Corrective Action Plans

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Department of the Treasury Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR se...
Department of the Treasury Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend that the Organization review its procurement policy and conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR sections 200.318 and 200.326. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review and modify the procurement policy and conflict of interest policy and make all necessary changes for compliance. Name of the contact person responsible for corrective action: Michael Riso, CFO Planned completion date for corrective action plan: June 30, 2024
We concur with the assessment noted by the auditor.  During 2023 there was significant staff turnover in the department which led to a significant delay in reconciling certain account and their related balances in a timely manner. We will continue to further review and augment staffing levels, conti...
We concur with the assessment noted by the auditor.  During 2023 there was significant staff turnover in the department which led to a significant delay in reconciling certain account and their related balances in a timely manner. We will continue to further review and augment staffing levels, continue our cross-training efforts, and reestablish internal account reconciliations of accounts, especially for the grants receivable, loans receivable and cash and related bank accounts.  We will also refine our internal accounting checklists, work to ensure proper training of the accounting team, and have a responsible individual review and ensure account reconciliations are completed in a timely manner.
Finding 498873 (2023-002)
Material Weakness 2023
Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay Count...
Finding Number: 2023-002 Finding Title: Eligibility Program: Medical Assistance Program (AL No. 93.778) Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Director and Karen Syverson, Supervisor Corrective Action Planned: To address the findings from the recent audit, Clay County Social Services will take both immediate and long-term corrective actions. First, the case files identified with discrepancies will be revie.wed in detail, and necessary corrections will be made to ensure that the documentation in both the case files and the MAXIS system aligns with program requirements. Requests for case file numbers have already been submitted to the MA team lead to identify the cases needing correction. This will include reverification of asset amounts, we will match MAXIS's citizenship status with the appropriate documentation within the case file. In addition, one-on-one reviews will be conducted with the staff responsible for administering the affected cases. During these reviews, case-specific feedback will be provided, detailing the nature of the errors and explaining corrective actions to prevent recurrence. For long-term preventative measures, Clay County will implement a more comprehensive and mandatory training program for all staff involved in eligibility determination. This training will focus on key areas such as proper documentation for citizenship, asset verification, and data entry protocols to reduce human errors in MAXIS. We will continue conducting periodic case file audits with increased frequency to detect errors early and provide timely feedback to staff. Audit results will be shared with the entire team to promote learning from errors and reinforce best practices in documentation and data entry. Anticipated Completion Date: The cases found in error will be corrected by November 15, 2024. Case file reviews will continue monthly.
The City will ensure that the Annual MBE Report is filed.
The City will ensure that the Annual MBE Report is filed.
Views of Responsible Officials and Planned Corrective Actions: This condition was primarily the result of a heavy reliance on external subject matter experts (SMEs) for technical aspects of programmatic workplan deliverables, as well as the use of single-sourcing selection carveouts in the interests...
Views of Responsible Officials and Planned Corrective Actions: This condition was primarily the result of a heavy reliance on external subject matter experts (SMEs) for technical aspects of programmatic workplan deliverables, as well as the use of single-sourcing selection carveouts in the interests of efficiency, that are provided for in the organization’s procurement policies & procedures. These instances of single sourcing nonetheless required additional levels of documentation and justification when in use, which was always not the case. Starting in August 2024, all program and compliance staff will be re-trained on federal procurement policy documentation and justification requirements. The Organization will also embark on concerted efforts to expand its pool of qualified and eligible SME vendors, to ensure more reliance on competitive bidding and minimize the future use single-source procurement. A comprehensive review of current Organizational policies and procedures will also be undertaken, to ensure that they are aligned and consistent with current federal procurement guidelines and requirements. Responsible Official: Peter Kiburi, Senior Director of Finance.
Finding 2023-001 – Information Technology General Controls Identification of the federal program: Federal Program: Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing No. 84.063) and Federal Direct Student Loans (Assistance Listing No. 84.268) Federal Agency: United ...
Finding 2023-001 – Information Technology General Controls Identification of the federal program: Federal Program: Student Financial Assistance Cluster: Federal Pell Grant Program (Assistance Listing No. 84.063) and Federal Direct Student Loans (Assistance Listing No. 84.268) Federal Agency: United States Department of Education BJC HealthCare Location: Goldfarb School of Nursing (GSON) Award Periods: January 1, 2023 through June 30, 2023 (included in award year July 1, 2022 through June 30, 2023) and July 1, 2023 through December 31, 2023 (included in award year July 1, 2023 through June 30, 2024) Views of responsible officials and planned corrective actions: BJC HealthCare (BJC) agrees with the findings as reported. GSON is committed to complying with program requirements and meeting program objectives as defined in Section 200.303(a) of the Uniform Guidance, regarding auditee internal controls. To facilitate these requirements, GSON has instituted the following controls: • Establishment of a formal provisioning and deprovisioning process for Banner system access • Refinements to formal access review process to include an independent review of system access, as well as an overseer or manager approval. • Establishment of a formal testing process for Banner system patches or updates to include review from key functional areas within GSON. Responsible Parties: Michael Durbin, Interim Director Information Technology, Goldfarb School of Nursing Completion Date: The corrective action plan was implemented in Q3 2024
Timesheets will be updated to reflect all active programs and support functions. The worksheet that is used to compile employee hours will be used for allocations in the financial system and on the grant cost reports, so that all systems align. Tony Kearney Sr. is responsible for compliance and the ...
Timesheets will be updated to reflect all active programs and support functions. The worksheet that is used to compile employee hours will be used for allocations in the financial system and on the grant cost reports, so that all systems align. Tony Kearney Sr. is responsible for compliance and the implementation is expected in September 2024.
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster FFAL #10.766 Finding Summary: During review of expenditure listings, three expenditures were claimed under the USDA Grant Program after the Center received an advancement of U...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster FFAL #10.766 Finding Summary: During review of expenditure listings, three expenditures were claimed under the USDA Grant Program after the Center received an advancement of USDA loan funds for those same three expenditures. We did not have a formal review process in place over the USDA Grant expenditure listing and the USDA loan advancement to ensure double dipping was not occurring. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: Due to staffing shortages there was no review of the grant applications to check for duplicate coverage. A Controller was hired November 20, 2023 to allow for reviews of documents and spreadsheets prior to submission. Anticipated Completion Date: 2025
View Audit 321577 Questioned Costs: $1
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster FFAL #10.766 Finding Summary: The Center did not have a formal process in place for formal review of the monthly reserve fund account reconciliations as compared to the requir...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster FFAL #10.766 Finding Summary: The Center did not have a formal process in place for formal review of the monthly reserve fund account reconciliations as compared to the required minimum balance. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Corrective Action Plan: Management will include the Debt Reserve balance reporting in the Governing Board Packets each month for review and approval to meeting the required minimum balance. Anticipated Completion Date: 2025
Finding 2023-002 - Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SCLFRF) ALN 21.027 Reporting Recommendation: We recommend the County ensure proper correction of previously submitted reports. Corrective Action Plan (as originally stated 09/27/2023 ...
Finding 2023-002 - Reporting U.S. Department of Treasury COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SCLFRF) ALN 21.027 Reporting Recommendation: We recommend the County ensure proper correction of previously submitted reports. Corrective Action Plan (as originally stated 09/27/2023 with edits to show current status: We concur with the importance of this recommendation. Our general ledger continues to record properly all transactions. Some entries for prior years are duplicated in the US Treasury Reporting System. In late 2023 we established a tracking worksheet in which we have posted our general ledger transaction data, classifying each expenditure since inception by the "project" and by the quarter in which it was made. We used the tracking worksheet to complete prior to the due date the report for the quarter ending September 30, 2023, and filed timely the subsequent reports for the quarters through June 30, 2024. The following step has not yet been done due to time and staffing constraints. It will be completed by December 31, 2024. "We will use the tracking worksheet to work with the U.S. Treasury "Help Desk" to determine the proper protocol to resolve all prior reporting duplications and to revise the previous quarterly reports so each quarter's cumulative expenditures agree with the County general ledger.
Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly revie...
Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and quarterly review and testing of compliance with Center sliding fee discount policy is ongoing.
The required reporting package for the year ended December 31, 2022, was not submitted to the Federal Audit Clearinghouse (FAC) in a timely manner. Planned Corrective Action: CSG will ensure appropriate staff have adequate time to prepare for the audit and work with t he audit firm to make sure the ...
The required reporting package for the year ended December 31, 2022, was not submitted to the Federal Audit Clearinghouse (FAC) in a timely manner. Planned Corrective Action: CSG will ensure appropriate staff have adequate time to prepare for the audit and work with t he audit firm to make sure the reporting package is submitted by the due dates. Name of Contact Person: Rich Kisner, Executive Director Anticipated Completion Date: Prior to the issuance of the 2023 financial statements.
Finding 498803 (2023-001)
Significant Deficiency 2023
Name of Entity: County of Burlington Type of Audit: 2023 Annual Audit Contact Person: Carolyn Havlick Contact Person Title: Chief Financial Officer Phone Number: 609-265-5018 Email: chavlick@co.burlington.nj.us Information on the Federal Programs U.S. Department of Labor Passed through State of N...
Name of Entity: County of Burlington Type of Audit: 2023 Annual Audit Contact Person: Carolyn Havlick Contact Person Title: Chief Financial Officer Phone Number: 609-265-5018 Email: chavlick@co.burlington.nj.us Information on the Federal Programs U.S. Department of Labor Passed through State of NJ Department of Labor WIOA Cluster: WIOA Adult Program (Assistance Listing No. 17.258) WIOA Youth Activities (Assistance Listing No. 17.259) WIOA Dislocated Workers Formula Grants (Assistance Listing No. 17.278) Finding/Recommendation Number: 2023-001 Finding: Some expenditure reports were not filed by the 15th of each month. Corrective Action: Expenditures reports will be always filed by the 15th of each month. Method of Implementation: Additional Finance Office Staff will be assigned. Individual Responsible for Implementation: Chief Financial Officer and/or designee. Completion Date of Implementation: 10/1/24-12/31/24
Condition: The total amount of expenditures originally reported on the SEFA excluded $1,024,472 of expenditures related to the Congressional Directives program. Planned Corrective Action: Livingston County will implement a review process going forward to ensure all expenses are included on the SEFA....
Condition: The total amount of expenditures originally reported on the SEFA excluded $1,024,472 of expenditures related to the Congressional Directives program. Planned Corrective Action: Livingston County will implement a review process going forward to ensure all expenses are included on the SEFA. Contact person responsible for corrective action: Cynthia Arbanas, Deputy County Administrator Anticipated Completion Date: 12/31/2024
Management has enhanced internal controls over restricted contributions and grants with a system to track revenue and expenses for restricted funds. Inspiration has already hired a compliance administrator with the responsibility of tracking all local, state, and federal grant revenues and expenditu...
Management has enhanced internal controls over restricted contributions and grants with a system to track revenue and expenses for restricted funds. Inspiration has already hired a compliance administrator with the responsibility of tracking all local, state, and federal grant revenues and expenditures. Inspiration has implemented strategies to increase operating and unrestricted funds through 2024 and 2025 such as but not limited to targeting personal monthly Impact Partners and local Kingdom Church Partners. Inspiration has MOUs in place with local manufactures to implement a workforce pipeline to increase revenue for operations. Inspiration has made a considerable effort to improve cash flow and trim expenses to finish fiscal year 2024 with positive operating cash.
Management has included Butler CPA to help with accurately reporting and documenting internal and third-party transactions.
Management has included Butler CPA to help with accurately reporting and documenting internal and third-party transactions.
On June 30, 2022, Inspiration implemented a Document Retention and Destruction Policy that is still currently active and followed.
On June 30, 2022, Inspiration implemented a Document Retention and Destruction Policy that is still currently active and followed.
Management, with the inclusion of Butler CPA firm, will incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements and increase the accuracy of the interim financial reports used by management. The Organization has implemented ...
Management, with the inclusion of Butler CPA firm, will incorporate financial reporting internal controls to detect material adjustments, prevent materially misstated financial statements and increase the accuracy of the interim financial reports used by management. The Organization has implemented Administration Responsibilities January 1, 2024, to alleviate all material adjustments and lack of documentation.
Condition: During compliance testing, it was identified that an employee's wages were being charged to the grant after the employee was terminated. Corrective Action Taken or Planned: Management noted there was turnover in fiscal year 2023 which led to lack of some reviews. Controls have been pu...
Condition: During compliance testing, it was identified that an employee's wages were being charged to the grant after the employee was terminated. Corrective Action Taken or Planned: Management noted there was turnover in fiscal year 2023 which led to lack of some reviews. Controls have been put in place to ensure all worksheets are viewed for accuracy by the CFO prior to requesting drawdown amount. Name(s) of Contact Person(s) Responsible for Corrective Action Coleen Elias, Chief Executive Officer, Community Clinical Services. Anticipated Completion Date: Controls have been implemented as of the date of the audit report.
View Audit 321492 Questioned Costs: $1
In mid-2024 the organization implemented procedures to collect client intake data at the largest program identified in testing and expects to be following intake guidelines for all programs by the end of 2024.
In mid-2024 the organization implemented procedures to collect client intake data at the largest program identified in testing and expects to be following intake guidelines for all programs by the end of 2024.
Finding 2023-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evid...
Finding 2023-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to review and approve FEMA expenditures submitted to the FEMA Portal. Corrective Action Plan: Management will ensure documentation is retained to evidence the controls were performed. Responsible Party: Wah-chung Hsu, Chief Financial Officer Anticipated Completion Date: December 31, 2024
Corrective Action Plan September 25, 2024 Federal Audit Clearinghouse County of Orleans respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: EFPR Group, CPAs, PLLC 100 South Clinton Avenue, Suite 15...
Corrective Action Plan September 25, 2024 Federal Audit Clearinghouse County of Orleans respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: EFPR Group, CPAs, PLLC 100 South Clinton Avenue, Suite 1500 Rochester, NY 14604 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING – FINANCIAL STATEMENT AUDIT FINDING 2023-001 - Material Weakness in Internal Control Over Financial Reporting - Material Adjustments Condition: The County is responsible for maintaining a proper system of controls to allow for all year end adjustments to be made prior to the preparation of the Annual Financial Report (AFR) and the start of the audit. Criteria: A proper system of controls would result in the County making all required year end closing adjustments prior to the preparation of the AFR and the start of the audit. Cause: Auditors were required to make material adjustments as part of the year end audit process. Effect of Condition: The County does not have the controls in place to make all required year end closing entries which resulted in material adjustments as part of the audit process. Recommendation: The County should re-evaluate the year end close process to ensure all required year end closing adjustments are completed timely. A training should be held with all employees involved with year end closing to review the process. Views of Responsible Officials and Planned Corrective Actions: The County Treasurer has created a written Year End Adjustment checklist for the County Treasurer and Deputy County Treasurer to both check and sign before the Annual Financial Report (AFR) is filed with the State Comptroller to ensure all normal year end adjustments are accounted for, justified and confirmed. FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAM AUDIT 2023-002 - CCDF Cluster - Child Care Development Block Grant - Assistance Listing No. 93.575; Grant Period - For the year ended December 31, 2023 Condition: Currently the senior social welfare examiner who handles the child care development block grant program processes the application and determines eligibility. There is no requirement for the documentation of review and approval by a secondary individual over this process. Criteria: Implementing internal controls that provide for segregation of duties over the child care development block grant would involve a secondary reviewer resulting in more than one individual being responsible for the entire process. Documenting this secondary approval process would provide for confirmation that the segregation of duties has occurred. Cause: The County does not have procedures in place to require a secondary review on the application process and eligibility determination. Effect of Condition: The County's internal control system for the child care development block grant was not designed to provide segregation of duties and the related documentation. Questioned Costs: None. Statistical Sampling: The sample was not intended to be, and was not, a statistically valid sample. Recommendation: The County should consider revisiting the segregation of duties over application and eligibility process to provide for a documented review and approval over the process. Views of Responsible Officials and Planned Corrective Actions: Effective immediately, 100% of new, denied and closed Child Care applications and 10% of recertification applications will be reviewed by a supervisor to verify that: o All required documentation is present in the case file. o All information was correctly entered into the electronic Child Care Time and Attendance system which determines eligibility. o A correct eligibility determination was produced. Contact Person Responsible for Corrective Action: Kimberly DeFrank, Orleans County Treasurer – finding 2023-001 and Holli Nenni, DSS Commissioner – finding 2023-002. Anticipated Completion Date: The corrective action plan was completed by September 27, 2024. If the Federal Audit Clearinghouse has questions regarding this plan, please call Kimberly DeFrank at 585-589-5353. Sincerely yours, Kimberly DeFrank
Management will restore funds to replacement reserve account when project funds become available. Management will review reserve withdrawals prior of release of funds from the reserve account to verify the release is approved by the HUD account executive and the release is not a duplicate. The app...
Management will restore funds to replacement reserve account when project funds become available. Management will review reserve withdrawals prior of release of funds from the reserve account to verify the release is approved by the HUD account executive and the release is not a duplicate. The approval will be reviewed by the person initiating the request and verified by the project bookkeeper.
Finding 498736 (2023-001)
Significant Deficiency 2023
Management agrees with the finding and has already implemented approval processes prior to purchasing. We have also implemented itemized receipts required for all purchase in our expense management software.
Management agrees with the finding and has already implemented approval processes prior to purchasing. We have also implemented itemized receipts required for all purchase in our expense management software.
View Audit 321411 Questioned Costs: $1
Finding 498729 (2023-005)
Significant Deficiency 2023
Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MN5MAP, 2023 Pass-Through Agency: Minnesota Department of Human Service...
Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award ldentification Number and Year: 2305MNSADM and 2305MN5MAP, 2023 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Number: 2305MN5ADM and 2305MNSMAP Award Period: Year-Ended December 31, 2023 Type of Finding: Signiflcant Deficiency in lnternal Control over Compliance Recommendation: lt is recommended the County increase review over casefiles and ensure that there are performed on a periodic basis throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will adhere to established procedures and policies. Name of the contact person responsible for corrective action plan: Barb Dietz, Human Services Director Planned completion date for corrective action plan: December 31, 2024
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