Corrective Action Plans

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Finding Number: 2023-002 CFDA Number: 14.157 – Supportive Housing for the Elderly Recommendations: Periodically throughout the year management should perform a proof of the account to make sure it is correct. Management Response: The processing of Reserve Requests is usually ceased at the end of bud...
Finding Number: 2023-002 CFDA Number: 14.157 – Supportive Housing for the Elderly Recommendations: Periodically throughout the year management should perform a proof of the account to make sure it is correct. Management Response: The processing of Reserve Requests is usually ceased at the end of budget season to ensure accuracy. This error was overlooked while pending approval and execution of the new budget. A deposit will be made immediately to rectify the amount– this will be completed prior to the end of the current fiscal year.
Finding number 2023-001 CFDA Number:14.157 – Supportive Housing for the Elderly Recommendations: When preparing reserve requests management should match invoices to the request and make sure invoices not already paid are paid timely paid after the withdrawal is made and have not been used for previo...
Finding number 2023-001 CFDA Number:14.157 – Supportive Housing for the Elderly Recommendations: When preparing reserve requests management should match invoices to the request and make sure invoices not already paid are paid timely paid after the withdrawal is made and have not been used for previous requests. Management Response: Management’s internal process for tracking and reviewing Replacement Reserve requests was revised in October 2023. The procedure now involves internal reviews of invoices by two separate parties, as well as an on-going shared tracking system for requests, prior to submission to avoid duplication.
Identifying Number: Finding 2023-002 – Federal Funding Accountability and Transparency Act Reporting (Significant Deficiency) Finding: Reports in compliance with the Federal Funding Accountability and Transparency Act (FFATA) were not completed. U.S. Department of Health and Human Services, Head ...
Identifying Number: Finding 2023-002 – Federal Funding Accountability and Transparency Act Reporting (Significant Deficiency) Finding: Reports in compliance with the Federal Funding Accountability and Transparency Act (FFATA) were not completed. U.S. Department of Health and Human Services, Head Start Cluster: Assistance Listing Number 93.600 Name of contact person and title: David Chimahusky, CFO, GLCAP Anticipated completion date: July 31, 2024 Great Lakes Community Action Partnership’s response: Concur Great Lakes Community Action Partnership agrees with this finding and provided the following response and corrective actions: Corrective Actions Taken or Planned: Management agrees that ineffective controls resulted in missed reporting required by the Federal Funding Accountability and Transparency Act (FFATA). To correct this, management will review all current awards for reporting applicability and will develop procedures to ensure all future awards are evaluated for FFATA reporting requirements and submitted in a timely manner. Tracking of awards and FFATA submission dates will be maintained for regular secondary review. Person(s) Responsible for Implementation: David Chimahusky, CFO
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action pla...
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has addressed the finding that its policies and procedures over reimbursement requests for federal funds lacked proper documentation of approvals according to the Uniform Guidance for federal grants. We have added a step in the online submission process with the Substance Abuse and Mental Health Services Agency (SAMHSA) to capture a screenshot of the reimbursement form to be approved before submission. Due to the timing of the FY 2022 Single Audit completion and the ending of the CCBHC contract, we were limited in the execution of this new procedure, however it is now part of our Single Audit accounting Policies and Procedures Manual. Anticipated completion date: Completed September 2023.
Finding: 2023-002 - Written policies required by the Uniform Guidance Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned:...
Finding: 2023-002 - Written policies required by the Uniform Guidance Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has implemented written policies and procedures for Single Audit accounting that comply with the Uniform Guidance for federal grant payments, procurement, allowable costs, and compensation. They will also be posted online via the company website for access by all staff. Going forward, these policies will be reviewed and updated as needed following the general CLR process for all policies and procedures. Anticipated completion date: Completed September 2023.
Views of Responsible Individuals and Planned Corrective Action - Management is attempting to repay $35,248 into the replacement reserve over the next 12 months. Management is awaiting response from HUD regarding receiving the balance due for the voucher which was not paid in full. Completion date - ...
Views of Responsible Individuals and Planned Corrective Action - Management is attempting to repay $35,248 into the replacement reserve over the next 12 months. Management is awaiting response from HUD regarding receiving the balance due for the voucher which was not paid in full. Completion date - March 31, 2025 Contact person - Sonal Shah, Controller
Views of Responsible Individuals and Planned Corrective Action - Management is aware of the deposit requirements and has funded the delinquent amount. Completion date - March 20, 2024 Contact person - Sonal Shah, Controller
Views of Responsible Individuals and Planned Corrective Action - Management is aware of the deposit requirements and has funded the delinquent amount. Completion date - March 20, 2024 Contact person - Sonal Shah, Controller
Corrective Action Plan – Infor Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Marley Crowell Title: Senior Director, Finance Systems Telephone: 617-780-6400 E-mail address: marley.crowell@bmc.org Audit Report Reference: 2023-002 Anticipated Completion Da...
Corrective Action Plan – Infor Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Marley Crowell Title: Senior Director, Finance Systems Telephone: 617-780-6400 E-mail address: marley.crowell@bmc.org Audit Report Reference: 2023-002 Anticipated Completion Date: September 30, 2025 Corrective Action Planned: 1) For the Infor user access review deficiency: a. Management has scoped and performed limited access reviews in FY2024 related to privileged administrative access. b. Management has worked to identify financially significant Infor user security roles in order to properly scope and implement business user access reviews starting in FY2024, noting that the implementation timeframe will span FY2024 and FY2025. c. IT management will be working with operational management to educate as to how to properly perform access reviews, and then to implement those reviews starting in FY2024 and FY2025. d. Once reviews have been performed, IT management will assess the results and terminate any access deemed to be unnecessary. As part of this process IT management will perform risk assessment procedures for these users if deemed necessary (e.g. if no other controls are in place to mitigate the perceived risk, etc.). 2) For the access termination deficiency: a. Management completed an education session for BMC leaders in FY24 which included the importance of the termination process including timeliness of employee terminations by the business to HR and IT via the established pathways of communication of these items. b. The established process would automatically allow for very timely termination of access provided that initial notification was timely. c. Communication and/or education about timely termination of employees will be repeated at intervals throughout the year in order to reinforce the message and account for changes in management personnel, who are tasked with this process.
Corrective Action Plan – Workday Fiscal Year Ended September 30, 2023 Program name: Research and Development Cluster (R&D) and Provider Relief Fund (PRF) (93.498) Audit Contact: Matthew O’Connor Title: Senior Director, Human Resources Operations & Analytics Telephone: 617-638-8495 E-mail address: ...
Corrective Action Plan – Workday Fiscal Year Ended September 30, 2023 Program name: Research and Development Cluster (R&D) and Provider Relief Fund (PRF) (93.498) Audit Contact: Matthew O’Connor Title: Senior Director, Human Resources Operations & Analytics Telephone: 617-638-8495 E-mail address: Matthew.OConnor@bmc.org Audit Report Reference: 2023-001 Anticipated Completion Date: December 31, 2024 Corrective Action Planned: 1) For the Workday change review, management has been re-educated on the importance of this review as well as how to complete it completely and timely. Management will perform this review for the fiscal year ended September 30, 2024 and each subsequent fiscal year. Additionally, this review will be timely reviewed by somebody separate from the preparer and the documentation of the review and subsequent approval will be retained in BMC’s records. 2) For the access provisioning deficiency, management has been re-educated on the importance of following policy with respect to granting new access to Workday, including that this granting of access be appropriately documented and approved prior to the date of provisioning said access. Additionally, documentation of the approval of access will be properly retained in the company’s records.
Finding 404938 (2023-001)
Significant Deficiency 2023
Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.568 Low Income Home Energy Assistance Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of taking the LIHEAP Operators Guide and creating an Action Policy/Procedure manual ...
Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.568 Low Income Home Energy Assistance Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of taking the LIHEAP Operators Guide and creating an Action Policy/Procedure manual updating /highlighting findings from current and past audits for staff to keep current and for new staff to review when they start working in the LIHEAP program. At the start of the LIHEAP program year, the Energy Director will meet with all staff and review program highlights, changes and new instructions and have staff signoff having participated in the meeting. Anticipated Completion Date June 30, 2024
Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting o...
Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting operations. We will consult with other agencies of similar size and construct, as well as the Michigan Association of Local Public Health in areas where guidance is needed to return to strict compliance.
View Audit 311309 Questioned Costs: $1
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-005 Special Tests and Provisions Significant Deficiency in Internal Co...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-005 Special Tests and Provisions Significant Deficiency in Internal Control Over Compliance Finding Summary: The Organization did not retain documentation of review and approval of certain invoices or Purchase Orders. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: The Organization has enhanced internal control policies to ensure all cash disbursements are reviewed and approval is documented prior to payment to ensure that all payments are necessary and correct. Anticipated Completion Date: June 1, 2024
Views of Responsible Officials: District Bridges is currently researching time-tracking options, specifically for employees whose salaries are covered, full or partially, by federally-funded grants.
Views of Responsible Officials: District Bridges is currently researching time-tracking options, specifically for employees whose salaries are covered, full or partially, by federally-funded grants.
Views of Responsible Officials: During our FY22 audit, GRF expressly noted that for an organization our size, tracking grant expenses outside of Quickbooks was understandable and acceptable. During this FY23 audit, GRF changed its stance and said we had to report grant expenses in Quickbooks. This s...
Views of Responsible Officials: During our FY22 audit, GRF expressly noted that for an organization our size, tracking grant expenses outside of Quickbooks was understandable and acceptable. During this FY23 audit, GRF changed its stance and said we had to report grant expenses in Quickbooks. This should be removed as a finding, as District Bridges was following the advice of GRF from the FY22 audit. It is unconscionable to discredit an organization after they followed the firm's advice. Additionally, over the last few months, we have consulted several other nonprofit finance experts, as well as peer organizations that receive federal funds, to see tracking templates and procedures, and understand best practices. We are currently exploring more robust grant expense tracking softwares based on their recommendations, but they all noted that spreadsheet tracking was acceptable for an organization of our size.
December 31, 2023 Corrective Action Plan Finding Number: 2023-001 Condition: As of the audit testing date, Easterseals had obtained the key data elements required under the Transparency Act for subawards issued during the year but had not reported the data using the FFATA FSRS Tool. Planned Correc...
December 31, 2023 Corrective Action Plan Finding Number: 2023-001 Condition: As of the audit testing date, Easterseals had obtained the key data elements required under the Transparency Act for subawards issued during the year but had not reported the data using the FFATA FSRS Tool. Planned Corrective Action: Management has updated our procedures to ensure FFATA subaward reporting requirements are completed in a timely manner. Management has also updated the Easterseals Prime Award Checklist and Grantee Subrecipient Checklist to include the reporting of the subrecipient awards in the FFATA reporting system is performed in a timely manner, consistent with the FFATA reporting requirements. Contact person responsible for corrective action: Glenda F. Oakley, Chief Financial Officer Anticipated Completion Date: Completed
Finding 404842 (2023-003)
Significant Deficiency 2023
Guild
MN
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifyin...
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifying their payment support to show any payer-initiated adjustments. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024
Finding 404826 (2023-002)
Material Weakness 2023
Guild
MN
Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: Working with all Rental Assistance staff, we will develop a standard for documentation and a chec...
Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: Working with all Rental Assistance staff, we will develop a standard for documentation and a checklist for signing off by the responsible official. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024
While the entry of the poverty tables into our case management system is largely an administrative matter, LAWV will engage in review of this process in the future. Both LAWV’s Grants and Trainings Manager and LAWV’s Access to Services Manager will review the poverty tables following import in the c...
While the entry of the poverty tables into our case management system is largely an administrative matter, LAWV will engage in review of this process in the future. Both LAWV’s Grants and Trainings Manager and LAWV’s Access to Services Manager will review the poverty tables following import in the coming years. Furthermore, Legal Server has issued guidance that their case management system can import this information automatically as it serves numerous programs that are recipients of LSC funding. By using Legal Server’s automatic import feature to annually update the poverty tables and by adding the review by two LAWV managers, we believe that this will address the issue prospectively so that an incident such as this will not be repeated.
CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in g...
CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in gathering the necessary information earlier in the year for the yearly property reporting (SF-429). The Head Start Fund Accountant will email copies of these reports to the Director of Head Start to ensure compliance.
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024
View Audit 311195 Questioned Costs: $1
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeeping account or as a separate bank account. The Hospital had excess cash available to cover the required reserve amount. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will establish a separate bookkeeping account in the general ledger to establish the correct reserve amount of cash within its general operating bank account. The reserve account will be part of total cash in the bank to maximize interest earned on the reserve balance. Anticipated Completion Date: June 30, 2024
he County agrees with the recommendation and will continue to work with the Procurement Services Department to ensure acceptable documentation has been retained. We will also discuss additional review procedures with the responsible departments for all contract awards with federal funding.
he County agrees with the recommendation and will continue to work with the Procurement Services Department to ensure acceptable documentation has been retained. We will also discuss additional review procedures with the responsible departments for all contract awards with federal funding.
View Audit 311191 Questioned Costs: $1
The County agrees with the recommendation and will work with the Grant Administrator to implement policies and procedures to ensure all pre-award payments occur within the grant timelines.
The County agrees with the recommendation and will work with the Grant Administrator to implement policies and procedures to ensure all pre-award payments occur within the grant timelines.
View Audit 311191 Questioned Costs: $1
COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no d...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Grants Management requires annual reports from all SLFRF subrecipients. We will be requesting a copy of all annual audits from the subrecipients for the most recent completed year. The accountant team will review audit reports for any findings of note. We recognize that some subrecipients will not have their most recent audit completed and will allow those who need extra time to submit their audits by the fall. Name(s) of the contact person(s) responsible for corrective action: Ashley Meyer Planned completion date for corrective action plan: 6/30/2024
COVID-19 – Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: We recommend that management review their policies and make revisions where necessary to ensure that documentation is maintained to support amounts reported by the County in their quarterly grant reporting. We al...
COVID-19 – Emergency Rental Assistance – Assistance Listing No. 21.023 Recommendation: We recommend that management review their policies and make revisions where necessary to ensure that documentation is maintained to support amounts reported by the County in their quarterly grant reporting. We also recommend that management review their policies and procedures and make changes necessary to ensure reports are filed timely. Explanation of disagreement with audit finding: The one instance when the County submitted its quarterly report after the due date occurred due to a technical problem with submission. The Treasury data system would not accept the County’s report on the due date. The County sent Treasury an email alerting them to the problem as soon as it was determined that the County was unable to submit. Once the issue was resolved, the County submitted a few days later with no adverse impact to the County or its use of federal ERA funding. As per the concern that audit staff could not verify key line items in the submitted quarterly report, the County completed all required line items in the reports, however, the Treasury report downloads with multiple blank items in report cells. The County cannot control this deficiency in the Treasury downloads. If any submitted report were incomplete, Treasury would have returned the incomplete report to a local jurisdiction for missing elements. No referenced reports were returned to the County for completion, thereby demonstrating that all reports were complete at the time of submission. The problem relates solely to the downloaded report from the Treasury website. Neither the County nor the audit staff were able to determine a workaround for the incomplete Treasury report downloads. Action taken in response to finding: No additional action is needed because the one late quarterly reporting problem was resolved and the report was uploaded as soon as the technical glitch was resolved. Name(s) of the contact person(s) responsible for corrective action: Colleen Mahoney Planned completion date for corrective action plan: Already Completed
View Audit 311187 Questioned Costs: $1
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