Corrective Action Plans

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2023‐007 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working within the invoice approval system to build in safeguards to p...
2023‐007 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working within the invoice approval system to build in safeguards to prevent invoices from being routed without CEO approval. Planned implementation date of corrective action – Calendar year 2025.
2023‐006 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – The financial management team is reviewing the requirements for federal expenditures...
2023‐006 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – The financial management team is reviewing the requirements for federal expenditures under Uniform Guidance for better understanding of the requirements and to establish appropriate policies and procedures for handling of federal funding. Planned implementation date of corrective action – Calendar year 2025.
Audit Finding Reference: 2023-001 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melis...
Audit Finding Reference: 2023-001 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melissa Martel, Director of Finance Completion Date: December 12, 2023
DSCEJ will enforce its existing month-end and year-end close procedures with accounting staff to ensure all expenses are consistently recorded in the correct accounting period.
DSCEJ will enforce its existing month-end and year-end close procedures with accounting staff to ensure all expenses are consistently recorded in the correct accounting period.
View Audit 363601 Questioned Costs: $1
An individual independent of the record keeping should be responsible for opening the mail and documenting its contents within the donor software utilized by the Organization. The contents of the mail should then be given to the Finance and Office Administrator for recording the transactions within ...
An individual independent of the record keeping should be responsible for opening the mail and documenting its contents within the donor software utilized by the Organization. The contents of the mail should then be given to the Finance and Office Administrator for recording the transactions within QuickBooks and for depositing the funds.
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family has initiated several corrective actions. Since the first months of Fiscal Year 2024, the Accounting Department has started a review of unliquidated obligations on a monthly basis, canceling any invalid obligations and reporting them in the...
VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family has initiated several corrective actions. Since the first months of Fiscal Year 2024, the Accounting Department has started a review of unliquidated obligations on a monthly basis, canceling any invalid obligations and reporting them in the FY 2024 SSA-4513 report. In fact, Budget and Finance staff had multiple working sessions with PR-DDS personnel to identify and write-off unliquidated obligations that were no longer current. Also, we conducted training for finance and budget staff on accounting controls and administrative cost reporting to ensure compliance with federal regulations. Includes a review of 2 CFR Part 225 on allowable costs (direct allowable and indirect allocable, the difference between direct and indirect costs), reasonable and allocable costs. In addition, we addressed issues of unliquidated obligations (Consultative Examinations (CE) and Medical Evidence of Record (MER), among others). Nevertheless, beginning the first quarter of FY2026, following recent staffing changes in the Finance Department, we are in the process of re-training our team to ensure that unliquidated obligations are reviewed every month and invalid commitments are promptly canceled. To reinforce these practices, the Department of the Family will also deliver a series of new workshops to relevant staff outlining the procedures and best practices for SSA-4513 preparation and POMS compliance. IMPLEMENTATION DATE September 2025 RESPONSIBLE PERSON Office of the Secretariat
VIEWS OF RESPONSIBLE OFFICIALS ADSEF has controls and procedural manuals related to data collection. As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. Annexes IMPLEMENTATION DATE Up to Dat...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF has controls and procedural manuals related to data collection. As part of the digitization project process, ADSEF seeks to standardize procedures and ensure the organization and proper location of documents within the files. Annexes IMPLEMENTATION DATE Up to Date RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym) AUDITORS’ COMMENT ADSEF did not provide us with a manual describing the data collection process as requested during the auditing procedures. An unsigned and undated Manual was attached to the Corrective Action Plan. Also, ADSEF was required to provide us with the corresponding participant worksheet appendix and the physical file to corroborate the information included in the report. ADSEF provided us with evidence of the hand-completed forms; however, we were not provided with the physical files to validate the information included in each document. This represents a scope limitation.
VIEWS OF RESPONSIBLE OFFICIALS 1. Assess the need to hire additional staff or reallocate existing resources to ensure the necessary capacity for continued FFATA/FSRS compliance. 2. Create a detailed and comprehensive Procedures Manual for FFATA/FSRS management and reporting, including steps for effe...
VIEWS OF RESPONSIBLE OFFICIALS 1. Assess the need to hire additional staff or reallocate existing resources to ensure the necessary capacity for continued FFATA/FSRS compliance. 2. Create a detailed and comprehensive Procedures Manual for FFATA/FSRS management and reporting, including steps for effective implementation of the process. 3. Develop and deliver a mandatory training program for all Office of Legal Affairs staff, and any other staff involved in the administration or monitoring of sub-awards. 4. Establish regular monitoring to ensure that FSRS reporting is conducted in a timely and accurate manner. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Office of Legal Affairs Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-...
VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Sidnia Vélez, Child Care Program Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)
View Audit 363366 Questioned Costs: $1
VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026....
VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPL...
VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Doris Jiménez, Finance Director Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)
View Audit 363366 Questioned Costs: $1
Finding 572167 (2023-001)
Significant Deficiency 2023
Re: 2023-001 Improve Internal Controls over Reporting This letter is in response to the above referenced finding in the FY2023 Single Audit. The Town acknowledges the lateness of the filing of the report for FY2023, which was due to a misunderstanding as to the requirements on the use of ARPA fund...
Re: 2023-001 Improve Internal Controls over Reporting This letter is in response to the above referenced finding in the FY2023 Single Audit. The Town acknowledges the lateness of the filing of the report for FY2023, which was due to a misunderstanding as to the requirements on the use of ARPA funds that were considered as the standard allowance for revenue loss. Similarly, a reporting delay also happened for FY2024. We have taken action to ensure the issue does not reoccur.
Issue: Summary Condition: The Auditee submitted reimbursement requests to the Mississippi Department of Education (MOE) that were not fully supported: Standard monthly amounts requested for Digital Learning Instructor (DU) labor exceeded actual contract costs, resulting in overstatements. 1 of 60 it...
Issue: Summary Condition: The Auditee submitted reimbursement requests to the Mississippi Department of Education (MOE) that were not fully supported: Standard monthly amounts requested for Digital Learning Instructor (DU) labor exceeded actual contract costs, resulting in overstatements. 1 of 60 items sampled lacked support for $11,700 in charges. Cause: The Consortium requested funds before receiving invoices or verifying actual expenses. There was no reconciliation process in place to verify that reimbursement requests matched actual expenditures. Effect: Federal funds were received in excess of allowable costs and not returned to the grantor. These excess reimbursements represent questioned costs which the grantor could request funds to be refunded. Criteria: In accordance with 2 CFR 200.403 and 200.430, costs must be necessary, reasonable, and allocable, and adequately documented to be allowable under federal awards. Questioned Costs: Total known questioned costs are $49,082, which includes: $37,382 related to Digital Learning Instructor (DLI) contract labor, including $34,445 in excess labor charges and $2,937 in related indirect costs. These charges were identified through a 100% review of all DU contract labor activity for fiscal year 2023. $11,700 from a single reimbursement request that partially lacked supporting documentation. This item was identified during testing of a sample of 60 items totaling $6,545,759.87. Response: The Consortium acknowledges the finding and agrees with the audit's assessment. The practice of requesting reimbursement based on estimated monthly amounts without timely reconciliation to actual expenses was not in alignment with federal cost principles under 2CFR 200.403 and 200.430. We recognize that this oversight led to the disbursement of excess federal funds, and we are committed to promptly resolving this issue and implementing strong internal controls to prevent recurrence. Corrective Action Plan: Reconciliation Process Implementation: We have implemented a formal reconciliation process to ensure reimbursement requests are in line with actual cost. This includes reviewing all invoices and matching them to amounts requested. Return of Excess Funds: We are identifying and preparing to return any excess federal funds that were distributed as a result of these overstatements, as part of our reconciliation review. Corrective Action Timeline: The reconciliation process was initiated in June 2025. The return of fund to Mississippi Department of Education will begin with sending the audit report to MDE and getting directions on how to return overstated funds. Responsible Individuals: Mark Brown, business manager, is leading the implementation of the corrective action measures, in collaboration with Projects Coordinator, Susan Scott.
View Audit 363217 Questioned Costs: $1
Finding 572058 (2023-004)
Significant Deficiency 2023
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develo...
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develop written policies requiring cash disbursements to follow a clear, tiered approval process based on the amount. For example: • Up to a set threshold: Department manager approval • Above threshold: Department manager plus finance director/CFO approval • High-value disbursements: Additional executive or board-level approval. Requiring supporting documents (invoices, contracts, purchase orders) for every disbursement. Approvers must verify accuracy and completeness before authorizing payment. If there are any questions regarding this plan, please e-mail Yumiko Molden at ymolden@waikikihealth.org. Sincerely, Yumiko Molden CFO
Finding 572057 (2023-003)
Significant Deficiency 2023
Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directl...
Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
View Audit 362889 Questioned Costs: $1
GLRC is currently experiencing a delay in completion of their required audit which is causing us to miss filing to the single audit clearinghouse by June 30, 2025. We will be out of compliance for the 2024 audit but will be cathing up for meeting the June 2026 deadline for the 2025 audit. GLRC will ...
GLRC is currently experiencing a delay in completion of their required audit which is causing us to miss filing to the single audit clearinghouse by June 30, 2025. We will be out of compliance for the 2024 audit but will be cathing up for meeting the June 2026 deadline for the 2025 audit. GLRC will be engaging a new audit firm for the upcoming fiscal year. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: GLRC expects to be caught up for June 30, 2026
Finding 571785 (2023-003)
Significant Deficiency 2023
We will develop a checklist to ensure all documentation and eligibility requirements are met. We will review monthly with the teams to validate all documentation. During this review we will also make sure that all program directors are trained on the proper documentation and eligibility requirements...
We will develop a checklist to ensure all documentation and eligibility requirements are met. We will review monthly with the teams to validate all documentation. During this review we will also make sure that all program directors are trained on the proper documentation and eligibility requirements. Reasonable completion date: 06/30/25 Responsible Party: Erin Lasiter, VP Programs/Operations
The District will work with the Auditors to get the District caught up and ensure audits are submitted on time. There were no prior year findings in the Schedule of Findings and Questioned Costs in our audit for the year ended June 30, 2021.
The District will work with the Auditors to get the District caught up and ensure audits are submitted on time. There were no prior year findings in the Schedule of Findings and Questioned Costs in our audit for the year ended June 30, 2021.
Finding 2023-005 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF will enhance its internal processes and staffing to ensure the timely submission of future Single Audit Reporting Packages...
Finding 2023-005 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF will enhance its internal processes and staffing to ensure the timely submission of future Single Audit Reporting Packages. In January 2025, CDF hired an Outsourced Grant Manager dedicated to overseeing federal grant management, including the coordination and timely submission of all required audit and reporting packages. Key actions include:  Establishing and maintaining a robust timeline for audit activities, closely collaborating with both the accounting team and external auditors to guarantee adherence to submission deadlines.  Implementing a cross-training program within the accounting and compliance departments to mitigate the risk of disruption due to staff turnover, ensuring multiple staff members are proficient in handling audit-related tasks.  Scheduling regular internal audits and compliance checks to proactively identify and address potential issues well in advance of filing deadlines. Anticipated Completion Date: December 31, 2025.
Finding 2023-004 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF will conduct a thorough review and update of its reporting policies and procedures to ensure alignment with the requiremen...
Finding 2023-004 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF will conduct a thorough review and update of its reporting policies and procedures to ensure alignment with the requirements of Federal Awards. In January 2025, CDF hired an Outsourced Grant Manager responsible for overseeing the preparation, review, and submission of all grant-related reports. Key actions include:  Ensuring compliance with GAAP and federal regulations for timely and accurate submission of quarterly financial and progress reports.  Coordinating with relevant departments, managing grant accounting processing system submissions, and acting as the primary point of contact for grantor agencies regarding reporting matters.  Conducting mandatory training sessions for existing staff on the updated reporting procedures and compliance with federal requirements, with detailed instructions on Financial Reporting Forms emphasizing accuracy and timeliness.  Implementing a tracking system to monitor deadlines and the submission status of all required reports.  Scheduling regular internal audits to verify adherence to these reporting protocols and identify potential gaps in compliance. Anticipated Completion Date: December 31, 2025.
Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant adm...
Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant administration and compliance. The grant manager's duties will include ensuring that all reimbursement requests are substantiated by adequate documentation, such as actual invoices, payroll registers, and payment records. Key actions include:  Establishing a systematic process for the collection, organization, and retention of all requisite documents.  Implementing internal review and approval procedures to guarantee that every reimbursement request undergoes thorough vetting and receives approval prior to submission, with explicit documentation of the review process.  Instructing both existing and new personnel on these newly instituted procedures to prevent future inconsistencies. Anticipated Completion Date: December 31, 2025.
Finding 2023-002 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal a...
Finding 2023-002 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal awards, ensuring adherence to 2 CFR Part 200. The Outsourced Grant Manager will implement systems to accurately allocate salaries, wages, and other expenditures. Key actions include:  Payroll Expenditures: Establish procedures to approve payroll allocations based on actual time and effort reporting, requiring supervisor approval and periodic reviews for compliance.  Non-Payroll Expenditures: Develop approval processes for non-payroll expenses, ensuring detailed documentation and implementing checks to verify overhead allocations.  Documentation and Review: Implement a comprehensive filing system for approvals and supporting documents, with regular training for staff.  Ongoing Compliance Monitoring: Conduct periodic internal audits to ensure adherence to internal controls and federal regulations, addressing issues promptly. These measures will strengthen CDF’s internal controls, ensure compliance, and maintain the integrity of federal award management. Anticipated Completion Date: December 31, 2025.
View Audit 362526 Questioned Costs: $1
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