Corrective Action Plans

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Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20...
Finding 2023-002 - Source Documentation (Significant Deficiency) CFDA Title and Number: 20.513 (5310) Enhanced Mobility of Seniors and Individuals with Disabilities. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management CFDA Title and Number: 20.509 (5311) CARES 5311 Operating Assistance. Formula Grants for Rural. Name of Federal Agency: Transit Services Program Cluster Internal Control over Compliance: Cash Management Criteria: 2 CFR Part 200.302(b)(1) The financial management system of each non-federal entity must provide for the following: Identification, in its accounts, of all Federal awards received and expended and the Federal programs under which they were received. 200.302(b)(2) Accurate, current, and complete disclosure of the financial results of each Federal award or program in accordance with the reporting requirements set forth in 200.328 and 200.329. Condition: The District prepared reimbursement calculations according to an internally developed spreadsheet tool, rather than using amounts directly obtained from the general ledger and supporting documentation. Cause: General ledger data used to prepare spreadsheets, then used to complete reimbursement requests added unnecessary complexity and potential for errors in the reimbursement and request and grant reporting process. Internal control procedures assuring accurate and timely review of reports and filing of the reimbursement requests were not designed or implemented. Effect or Potential Effect: The lack of effective internal control activities over financial reporting could allow for inadvertent errors, such as calculation errors, payments for unauthorized purposes, and result in improper grant accounting, reporting, and reimbursement. Questioned Cost: No Context: Internal disputes regarding grant reimbursement request procedures were evident. The weak or nonexistent controls over the reimbursement request procedures created a potential for inaccurate, incomplete reporting. Repeat of a Prior-Year Finding: Yes, Findings and Questioned Costs 2022-003 Recommendation: The District should continue to improve grant accounting efforts, and establish a more simplified and effective process for the review and approval of grant accounting and reimbursement requests. Additional training of management should occur to ensure they fully understand all compliance regulations and have the skills to assist in designing and implementing effective controls. Monitoring of the control procedures related to the grant accounting and reimbursement request should be performed regularly to ensure reports are filed accurately and timely. Information and communication regarding identified weaknesses and opportunities to improve the policies and procedures should occur among management and the individual performing the monitoring of the procedures. District's Response: The District’s Finance Manager and District Manager are working towards using general ledger reporting exclusively for reimbursement request reporting. General ledger activity became more timely as improvements were implemented based on prior year findings. Management acknowledges delays in that process that continued as a result, to some extent, of the use of the self-developed spreadsheet reports then used for completing grant reimbursement requests. Corrective Action Plan: The District’s Finance Manager will continue to make improvements in general ledger recording and reporting systems so that those reports can then be used without intermediary report methods to prepare reimbursement request forms. Review of the reimbursement requests will take place within data reports generated directly from the general ledger. The district will engage an individual or firm to ensure that the timing and overall processes related to grant reimbursement and reporting does not result in reporting errors or omissions. . Planned Implementation Date: September 30, 2024 Responsible Person: General Manager, Umpqua Public Transit District
Management agrees with the finding. Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will provide a new updated Federal Awards ...
Management agrees with the finding. Management will update current policies and procedures and review and enforce the polices. Management will be responsible for proper documentation and confirmation that all policies and procedures are followed. Management will provide a new updated Federal Awards and Accounting Manual to all management of Federal Awards.
View Audit 323241 Questioned Costs: $1
2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management ...
2023-003- Significant Deficiency - Segregation of Duties WPHW understands this finding and recognizes that corrections that were planned for FY23 were not able to be fully implemented. Our prior year corrective actions and business process were redesigned to work with our new financial management system, NetSuite. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks, and the NetSuite changes would have demonstrated our corrective action for the segregation of duties, since this was part of the software’s functionality. However, we encountered several issues with the implementation of the new system and WPHW decide to move away from NetSuite in May 2024. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. WPHW has implemented the following process to ensure the separation of duties: 1) AR/AP Specialists and Accounting Specialists will have access to the accounting software and will not have any access to the bank accounts for entry of information. 2) Accountants, Accounting Manager and AR/AP Manager will have read-only access to the bank accounts and full access to the accounting software to verify and review day-to-day transactions. 3) The Director of Accounting will have full access to the bank and review only access to the accounting software to do the proper review process. 4) Tasks can be handed off between staff within each level, but to ensure appropriate separation of duties, task cannot cross levels With these implemented there will be clear separation of duties this will allow mitigating of procedures to be formed by somebody who has full access to both systems to help ensure that there is no cross between any possible chance of fraud and decrease risk of significant errors and/or misstated financial statements. Access for the Director of Accounting to make adjustments will be cut off by October 1, 2024, at which time the process will be fully implemented. With this process in place, we anticipate this issue being fully resolved in FY25.
2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our...
2023-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections that were planned for FY23 did not come to fruition due to the challenges with implementing a new financial management system. Despite these challenges, WPHW has made strides in improving our year-end processes and acknowledges that there is additional improvement needed. For FY23, WPHW created a year-end check list and started the review process. Unfortunately, due to staff absences and NetSuite issues, we were not able to fully implement these changes. Both situations have provided us with lessons learned for how to correctly implement changes in the future. For FY24, WPWH implemented the following process: 1) Full year-end check list is distributed and review by staff (Accounting Specialists, Accountants, and AR/AP Specialists) prior to year-end for review and training, conducted by the Director of Accounting and Accounting Manager a. Review each step with staff and provide training on the expectation for each step 2) Accounting Specialists and Accountants complete necessary year-end tasks 3) Accounting Manager reviews all completed tasks to ensure accuracy and completeness 4) Director of Accounting conducts a final review and signs off at the end of the year With this clear process in place, we anticipate this issue being fully resolved in FY24.
2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new ...
2023-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and recognizes that corrections that were planned for FY23 did not come to fruition. WPHW was in the process of implementing a new financial management system, NetSuite. It was our plan to implement new processes that would have fully addressed prior concerns. It was our plan to have the FY23 audit completed in both NetSuite and QuickBooks. However, we encountered several issues with the implementation of the new system, which delayed prior year corrected actions. In May 2024, WPHW decide to no longer work with NetSuite, due to the number of issues with the system and the company. Since that time, we have fully committed to QuickBooks and have started engaging in systematic business process redesign of our financial system. At the time of the transition back to QuickBooks fully, we also made significant staff role changes. Our accounting department now has a Director of Accounting and two new managers, AR/AP Manager and Accounting Manager. With these new positions, we have developed the following procedures for adjusting journal entries: 1) Accounting Director, Accounting Manager or AR/AP Manager identifying need for a journal entry 2) Accounting Specialist or AR/AP Specialist pulls the supporting documentation for the required entry, creates journal entry template in Excel, and prepares journal entry packet with supporting documentation for entry into QB. 3) Accountant or Accounting Manager reviews packet and determines who can enter journal a. If reviewed by Accountant, entry is entered QuickBooks by Accounting Specialist b. If reviewed by Accounting Manager, entry is entered into QuickBooks by Accountant 4) Once journal entry is entered into QuickBooks, entry is printed from QB system and added to packet. The packet is returned to the preparer to ensure all elements were completed corrected and signed off on 5) Completed packet goes to filing and are scanned into our electronic file system All adjustments must go through three different individuals to ensure separation of duties. This process will be implemented during Q4 of FY24. The Director of Accounting will go back over all the journals completed before this date to review how each were completed and delegate additional review to the Accounting Manager and Accounting Specialist to ensure each journal entry had appropriate review and support. With this process in place, we anticipate this issue being fully resolved in FY25.
Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Pro...
Planned Corrective Action: We will implement a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. This will be completed with each drawdown that is request where a cost match is reported. Name of Contact Person: Lisa Daniels, Program Director & Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024
Planned Corrective Action: Executive Director will be tracking their time spent on specific grants on a weekly basis. The Board of Directors will review and approve the time summary at least quarterly. Executive Director non‐payroll reimbursements will also be reviewed and approved by at least one b...
Planned Corrective Action: Executive Director will be tracking their time spent on specific grants on a weekly basis. The Board of Directors will review and approve the time summary at least quarterly. Executive Director non‐payroll reimbursements will also be reviewed and approved by at least one board member. The Program Director will provide oversight of these two newly established processes. Name of Contact Person: Rhonda Conn, Program Director Anticipated Completion Date: October 1, 2024
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memori...
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memorial Hospital Corporation’s (Grady) CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional management review of the SEFA to include the prior of any submission and to provide evidence of the related review Grady’s corrective action plan: Grady Memorial Hospital Corporation has implemented a new review policy for the submissions of PRF reports which also includes a new reporting and review procedure that are performed by the Controller and Tax & Technical Accounting Manager. GMHC will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained within the timeline it was signed. Contact person/s responsible for the correction action: Gina Smith, VP, Fiscal Service/Controller Anticipated Completion Date: Grady Memorial Hospital Corporation has implemented controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained.
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2024
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2024
View Audit 323201 Questioned Costs: $1
Finding 500429 (2023-005)
Significant Deficiency 2023
ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sa...
ELIGIBILITY Recommendation: The County should implement additional procedures to ensure case file reviews are being performed on a regular basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Supervisor will sample and perform a quality review on a quarterly basis to ensure case workers are accurately assessing eligibility. Review will be documented. Supervisor will review at least 1 casefile for each caseworker per quarter and randomly pull additional cases from new caseworkers. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024
Finding 500426 (2023-004)
Significant Deficiency 2023
REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in ...
REPORTING Recommendation: The County should design procedures and controls to ensure all reports are formally reviewed, all deadlines are met, and supporting documentation is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2024
Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CA...
Tom Keller, Executive Director, Jill Liebelt, CFO, & Chris Brungardt, CEO Corrective Action Plan The Authority will review its policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP December 31, 2024
The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.
The Authority will update their internal control policies over eligibility to require a review of the tenant file from another qualified personel and have a checklist to ensure compliance.
View Audit 323183 Questioned Costs: $1
The County will ensure that procedures are in place to ensure support is maintained on file for eligibility determinations.
The County will ensure that procedures are in place to ensure support is maintained on file for eligibility determinations.
View Audit 323181 Questioned Costs: $1
Finding 2023-004: Federal Procurement Requirements for Policies and Documentation a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities in response to a formal Request for Proposal are consistent with current federal requireme...
Finding 2023-004: Federal Procurement Requirements for Policies and Documentation a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities in response to a formal Request for Proposal are consistent with current federal requirements and specifically with the regard to ensuring that proper documentation and records are maintained in sufficient detail to support the history of each procurement transaction by having three competitive bids and retaining the bids in the procurement file. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately. c. Person Responsible for Corrective Action: Executive Director in conjunction with the Board of Directors.
View Audit 323177 Questioned Costs: $1
Finding 2023-003: Federal Procurement Requirements for Suspension and Debarment a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities are consistent with the current federal requirements and specifically with the regard to ensurin...
Finding 2023-003: Federal Procurement Requirements for Suspension and Debarment a. Responsible Official’s Response: Management will modify its internal control practices to ensure procurement activities are consistent with the current federal requirements and specifically with the regard to ensuring contractual parties are not disbarred. This is to ensure compliance with HUD entering into contracts with vendors who are disbarred or suspended from participation in federal programs. Maintain documentation in each vendor file to verify selected vendors are not disbarred or suspended. b. Planned Implementation Date of Corrective Action: Management will implement this change immediately to ensure proper documentation is in place for selected vendors. c. Person Responsible for Corrective Action: Executive Director
View Audit 323177 Questioned Costs: $1
Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be ta...
Contact Person: Melissa McCoy Management’s Response: As part of the submission of expenses into the Provider Relief Portal, Princeton Community Hospital inadvertently submitted expenses for payroll and supplies expense that were ineligible. As a result, the following corrective actions will be taken to prevent ineligible expenses from being submitted in the future: • Exclude all ineligible expenses from any future Provider Relief Fund Portal submissions. • Offset the ineligible costs with lost revenues and unreimbursed expenses attributable to Corona virus. Princeton Community Hospital was a new acquisition into West Virginia University Health System as of January 1, 2023 and had not fully integrated into our processes at the time that this portal submission was completed. Upon further review, Princeton Community Hospital had lost revenues that support a significant portion of the funding received for this reporting period. Those lost revenues, along with eligible expenses, fully support the funding received. Completion Date: 09/27/2024
Contact Person: Justin Gibson Management’s Response: Effective September 30, 2023, United Summit Center’s Grants G230723 Regional Jail and G230772 were renewed and as part of that renewal the monthly grant reporting date was moved from the 25th of the month to the 15th of the month. Management di...
Contact Person: Justin Gibson Management’s Response: Effective September 30, 2023, United Summit Center’s Grants G230723 Regional Jail and G230772 were renewed and as part of that renewal the monthly grant reporting date was moved from the 25th of the month to the 15th of the month. Management did not identify the earlier required monthly reporting deadline as part of the renewal and continued to submit monthly grant reports following the former reporting timeline which caused the monthly reports to be submitted late for the months of October 2023 through March 2024. Management identified the discrepancy and began submitting the monthly reporting timely with reporting for April. Going forward Management reviews the reporting timely requirements of all new grant agreements and grant agreement renewals to ensure required monthly reporting deadlines are met. Completion Date: 04/15/2024
The Management of Riderwood Village, Inc. and its subsidiary prioritize implementing and maintaining effective internal controls, particularly with respect to funds received from the Federal government. Through ongoing communication, training, and consistent policy enforcement, Management has contin...
The Management of Riderwood Village, Inc. and its subsidiary prioritize implementing and maintaining effective internal controls, particularly with respect to funds received from the Federal government. Through ongoing communication, training, and consistent policy enforcement, Management has continued to promote sound business practices and strong internal controls throughout Riderwood Village, Inc. and its subsidiary. The following outlines Management’s Views and Corrective Action Plan concerning the Schedule of Findings and Questioned Costs for the year ended December 31, 2023. Finding 2023-001: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Reporting Cluster: Not applicable Federal Agency: Department of Health and Human Services (“HHS”) Award Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution – Period 5 Award Year(s): January 1, 2020 – December 31, 2023 Management acknowledges the issue identified in the audit. Based on the email evidence provided, Management confirms that all proper authorizations were obtained, and the disbursement of the stay bonus to employees were deemed allowable. Prospectively, Management remains committed to ensuring the accuracy and compliance of all disbursements under the Provider Relief Fund and ARP Rural Distribution programs.
Management established formalized internal controls in the second quarter of 2023, approved by the Board of Directors, with all fund requests approved by the Executive Director and the CFO.
Management established formalized internal controls in the second quarter of 2023, approved by the Board of Directors, with all fund requests approved by the Executive Director and the CFO.
View Audit 323160 Questioned Costs: $1
Management has implemented and adopted a new procurement policy effective May 2023 regardless of dollar value that will maximize open and free competition and that the Trust shall not engage in procurement practices which may be considered arbitrary or restrictive. Purchases will be reviewed by the ...
Management has implemented and adopted a new procurement policy effective May 2023 regardless of dollar value that will maximize open and free competition and that the Trust shall not engage in procurement practices which may be considered arbitrary or restrictive. Purchases will be reviewed by the Tule Trust Finance Committee to prevent duplication and to ensure that costs are reasonable.
View Audit 323160 Questioned Costs: $1
Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 202...
Finding Number: 2023-005 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), there was no evidence that reports were reviewed for completeness and accuracy prior to submission. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed and approved by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024
Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to e...
Finding Number: 2023-004 Condition: Related to the Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027), the City did not retain evidence that they performed the suspension and debarment check prior to entering into the contract. Planned Corrective Action: Procedures will be enhanced to ensure prior to entering into an agreement with an outside entity using federal funds, the City will perform the suspension and debarment check. Documentation of this review will be retained with the grant documents. In addition, the City will research grant management software options to further enhance grant monitoring. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024
Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establ...
Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024
Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Divi...
Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024
View Audit 323157 Questioned Costs: $1
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