Corrective Action Plans

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Finding 387369 (2021-007)
Significant Deficiency 2021
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been e...
Audit Finding Reference: 2021-007 Lack of Documentation to Support Distribution of Wages Management’s View and Planned Corrective Action: After review we have also determined that this documentation was lacking. Since 2021 many changes have occurred. A Time and Effort policy and procedure has been established, documented and implemented. Federally funded stipends are no longer processed until the Time and Effort Log of hours have been received. Once we have received the form(s), which we now attach to the position in our accounting system we then process in payroll. This procedure is also located in our Federal Funds Handbook. A communication will be sent to Grant Manager’s reminding them of the Time & Effort policy and procedures. Name of Contact Person and Completion Date: Name 1 Amber Wheeler Name 2 Danielle Rossetti Anticipated Completion Date : Procedure has changed a reminder will be communicated by March 30th.
View Audit 299544 Questioned Costs: $1
Condition: HealthSource did not have controls in place to ensure the inputs in their Covid related expense spreadsheet that was used to input the amount of 'Other PRF Expenses' reported in the portal submissions agreed to source documentation. Planned Corrective Action: All future submissions will b...
Condition: HealthSource did not have controls in place to ensure the inputs in their Covid related expense spreadsheet that was used to input the amount of 'Other PRF Expenses' reported in the portal submissions agreed to source documentation. Planned Corrective Action: All future submissions will be reviewed with the CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thorough...
Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place ov...
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid revenue and expenses will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
2021-006 – Special Tests and Provisions – Background Checks Corrective Action: In August 2021, CBNHC recruited and hired an experienced Human Resources Director. Filling this position allowed CBNHC to make progress in rectifying prior human resources weaknesses and improve processes. The position ag...
2021-006 – Special Tests and Provisions – Background Checks Corrective Action: In August 2021, CBNHC recruited and hired an experienced Human Resources Director. Filling this position allowed CBNHC to make progress in rectifying prior human resources weaknesses and improve processes. The position again became vacant in September 2022 and was most recently filled in March 2023. The addition of a Human Resources Assistant was approved in May 2023 and filled in January 2024. Filling these two positions has allowed CBNHC to further address gaps and delays in human resources operations and meeting compliance requirements. CBNHC is implementing the following corrective action plan to ensure compliance with the background check requirements of the Indian Self-Determination program. • Complete Human Resources Onboarding checklist recording all policies and background checks completed for every new employee to be stored in personnel files. • Build, maintain, and review (monthly) spreadsheets that record all CBNHC employees, contractors, and student interns, required background checks by vendor, date submitted/requested, date results received, and date next background check is required. • Audit of all employee background check files to identify and address any current deficiencies. • Develop and implement HR Standard Operating Procedures to ensure that processes for completing background checks are clearly documented for ease of execution. • Continue to monitor and reassess performance against current HR compliance requirements. • Monitor workload of HR staff in relation to continued organizational growth to determine if additional positions are necessary to ensure continued regulatory compliance. Person Responsible: Several individuals will be responsible for the corrective action plan, by area, as follows: • HR Standard Operating Procedures: The Human Resources Director (Christina Chavez) will create and maintain the detailed instructions for carrying out the functions and duties of the HR Department, to include the procedures for completing all required background checks in a timely manner to ensure compliance. • Background Check Spreadsheet: The Human Resources Director (Christina Chavez) will create the spreadsheet to include all CBNHC employees, contractors, and student interns, required background checks by vendor, date submitted/requested, date results received, and date next background check is required. The Human Resources Director (Christina Chavez) and Human Resources Assistant (Tiffany Begay) will jointly review the spreadsheet monthly, typically within the first 10 days of each month, to determine any necessary action. Both will participate in maintaining the data as appropriate. • Audit: The Human Resources Director (Christina Chavez) and Human Resources Assistant (Tiffany Begay) will complete an initial audit of all existing background check files to identify and address any current deficiencies. Going forward, the Human Resources Assistant (Tiffany Begay) will conduct a full audit of these files biannually, with the Human Resources Director (Christina Chavez) auditing three (3) random samples quarterly. Completion Date: Work in progress as of March 15, 2024. The HR Department staff meet daily to discuss progress on successes and challenges. The target date for completion of the background check spreadsheet and initial audit of existing files is April 26, 2024. The target date for completion of the HR Standard Operating Procedures is within six (6) months of this response (September 15, 2024).
Management Response and Corrective Action Plan: City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: CDBG staff worked with program auditors to resolve the issues. Finance Staff and related C...
Management Response and Corrective Action Plan: City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: CDBG staff worked with program auditors to resolve the issues. Finance Staff and related CDBG staff have been trained to ensure there is not duplication of expenditures in multiple programs. In addition, the City has hired third-party consultants to provide guidance and oversight. Planned Implementation Date: started in Q4 of FY 2023 Responsible Person: Finance Staff and CDBG Staff
View Audit 298952 Questioned Costs: $1
Management will review its process for requesting reimbursements and reconciling same to the ledger.
Management will review its process for requesting reimbursements and reconciling same to the ledger.
View Audit 298328 Questioned Costs: $1
Management will review its process for reviewing disbursements under the program and related documentation requirements for same to ensure that adequate documentation is available upon request.
Management will review its process for reviewing disbursements under the program and related documentation requirements for same to ensure that adequate documentation is available upon request.
View Audit 298328 Questioned Costs: $1
Management will evaluate its subrecipient monitoring process and implement new procedures to ensure that funds are on a reimbursement basis or that there is a formalized review process in place.
Management will evaluate its subrecipient monitoring process and implement new procedures to ensure that funds are on a reimbursement basis or that there is a formalized review process in place.
View Audit 298328 Questioned Costs: $1
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds. A sample of HRSA paid claims were reviewed for ineligible diagnosis codes and appropriate refunds were made.
The Authority has performed a review of all patients who have had indications of additional health insurance on an account with a HRSA payment, and made appropriate refunds. A sample of HRSA paid claims were reviewed for ineligible diagnosis codes and appropriate refunds were made.
View Audit 296290 Questioned Costs: $1
2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quart...
2021-009 – Allocations of Salaries of Other Costs; In February 2024, J.E. Ryan & Associates determined the allocation methodology most appropriate for our Agency is to use square footage. Where appropriate and possible, employees will be directly charged to their funding source (project code). Quarterly time studies will be implemented as of April 2024 for employees who work across multiple programs and provide direct care. For employees working in Maintenance, Food Services, Human Resources, Finance, and IT, square footage allocation will be utilized. During the upcoming fiscal year, the Controller will review, on a monthly or quarterly basis, the incurred expenses compared to the UAC approved budget.
2021-008 – Submission to Federal Audit Clearinghouse; Beginning March 2024, the Agency will establish and implement internal controls over financial reporting sufficient to ensure Single Audits are completed and submitted in a timely manner. The Board of Directors will request a review of Financial ...
2021-008 – Submission to Federal Audit Clearinghouse; Beginning March 2024, the Agency will establish and implement internal controls over financial reporting sufficient to ensure Single Audits are completed and submitted in a timely manner. The Board of Directors will request a review of Financial Audits annually. This will ensure Single Audits are completed and submitted in a timely manner. The Chief Executive Officer [CEO, Executive Director], Marianne Gribbon will meet with the Controller (Jarri Melton) weekly to ensure timely financial reporting. Reports will be provided to the board of Directors monthly. The Agency plans to adhere to the following timeline: •June 2024: completion of 21-22 (2022) audit •December 2024: completion of 22-23 (2023) audit •March 2025: completion of 23-24 (2024) audit •December 2025: completion of 24-25 (2025) audit Additionally, the Board of Directors will meet with the auditors during the December Board of Directors meeting to review the findings of the previous year’s audit (i.e., in December 2025, the auditors will review the 2024-2025 audit.) This will be a standing meeting between the Board of Directors and the auditors. Considering the significant delay in reporting, the Board of Directors will review the audit within one month of finalizing the audit. The timeline for outstanding audits is as follows: •21-22 (2022) audit will be reviewed no later than July 2024 •22-23 (2023) audit will be reviewed no later than January 2025 •23-24 (2024) audit will be reviewed no later than April 2025 •24-25 (2025) audit will be reviewed no later than January 2026 The Board is aware of the significant reporting delay. The CAP, presented here, will be shared with the Board during March 2024 to ensure compliance and timely reporting.
Depository Agreements (Non Compliance) Recommendation: The Authority should enter into depository agreements with all financial institutions holding Federal funds for the Authority. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
Depository Agreements (Non Compliance) Recommendation: The Authority should enter into depository agreements with all financial institutions holding Federal funds for the Authority. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has prior communications with the Bank regarding the depository agreements requirements. The Bank would not sign due to internal policies. The Commission will coordinate discussions between our HUD local field office and the Bank to discuss the requirements for obtaining a depository agreement. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Authority develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. Explanation of disagreement with audit finding: There is no disag...
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Authority develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Financial Reporting (Material Weakness) Recommendation: The Authority must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Authority. This information must...
Financial Reporting (Material Weakness) Recommendation: The Authority must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Authority. This information must be shared timely and discussed to make the necessary changes that are needed and to prepare the proper cash flow projections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines; Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Missing Depository Agreements (Non Compliance) Recommendation: The Commission should enter into depository agreements with all financial institutions holding Federal funds for the Commission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action tak...
Missing Depository Agreements (Non Compliance) Recommendation: The Commission should enter into depository agreements with all financial institutions holding Federal funds for the Commission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission has had prior communications with the Bank regarding the depository agreements requirements. The Bank would not sign due to internal policies. The Commission will coordinate discussions between our HUD local field office and the Bank to discuss the requirements for obtaining a depository agreement. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Commission develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. EQ\JALHOUSIIIG OPPORTUNITY Explanation of disagreement ...
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Commission develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. EQ\JALHOUSIIIG OPPORTUNITY Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Financial Reporting (Material Weakness) Recommendation: The Commission must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Commission. This information mu...
Financial Reporting (Material Weakness) Recommendation: The Commission must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Commission. This information must be shared timely and discussed to make the necessary changes that are needed and to prepare the proper cash flow projections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Commission will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely. In addition, we create policy and procedures to perform an assessment for component unit determination of any new legally separate organization that is established. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
See the Corrective Action Plan for chart/table.
See the Corrective Action Plan for chart/table.
Since the date of the deficiency was identified, the MTE Finance Department recalculated the allowable costs for the project worksheet #136175 and submitted a revised worksheet to FEMA. We met with the employees responsible for completion and filing of eligible costs with FEMA. We believe this was a...
Since the date of the deficiency was identified, the MTE Finance Department recalculated the allowable costs for the project worksheet #136175 and submitted a revised worksheet to FEMA. We met with the employees responsible for completion and filing of eligible costs with FEMA. We believe this was an isolated incident due to preparation and submittal on our behalf by an independent contractor. We will have an employee of the Finance Department perform a review of any future projects submitted for reimbursement.
View Audit 295000 Questioned Costs: $1
Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the pote...
Description of Finding: Expenditure detail does not support the amounts billed Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the serious nature of this finding and the potential for damage to relationships with the grantors and Federal entities. The Interim Controller and Director of Finance are working to secure an ERP system which will allow for better cost collection, reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. Subcontractor invoices will be required to provide specific information related to the grant, scope of work and any other pertinent details for proper charging in the accounting system. Detailed paper timesheets will be provided in the interim for all employees to ensure compliance with the requirements and provide proper support for all grant costs. Monthly reviews by the Project Directors/Managers plus Accounting will be performed to identify any potential cost charging issues and corrective action(s) required. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2024 for detailed paper timesheets, December 2024 for ERP system
View Audit 294918 Questioned Costs: $1
Finding 375511 (2021-002)
Significant Deficiency 2021
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been impl...
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been implemented in which the bank and credit card statements are reconciled to C@P’s General Ledger. These procedures were evaluated to effectiveness as part of the 2022 Single Audit. Andrew Squires, Finance Director, is responsible for the implementation of these procedures. The procedures were implemented in February of 2022 and have been followed since then. If the Department of the Treasury has questions regarding this plan, please contact Andrew at Andy.Squires@church-at-the-park.org.
Finding 375510 (2021-001)
Significant Deficiency 2021
Church at the Park has created formal, written policies relating to our procurements. This includes details on the dollar thresholds that determine when the procurement process is necessary, as well as the appropriate steps that need to be taken at those thresholds. It also details how vendors are t...
Church at the Park has created formal, written policies relating to our procurements. This includes details on the dollar thresholds that determine when the procurement process is necessary, as well as the appropriate steps that need to be taken at those thresholds. It also details how vendors are to be selected, how conflicts of interest are to be resolved, and how conflicts are to be administered. Andrew Squires, Finance Director, is responsible for the implementation of these procedures. The procedures were implemented in July of 2023 and have been followed since then. If the Department of the Treasury has questions regarding this plan, please contact Andrew at Andy.Squires@church-at-the-park.org.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536 Questioned Costs: $1
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
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