Corrective Action Plans

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Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
View Audit 361721 Questioned Costs: $1
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
View Audit 361721 Questioned Costs: $1
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the Organizations parent company (Total Health Care, Inc.). Org...
Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the Organizations parent company (Total Health Care, Inc.). Organization contact persons responsible for corrective action: Richard Greene, CFO Anticipated completion date: Correction action has been completed and is awaiting feedback from HRSA on how to submit updated lost revenue calculation.
The Organization agrees with the finding and recognizes the importance of accurate financial and programmatic reporting in compliance with federal grant requirements. To address this issue, the Organization is strengthening its internal controls surrounding the preparation and review of all financia...
The Organization agrees with the finding and recognizes the importance of accurate financial and programmatic reporting in compliance with federal grant requirements. To address this issue, the Organization is strengthening its internal controls surrounding the preparation and review of all financial and programmatic reports submitted to granting agencies. Specifically, the finance department and program staff will implement a joint review process to reconcile reported expenditures and program statistics --such as patient counts --against underlying financial and operational records prior to submission. A standardized reporting checklist will be developed to ensure that all data points are verified for accuracy and that supporting documentation is retained and reviewed. In addition, staff responsible for grant reporting will receive training on federal reporting requirements, including those outlined in 45 CFR 75.342, to ensure consistency and compliance across all submissions. These steps will help ensure that all future reports accurately reflect grant expenditures and program outcomes, minimizing the risk of misreporting and ensuring transparency and accountability. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developin...
The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developing and implementing formal time and effort reporting procedures to ensure that personnel costs charged to federal grants are supported by actual activity records and certified by employees on a regular basis. This will include the adoption of time distribution systems that comply with 2 CFR Part 200 Subpart E and the requirement for supervisory approval of time reports. Additionally, the Organization will revise its expenditure review and approval processes to require that all costs charged to federal programs are supported by appropriate documentation, including vendor invoices and receipts. Staff involved in grant management and accounting will receive training on federal cost principles, documentation requirements, and period of performance compliance. A document retention policy in accordance with 2 CFR 200.334 will also be established to ensure that all supporting documentation is maintained and readily available for audit and program oversight. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
View Audit 361677 Questioned Costs: $1
Finding 570503 (2022-003)
Significant Deficiency 2022
FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting ...
FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Significant Deficiency Condition: The City did not have proper controls in place to ensure that the annual report was accurately filled out and agreed to underlying detail. Context: Variances to key line items were noted when comparing the Form RD442-2 and Form RD442-3 to supporting documents. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that reports agree to underlying detail. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.
Finding Reference Number: MW2022-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behi...
Finding Reference Number: MW2022-004 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting audits for fiscal years (FY) 2022 and 2023. Management has made clearing this backlog its highest priority. The schedule is to complete and file the FY 2022 audit package in mid-2025, the FY 2023 package by fall 2025, and the FY 2024 package by the end of calendar-year 2025, at which point CUAHSI expects to return to on-time Federal Audit Clearinghouse filings. Recent upgrades to the accounting system, the hiring of in-house finance staff, and revised closing procedures are designed to streamline and accelerate future audit preparation so that all subsequent audits are filed by the required deadlines. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: 2025-12-31
Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program incom...
Finding Reference Number: MW2022-008 Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHSI impacting audit year 2022: External contract accounting staff in place during audit year 2022 failed to declare program income in advance of the deadline specified by NSF. Program income for 2022 was filed was filed on 3 December 2022, approximately three weeks late. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI continues to use a single payment gateway for events and registration fees which supports segregation of payments per event and per grant. Program income has been reported to NSF accurately and on time as of audit year 2023 and appropriate staff and policies are in place to ensure continued future compliance. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
2022-003 Disbursement to vendor not Registered in SAM Category: Material weakness in Internal Control and Material Noncompliance Condition: During the audit, it was noted that Jorge R. Calderon Lopez, to which disbursements were made for legal services was not registered in SAM at the time of the aw...
2022-003 Disbursement to vendor not Registered in SAM Category: Material weakness in Internal Control and Material Noncompliance Condition: During the audit, it was noted that Jorge R. Calderon Lopez, to which disbursements were made for legal services was not registered in SAM at the time of the award and remained unregistered throughout the audit period. Management’s Response: Starting in FY 2024-2025, the finance department will strengthen communication and create a tool for the legal department to identify the federal funds to be used. This will enable the legal department to request the SAM registration document during the procurement process. This approach will enhance control and ensure that the vendor is registered in SAM before beginning their services. Person in charge: Juan C. Rodriguez Rivera – Accounting Official Yanina Cuadrado Sanjurjo - Lawyer 787-705-7188 Juan.rodriguez@lra.pr.gov & Yanina.cuadrado@lra.pr.gov Implementation Date: FY 2024-2025
View Audit 361348 Questioned Costs: $1
2022-002 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Fi...
2022-002 Late Single Audit Submissions Category: Material weakness in Internal Control and Material Noncompliance Condition: The Authority has not timely submitted the Single Audit Reporting Packages for the years ended June 30, 2021, and 2022. Management’s Response: Starting in FY 2024-2025, the Finance Department will maintain detailed records of all payments made, deposits received, and the reimbursement and transfer processes. This approach ensures that all reports are completed in a timely manner. To strengthen internal control over accounts, disbursements, and fund entries, the LRA’s Finance Department will hire additional personnel. These new team members are responsible for updating and managing accounting records. Together, they have established a strict timeline for completing important tasks to ensure a clear and concise flow of funds. The workloads will be divided among the team, with specific responsibilities assigned for Accounts Receivable, Accounts Payable, Bank Reconciliation, and Bookkeeping. Some responsibilities are interlinked, allowing team members to support one another in the event of absence or the need for assistance and providing documents to the external audits for the Single Audits. Person in charge: Juan C. Rodriguez Rivera Accounting Official 787-705-7188 Juan.rodriguez@lra.pr.gov Implementation Date: FY 2024-2025
The Organization became behind on audits and is in the process of cathing up. The Chief Executive Officer will implement a procedures that makes sure that the federal clearinghouse form will be uploaded on a timely basis. This will be implemented with the June 30, 2024 audit.
The Organization became behind on audits and is in the process of cathing up. The Chief Executive Officer will implement a procedures that makes sure that the federal clearinghouse form will be uploaded on a timely basis. This will be implemented with the June 30, 2024 audit.
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced m...
Our Organization has developed a Monitoring Policy to have better oversight of our sub-recipients. Our Chief Executive Office will implement this Monitoring Policy. The Grant Coordinator, will oversee the direct communications related to sub-recipients monitoring. The implementation of enhanced monitoring tools and documentation standards will be completed by June 30, 2025
THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT EXPENDITURES SUBMITTED FOR REIMBURSEMENT OF FEDERAL AWARD PROGRAMS. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. ...
THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT EXPENDITURES SUBMITTED FOR REIMBURSEMENT OF FEDERAL AWARD PROGRAMS. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION WILL TERMINATE THE CURRENT AGREEMENT WITH THE CPA AND MOVE TO ANOTHER CPA FIRM TO MEET THE NEEDS OF THE ORGANIZATION IN A PROFESSIONAL, QUALIFIED AND TIMELY MANNER. MOVE TO ANOTHER CPA FIRM BY NO LATER THAN SEPTEMBER 1, 2025. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE MEMBERS ON JUNE 25, 2025.
View Audit 361193 Questioned Costs: $1
THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD...
THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE ON JUNE 25, 2025.
View Audit 361193 Questioned Costs: $1
THE ORGANIZATION WILL USE ACTUAL PAYROLL COSTS TAKEN FROM PAYROLL REPORTS TO SUPPORT PAYROLL EXPENSES APPLIED TO THE PROGRAM. IMMEDIATELY, THE PROCESS BEGAN IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE IDAHO IMMUNIZATION COALITION WILL TERMI...
THE ORGANIZATION WILL USE ACTUAL PAYROLL COSTS TAKEN FROM PAYROLL REPORTS TO SUPPORT PAYROLL EXPENSES APPLIED TO THE PROGRAM. IMMEDIATELY, THE PROCESS BEGAN IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE IDAHO IMMUNIZATION COALITION WILL TERMINATE THE CURRENT AGREEMENT WITH THE CPA AND MOVE TO ANOTHER CPA FIRM TO MEET THE NEEDS OF THE ORGANIZATION IN A PROFESSIONAL, QUALIFIED AND TIMELY MANNER. MOVE TO ANOTHER CPA FIRM BY NO LATER THAN SEPTEMBER 1, 2025. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE ON JUNE 25, 2025.
View Audit 361193 Questioned Costs: $1
Procurement documentations were provided on May 19, 2025. The MOF management designated three audit focal points to coordinate effectively with external auditors in regards to timely submissions of required supporting documents.
Procurement documentations were provided on May 19, 2025. The MOF management designated three audit focal points to coordinate effectively with external auditors in regards to timely submissions of required supporting documents.
View Audit 359422 Questioned Costs: $1
Condition #1 & #2: In preparation for the FY2026 budget entry exercise, MOF management will arrange for a training, to be conducted annually, for all Senior Budget Officers handling US Federal Grants. The training will focus on the need for proper and thorough review of grant budget proposals (i.e....
Condition #1 & #2: In preparation for the FY2026 budget entry exercise, MOF management will arrange for a training, to be conducted annually, for all Senior Budget Officers handling US Federal Grants. The training will focus on the need for proper and thorough review of grant budget proposals (i.e., every contract submitted to the Budget Division for obligation should be supported by the budget narrative otherwise, such will be returned).
View Audit 359422 Questioned Costs: $1
Effective 3rd qtr. of FY2025, all transactions charged to the Enewetak grant will go through the national procurement and payment process. The detailed compliance checklist covering Procurement and Supply, Budget, Accounting, and Compliance will be reinstated.
Effective 3rd qtr. of FY2025, all transactions charged to the Enewetak grant will go through the national procurement and payment process. The detailed compliance checklist covering Procurement and Supply, Budget, Accounting, and Compliance will be reinstated.
View Audit 359422 Questioned Costs: $1
Grant agreements are filed with the respective Budget Officers. The period of performance is entered into the FMIS (Bisan) prior to account setup, which automatically halts transactions after the grant’s closing date.
Grant agreements are filed with the respective Budget Officers. The period of performance is entered into the FMIS (Bisan) prior to account setup, which automatically halts transactions after the grant’s closing date.
View Audit 359422 Questioned Costs: $1
Upon verification, supporting documents for salaries and wages, such as timesheets and payroll registers, for the 18 samples were submitted to external auditors. MoF management will ensure responsible senior budget officers are well versed in all grant conditions and ensure that all transactions a...
Upon verification, supporting documents for salaries and wages, such as timesheets and payroll registers, for the 18 samples were submitted to external auditors. MoF management will ensure responsible senior budget officers are well versed in all grant conditions and ensure that all transactions are in accordance with the grant agreement. MoF will conduct annual training on grants management.
View Audit 359422 Questioned Costs: $1
Condition #1: A compliance checklist will be developed and implemented July 1, 2025 on all subrecipients. Condition #2: There is currently one consolidated subrecipient monitoring schedule that is monitored by the Compliance Unit and the SOEMU. Condition #3: The Grants Manual will be updated to ...
Condition #1: A compliance checklist will be developed and implemented July 1, 2025 on all subrecipients. Condition #2: There is currently one consolidated subrecipient monitoring schedule that is monitored by the Compliance Unit and the SOEMU. Condition #3: The Grants Manual will be updated to reflect audit determination letter processes for subrecipients.
View Audit 359422 Questioned Costs: $1
#A26328 - MOF is drafting a new Travel Policy to address this issue. The MOF management designated three audit focal points to coordinate effectively with external auditors in regards to timely submissions of required supporting documents.
#A26328 - MOF is drafting a new Travel Policy to address this issue. The MOF management designated three audit focal points to coordinate effectively with external auditors in regards to timely submissions of required supporting documents.
View Audit 359422 Questioned Costs: $1
The fixed assets manual has been in place since FY2019; however, challenges exist in fully implementing the manual. The MoF management undertook the following actions: 1) Hired additional asset management staff in May 2024. 2) Issued a memo to ministries that custodize government’s assets to for...
The fixed assets manual has been in place since FY2019; however, challenges exist in fully implementing the manual. The MoF management undertook the following actions: 1) Hired additional asset management staff in May 2024. 2) Issued a memo to ministries that custodize government’s assets to formally designate a property coordinator. To issue another memo to meet and train the designated property coordinators on their roles, responsibilities, & templates pertaining to the fixed assets management. 3) Developed a collaborative approach between the ministries, outer island jurisdictions, and overseas’ missions, in accomplishing the physical inventory with the MoF assets’ manager serving as the lead. 4) The asset management module of FMIS (BISAN) will be fully operationalized when the assets registry is complete.
View Audit 359422 Questioned Costs: $1
Condition 1: #1 All supporting documents for travel mission vouchers are now uploaded onto Bisan. #2 & #3: The MOF Secretary reiterated to Accounting management the need to ensure that manual JVs have complete supporting documents. Bisan has an online approval workflow for manual JVs which facili...
Condition 1: #1 All supporting documents for travel mission vouchers are now uploaded onto Bisan. #2 & #3: The MOF Secretary reiterated to Accounting management the need to ensure that manual JVs have complete supporting documents. Bisan has an online approval workflow for manual JVs which facilitates the review of manual entries, including supporting attachments, prior to posting to the general ledger. Condition 2: #1 & #2: Effective FY2025 PPE 14, MoF will no longer charge leave slips without proper supporting documents. . Condition 2, continued: #1 Employee did not receive a night differential for PP21 & PP22. #2 & #5: The online approval workflow in the payroll module of Bisan, where the ministry enters hours claimed while the MOF Payroll Division reviews and approves against supporting timesheets, helps ensure that payroll calculations are accurate. #3 and #4 Employee did not receive 8 regular hours in previous pay period (PP01) #6: 30% is a combination of 20% standby differential and 10% Ebeye differential.
View Audit 359422 Questioned Costs: $1
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