon as possible – before FY24 year end Name of Contact Person: Cathy Russell, CEO Management Response: Since the audit, we have evaluated our payroll controls and we are working on improving our current procedures and controls over the grant expenditure reporting process.
View Audit 294947 Questioned Costs: $1
Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 9...
Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Substance Abuse and Mental Health Services Projects of Regional and National Significance Assistance Listing Number: 93.243 Federal Award Identification Number and Year: H79TI081935 – 2022, H79TI080298 – 2022, H79TI085517 – 2022 Pass-Through Agency: Pierce County Pass-Through Number(s): SC-107323, SC-105454, SC-110121 Award Period: May 31, 2019 through May 30, 2024, September 30, 2017 through September 29, 2022, September 30, 2022 through September 30, 2027 Criteria or specific requirement: 2 CFR 200.430(i)(1)(viii) states that “budget estimates (i.e., estimates determined before the services are performed) alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that: (A) The system for establishing the estimates produces reasonable approximations of the activity actually performed; (B) Significant changes in the corresponding work activity (as defined by the non-Federal entity's written policies) are identified and entered into the records in a timely manner. Short term (such as one or two months) fluctuation between workload categories need not be considered as long as the distribution of salaries and wages is reasonable over the longer term; and (C) The non-Federal entity's system of internal controls includes processes to review after-the-fact interim changes made to a Federal award based on budget estimates. All necessary adjustments must be made such that the final amount charged to the Federal award is accurate, allowable, and properly allocated.” Condition: Grant hours are not consistently tracked on the employee monthly timesheet. Wages charged to the program are based on budgeted estimates. Per 2 CFR 200.430(i)(1)(viii), this is not allowed without additional steps to ensure accuracy, allowability and proper allocation. Insufficient evidence was presented to support a reasonable reflection of employee federal and non-federal activity. The alliance does not have a written policy nor system of internal controls to review and true-up grant wages to actual. Questioned costs: $447,634 Context: A sample of 40 was made from a population of 504 transactions charged to the major program for salaries and benefit expenses. Of the 40 sampled costs, all were found to be out of compliance with the provisions for 2 CFR 200.430 Compensation - personal services of Uniform Guidance. Sampled wages totaled $137,021.54. Total salaries and wages totaled $971,744 of the $1,599,883 tracked to the major program. Extrapolating the error to the actual costs reported on the SEFA results in a likely questioned cost amount of $447,634. Cause: Management was aware that estimated budgeted costs alone are not sufficient to support personnel costs charged to Federal awards. Effect: Charging grant wages based on estimates rather than actual hours worked on the program may raise compliance concerns. Estimating grant wages without adequate support for time and effort documentation may result in noncompliance with grant regulations. This can also lead to overcharging or undercharging the federal grant, which may result in penalties or repayment obligations. Repeat Finding: No. Recommendation: We recommend that the Alliance incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by adjusting the format of the monthly timesheet to include a column that specifies how many hours per day were spent on which federal and nonfederal activities. PCA can further enhance clarity, accountability, and transparency by moving from a "day" format to an "hour" format on their timesheets. View of Responsible Official: Pierce County Alliance has enjoyed the decades long relationship with our prior audit firm. We had been advised to record staff time on an hourly basis. We were then redirected to record time on a daily basis. However, with this recommendation, we are being redirected to record on an hourly basis. At no time has a finding been previously issued on how staff time is recorded, on timesheets or on the back end of our third-party payroll software. Corrective Action: Pierce County Alliance will reinstitute an hourly timesheet format in order to account for positions with multiple funding sources.
View Audit 294914 Questioned Costs: $1
Finding 375658 (2022-003)
Significant Deficiency 2022
Type of Finding: • Significant Deficiency in Internal Control over Compliance – Allowable Costs/Cost Principles • Other Matter – Non-Compliance with Allowable Costs/Cost Principles Compliance Requirements Federal Agency: Department of Transportation Federal Program Name: Enhanced Mobility of Seni...
Type of Finding: • Significant Deficiency in Internal Control over Compliance – Allowable Costs/Cost Principles • Other Matter – Non-Compliance with Allowable Costs/Cost Principles Compliance Requirements Federal Agency: Department of Transportation Federal Program Name: Enhanced Mobility of Seniors and Individuals with Disabilities Assistance Listing Number: 20.513 Federal Award Identification Number and Year: PTD0287-2022 Pass-Through Agency: WADOT Pass-Through Number(s): PTD0287 Award Period: July 1, 2021 through June 30, 2023 Criteria or specific requirement: 2 CFR 200.423 specifically identifies alcoholic beverages as unallowable costs. Condition: CLA noted one sample in which federal funds were expended on unallowable costs. Questioned costs: $85 known, $910 likely Context: A sample of 25 was made from a population of 942 nonpayroll-related general disbursement costs charged to the major program. Of the 25 sampled costs, one was found to be out of compliance with the requirements of Allowable Costs / Cost Principles, totaling $85. Sampled nonpayroll-related general disbursement costs totaled $24,560. General disbursements totaled $263,090 of the $1,706,762 tracked to the major program. Extrapolating the error to the actual costs reported on the SEFA results in a likely questioned cost amount of $910. Cause: The individual in charge of entering the purchase into Microix did not code the alcoholic beverages to a separate general ledger account that was established to track unallowable costs so that they are not charged to the federal programs. Effect: Without adequate controls in place to ensure costs are allowable, Sound Generations runs the risk of being out of compliance with not only the major program but all federal programs. Repeat Finding: No. Recommendation: CLA recommends that emphasis be placed (via an employee training or organization-wide email) on specifically disallowed costs and the importance of tracking these costs separately so that they are not charged to federal programs. Views of responsible officials and planned corrective actions: Sound Generations agrees with the finding. Sound Generations has implemented the following additional practices and policies: 1) Allowable costs and expenditures in Federal Grants and Contracts training to all Authorized Purchasers. - to be completed in the first quarter of 2024 and annually thereafter. 2) Additional General Ledger Codes to record unallowable costs: implemented in July 2023 3) Automating unallowable expenses to be excluded in grant and contract reporting and expense reimbursements. - implemented in July 2023 Responsible Official: Chief Financial Officer; Christina Hannan, Controller Anticipated Completion Date: March 31, 2024
View Audit 294734 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a full range of controls over costs charged to federal programs. MARR's protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and en...
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a full range of controls over costs charged to federal programs. MARR's protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting process be accurate. Further, controls over grant billings will be established to ensure expenditures represent actual costs incurred. All control activities, including independent review, should be documented and evidence of review and approval will be maintained.
View Audit 294683 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR's primary decision-making authority regarding such controls shall be placed with the MARR's president. MARR's protocol sh...
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to implement a full-range of control over costs charged to federal programs. MARR's primary decision-making authority regarding such controls shall be placed with the MARR's president. MARR's protocol shall ensure that such costs are the direct benefit to the program, are reviewed, approved, documented and ensure the accounting and reporting process be accurate. Further, controls over grant billings will be established to ensure expenditures represent actual costs incurred. All control activities, including independent review, should be documented and evidence of review and approval will be maintained.
View Audit 294683 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to recommend to management the establishment of procedures and controls allocate costs between grants based on actual costs attributed to grant and the particular expenditure allowed by the grant. All su...
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to recommend to management the establishment of procedures and controls allocate costs between grants based on actual costs attributed to grant and the particular expenditure allowed by the grant. All such allocations will be supported by activity-level substantiation and be reviewed. Documentation of the allocation methodology, review and approval will be maintained in writing
View Audit 294683 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to establish procedures that incorporate controls to review expenditures for payment prior to submitting request for reimbursement, and that the outstanding checks (and other reconciling items) be resolv...
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to establish procedures that incorporate controls to review expenditures for payment prior to submitting request for reimbursement, and that the outstanding checks (and other reconciling items) be resolved in a reasonable period of time. Such evidence of control activities including review will be documented and maintained.
View Audit 294683 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to establish formal written policy documenting significant accounting procedures including but not limited to the independent review of the grant period of performance when recording transactions and pre...
Views of Responsible Officials and Planned Corrective Actions: MARR will retain a CPA consultant to establish formal written policy documenting significant accounting procedures including but not limited to the independent review of the grant period of performance when recording transactions and preparing grant reimbursement requests. Evidence of the review to be documented and maintained according to the procedures to be implemented.
View Audit 294683 Questioned Costs: $1
Finding 2022-005: Allowable Cost and Allowable Activities Determination and Documentation Condition: The Authority failed to maintain required documentation for program expenditures. Plan: The Authority plans to implement additional new procedures related to documentation of expenditures, including ...
Finding 2022-005: Allowable Cost and Allowable Activities Determination and Documentation Condition: The Authority failed to maintain required documentation for program expenditures. Plan: The Authority plans to implement additional new procedures related to documentation of expenditures, including scanning all documentation so that information can be accessed by the Authority personnel as necessary. The Authority also plans to implement additional training of staff. Employee Responsible for the CAP: Danita Childers, Executive Director Planned Completion Dates for CAP: March 2024
View Audit 294652 Questioned Costs: $1
Finding 2022-002: The Corporation made a payment to LAHD in the amount of $16,742. The payment does not meet HUD's criteria of eligible Property expenses and the Corporation did not obtain HUD approval. Comments on the Finding and Each Recommendation: The Corporation should request HUD approval for ...
Finding 2022-002: The Corporation made a payment to LAHD in the amount of $16,742. The payment does not meet HUD's criteria of eligible Property expenses and the Corporation did not obtain HUD approval. Comments on the Finding and Each Recommendation: The Corporation should request HUD approval for reimbursement from the residual receipts fund and deposit into the Property's operating account. Action(s) taken or planned on the finding: Management has requested approval from HUD. As of the report date, no response has been received.
View Audit 294494 Questioned Costs: $1
Finding 2022-001: The Corporation's required deposit of $33,484 to the residual receipts account per the December 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Comments on the Finding and Each Recommendation: Manage...
Finding 2022-001: The Corporation's required deposit of $33,484 to the residual receipts account per the December 31, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Comments on the Finding and Each Recommendation: Management should make all required residual receipt deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after fiscal year end. Action(s) taken or planned on the finding: Management deposited $33,484 into the residual receipts fund on June 13, 2022. No further action is required.
View Audit 294494 Questioned Costs: $1
Condition Sliding Fee Discounts. Testing performed on the sliding fee discounts charged to patients based on annual gross income and household size, found sliding fee scales to be inappropriately unsupported. The result was patients were given an improper sliding fee discount without documentation t...
Condition Sliding Fee Discounts. Testing performed on the sliding fee discounts charged to patients based on annual gross income and household size, found sliding fee scales to be inappropriately unsupported. The result was patients were given an improper sliding fee discount without documentation to support that the patient qualified based on their income. In addition, one encounter was given a sliding fee discount tin an amount that did not match their annual gross income and household size resulting in an over charge to the patient. Lack of retaining forms and inaccuracy in the application of the sliding fee program discounts were due to inadequate oversight and review. Corrective actions This is a repeat finding from prior fiscal year financial statements. Corrective actions were taken and implemented by March 2, 2022. Corrective action plan from prior year is stated below. Indication of repeat finding was remedied in March of 2022. Each of the findings noted were in fiscal year 2022, however were prior to the corrective action plan of March 2022. Once corrective action plan was implemented, there were no further findings related to the sliding fee discounts. Internal audit process is still in place and continued training to front office is in place. Corrective Action from prior year finding Training: Retrain staff on sliding fee policy procedures to ensure (1) income is properly verified, adequately documented and retained and (2) the sliding fee discount is properly determined and applied. All new Front Office staff will receive sliding fee program training as part of their 4-day front office training during onboarding. By Feb 28, 2022, the Front Office Trainer will review documentation requirements around sliding fee scale for patients, including checking applications for completion and making sure the sliding fee applied is being correctly calculated by all Front Office Leads, Supervisors and Center Managers. By Mar 2, 2022, the Front Office Trainer will help create a front office compliance checklist to review front office procedures around documentation, insurance, sliding fees and other programs. Sliding Fee Annual Update: The Revenue Cycle Director will notify the Applications Team and Front Office trainer each year when the sliding fee scale has been updated. The Applications Team will update the UDS table and map to the calculator in the EHR. The Front Officer trainer will review sliding fee updates on an annual basis update trainings with front office staff and within thirty days of notification of any sliding fee policy revisions. Internal Audit: An additional level of review will be added to the process to ensure program compliance. The Revenue Cycle Director will create and document a sliding fee scale internal audit process that will be performed monthly. When the audit is performed, findings will be reported to the following: General Cousnel & Compliance Officer, Chief Financial Officer, Chief Operating Officer, Front Officer Trainer, Center Manager, and lead/supervisors. Front Office Trainers will work closely with Center Managers, Leads and Supervisors to ensure that ongoing compliance on sliding fees are met based on internal audit findings. Refresher trainings to staff will be provided based on patterns determined by internal audit findings. This process will be implemented by February 28, 2022. Name of Contact Person(s) Responsible for Corrective Action: Jaime Allen, Chief Financial Officer Anticipated Completion Date: March 2, 2022 Update: All corrective actions were implemented as planned and are monitored by the monthly audit led by the Revenue Cycle Director. Front Office trainings continue on a regular basis to mitigate future reoccurrence.
View Audit 294123 Questioned Costs: $1
The Board of Education has now regained control of the District and moving forward, the District will closely monitor grant funded expenditures. The District utilizes its Grants Council to review grant awards and develop plans for expenditures. This includes ensuring the expenditures are necessary a...
The Board of Education has now regained control of the District and moving forward, the District will closely monitor grant funded expenditures. The District utilizes its Grants Council to review grant awards and develop plans for expenditures. This includes ensuring the expenditures are necessary and reasonable for the grant program in accordance with 2 CFR § 200.403(a) and allowable under the grant guidelines.
View Audit 293951 Questioned Costs: $1
Finding 2022-005 In the future, if such a program were available that required a review of diagnosis against a certain set of treatment and diagnostic charges, the Assistant Vice Chancellor for Revenue Cycle will work with the EPIC IT team to develop specific program parameters for billing or a manu...
Finding 2022-005 In the future, if such a program were available that required a review of diagnosis against a certain set of treatment and diagnostic charges, the Assistant Vice Chancellor for Revenue Cycle will work with the EPIC IT team to develop specific program parameters for billing or a manual review will be developed and implemented. Responsible official: Assistant Vice Chancellor for Revenue Cycle Anticipated completion date: January 1, 2023
View Audit 293814 Questioned Costs: $1
Finding 2022-006 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grant...
Finding 2022-006 Beginning June 1, 2022, grants accounting staff were trained to utilize a draw report that calculated cleared (paid) expense to ensure expenses were invoiced in accordance with federal and program regulations. During fiscal year 2022, a new director and staff were hired in the grants accounting office. In addition, with completing the implementation of the financial system, we believe adequate controls have been established and are working properly to ensure compliance with cash management regulations. Responsible Official: Associate Vice Chancellor for Finance & Treasurer Implementation Date: February 2023
View Audit 293814 Questioned Costs: $1
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