Corrective Action Plans

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The Government concurs with the auditor's findings and recommendations. DHS transitioned from a manual payroll process to the Government electronic Timeforce (STATS) system. All time and attendance are now vetted and approved through the various levels of applicable management, ultimately being appr...
The Government concurs with the auditor's findings and recommendations. DHS transitioned from a manual payroll process to the Government electronic Timeforce (STATS) system. All time and attendance are now vetted and approved through the various levels of applicable management, ultimately being approved by the Agency Head or designee. Payroll is generated based on the cost centers listed on the Notice of Personnel Action. Payroll is now reconciled by the Financial Analyst once it is posted by the Department of Finance to ensure that cost is applied appropriately. Additionally, a workflow is now established in the NOPA approval process to ensure the current org, objects and projects are listed on the Notice of Personnel Actions (NOPA) which is utilized for payroll purposes.
The Government concurs with the auditor's findings and recommendations. The Department of Health will make sure that any external consultant confers with their financial division to validate process or actions taken before finalizing any adjustments. In addition, the Department of Health will conduc...
The Government concurs with the auditor's findings and recommendations. The Department of Health will make sure that any external consultant confers with their financial division to validate process or actions taken before finalizing any adjustments. In addition, the Department of Health will conduct monthly reconciliation meetings to ensure all adjustments are completed and on time.
The Government concurs with the auditor's findings and recommendations. DOH will revise drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted. DOH will update drawdown SOPs for Fiscal Year 2...
The Government concurs with the auditor's findings and recommendations. DOH will revise drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted. DOH will update drawdown SOPs for Fiscal Year 2025, ensuring that all drawdown documentation includes a review confirmation. DOH will also incorporate this updated procedure into Federal Grants update training in December 2024 and make it accessible to all staff on Business Process Improvement SharePoint site.
The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit findings regarding Child Nutrition Cluster payroll and is committed to strengthening internal controls for federal compliance. VIDE will enhance timesheet management by developing clear policies for c...
The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit findings regarding Child Nutrition Cluster payroll and is committed to strengthening internal controls for federal compliance. VIDE will enhance timesheet management by developing clear policies for completion, submission, approval, and secure retention, ensuring accurate effort documentation. Federal Grants and Payroll staff will collaboratively verify employee authorization, accurate project coding, and consistent pay rates (NOPA vs. payroll register); this reconciliation will occur periodically and before key reporting deadlines. We will also improve payroll register completeness by adjusting reporting configurations to consistently include all mandatory employer-paid benefits (e.g., retirement, health insurance) and resolve individual instances where hours worked were inaccurate. Finally, mandatory training will be conducted for relevant staff and supervisors on new timesheet procedures, federal time and effort requirements, NOPA reconciliation, and accurate payroll documentation. This comprehensive approach, supported by ongoing monitoring from the Office of Fiscal and Administrative Services, will ensure sustained compliance and robust financial management for the Child Nutrition Cluster.
2022-011 Written Controls over Compliance (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management has worked to update its control procedures to ...
2022-011 Written Controls over Compliance (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management has worked to update its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. To address this, the organization hired an outside accounting firm as a consultant in January 2024 and updated its policies, the most recent update in February 2025 with review continuing as audits for 2023 and 2024 .
2022-010 Timely Submission of Audit Reports (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management is working to update its control procedures t...
2022-010 Timely Submission of Audit Reports (Significant Deficiency) Recommendation: We recommend the Organization become familiar with the requirements of Uniform Guidance and implement policies to ensure compliance. Action Taken (Unaudited): Management is working to update its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. Implementation of updated policies related to audits was completed November 2024. The organization will complete an additional review of the policies compared to Uniform Guidance 1st Quarter 2026.
2022‐009 Cash Disbursements (Material Weakness) Recommendation: We recommend policies and procedures over the segregation of duties between the accounting and banking functions be strengthened. In addition, policies and procedures should be implemented to ensure support for expenditures is retained ...
2022‐009 Cash Disbursements (Material Weakness) Recommendation: We recommend policies and procedures over the segregation of duties between the accounting and banking functions be strengthened. In addition, policies and procedures should be implemented to ensure support for expenditures is retained and includes evidence of approval. Additional oversight should be provided by those charged with governance. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. Implementation of updated policies was completed November 2024. Accounting and banking functions are segregated.
2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be ...
2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be established to allocate indirect costs in accordance with federal regulations. Policies and procedures are also needed to provide appropriate oversight of all grant accounting including reporting. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. A review process and coding within the accounting system was completed in January 2025. All invoices and staff time are evaluated for the level of effort towards each grant.
2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Acti...
2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. The Organization hired a Human Resource Manager June of 2024, moved to ADP for payroll in January 2025 and updated policies and process for review in May 2025. Procedures are in place for review and approval of each payroll.
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hosp...
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.
View Audit 367503 Questioned Costs: $1
Finding 1155242 (2022-008)
Material Weakness 2022
We agree with the recommendations offered and will establish and implement a comprehensive indirect cost allocation policy that aligns with Uniform Guidance requirements.
We agree with the recommendations offered and will establish and implement a comprehensive indirect cost allocation policy that aligns with Uniform Guidance requirements.
Finding 1155241 (2022-007)
Material Weakness 2022
We agree with the recommendations offered and have established updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel. We have addressed this finding by creating a list of government partners and ...
We agree with the recommendations offered and have established updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel. We have addressed this finding by creating a list of government partners and the key personnel identified in each PIA agreement. If it is not listed in the agreement, written documentation is provided from the government partners identifying the key personnel. When there are changes in the key personnel, verbal and written approval is obtained prior to changes and documentation is uploaded in the DEFENSEWERX SharePoint private site and a copy is added to the personnel file kept in the financial department.
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.
Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...
Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.
Management should immediately reimburse the amount due to the project and establish procedures to ensure payments of this nature are not made in the future.
Management should immediately reimburse the amount due to the project and establish procedures to ensure payments of this nature are not made in the future.
View Audit 366836 Questioned Costs: $1
Management should work with HUD to come to a resolution to this matter.
Management should work with HUD to come to a resolution to this matter.
View Audit 366836 Questioned Costs: $1
GSIL will continue to strive to maintain adequate staffing levels within the Finance Department to ensure work is completed timely and to maintain compliance with federal audit requirements. Efforts in this regard will include both internal and external recruiting and exploration of the use of contr...
GSIL will continue to strive to maintain adequate staffing levels within the Finance Department to ensure work is completed timely and to maintain compliance with federal audit requirements. Efforts in this regard will include both internal and external recruiting and exploration of the use of contracted help, if needed. Planned Implementation Date of Corrective Action: December 2025 Person Responsible for Corrective Action: Jill Bille, CFO
2022 – 007: Cash Collateralization Condition: During our review of the Organization’s cash, it was noted that as of September 30, 2022, they have not collateralized cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation. Cash balances of $11,685,898 were uninsu...
2022 – 007: Cash Collateralization Condition: During our review of the Organization’s cash, it was noted that as of September 30, 2022, they have not collateralized cash balances in excess of the amounts insured by the Federal Deposit Insurance Corporation. Cash balances of $11,685,898 were uninsured at September 30, 2022. Unearned revenue was reported at approximately $10,704,037 which includes advance payments of Federal funds. Corrective Action Plan: Management will review options with their bank to have a cash collateralization agreement put in place.
2022 – 005: Reporting (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, third-party income report, GPRA/GPRAM...
2022 – 005: Reporting (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide any of the required reports for the Title V program, including the financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory. Without these reports, we were unable to perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly so this should take care of this issue. Management has worked on procedures and training to assure financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory are completed.
2022 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide sufficient documentation to support compliance with federal procurement and suspension and debarment req...
2022 – 004: Procurement and Suspension and Debarment (Compliance; Internal Controls Over Compliance) Material Weakness – 93.U01 Title V Condition: The Organization was unable to provide sufficient documentation to support compliance with federal procurement and suspension and debarment requirements for purchases made under the Title V program. The general ledger did not allow for sufficient identification of transactions related to the Title V program as all expenditures were recorded through journal entries without supporting transaction-level detail. Due to this limitation, we were unable to select procurement transactions for testing or verify whether vendors had been screened for suspension and debarment before contracts were awarded. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software uused,and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly. The following are updated procedures that are now in place. All purchases must come with a purchase order request and be signed by the supervisor prior to purchase. All purchases over $1000 must be CEO approved too. All purchases over $5000 must have 3 bids and be Board approved. All purchase orders must be completed completely in all fields to know what grant/funding source is covering the cost for draw downs. Anyone who uses the SDUIH credit cards must sign a credit card statement
View Audit 365905 Questioned Costs: $1
2022 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major progr...
2022 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of transactions related to the major program, Title V. Title V expenditures were recorded through journal entries without supporting transaction-level detail. Because of this, the population of expenditures could not be tied to individual transactions, and pulling samples from this population would not provide a reasonable basis for drawing conclusions about the population tested. As a result, we were unable to select transactions for testing or perform the necessary audit procedures to assess compliance with federal requirements. Corrective Action Plan: As of October 1, 2024, the start of FY25 QuickBooks has been the only software used, and Revenue and Disbursements are being classed by Fund. General ledgers are reconciled monthly.
View Audit 365905 Questioned Costs: $1
This finding is due to the district not having fiscal year audits within nine months of the end of the year. The district is still behind on audits for 2022-2023, 2023-2024 and will be for 2024-2025 if Browning is unable to find an auditor. The current auditor gave notice to the district that they w...
This finding is due to the district not having fiscal year audits within nine months of the end of the year. The district is still behind on audits for 2022-2023, 2023-2024 and will be for 2024-2025 if Browning is unable to find an auditor. The current auditor gave notice to the district that they would not keep us as a client for the next two audits in May or June 2025. There are several reasons that the 2021-2022 audit has not been completed before now. There was a change in business office staffing, locating the requested information after two years, losing submitted data, and a changeover in auditors.
The Covid-19 pandemic caused delays in the audit and as such the required deadline could not be met. The Cooperative will work with the firm to establish appropriate deadlines to ensure timely completion of all upcoming audits.
The Covid-19 pandemic caused delays in the audit and as such the required deadline could not be met. The Cooperative will work with the firm to establish appropriate deadlines to ensure timely completion of all upcoming audits.
Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanatio...
Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2025
View Audit 365817 Questioned Costs: $1
View of Responsible Officials and Corrective Action Plan The excess drawdown may have occurred due to the carry fund balance being included as a debit balance on the trial balance during review of drawdown expenses and not adjusted to reduce the amount of the drawdown(s). The error was discovered wh...
View of Responsible Officials and Corrective Action Plan The excess drawdown may have occurred due to the carry fund balance being included as a debit balance on the trial balance during review of drawdown expenses and not adjusted to reduce the amount of the drawdown(s). The error was discovered when the Accounting Manager was in the process of preparing the SEFA schedule. The Accounting Manager disclosed this error to the auditor during the course of the audit. Corrective Action Plan Timeline AAIHB will consult with the Program Manager and awarding agency to determine the appropriate resolution of the excess drawdown within 30 days. AAIHB finance office has a process in place of reviewing drawdowns and monitoring expenses as grants approach the end of the project funding period. Designation of Employee Position Responsible for Meeting Deadline Accounting Manager and Finance Director
View Audit 365730 Questioned Costs: $1
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