Corrective Action Plans

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Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Cli...
Federal Agency Name Department of Agriculture Federal Assistance Listing #10.766 Program Name Community Facilities Loan and Grants Cluster Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.697 Program Name COVID 19 Testing and Mitigations for Rural Health Clinics Federal Agency Name Department of Health and Human Services Federal Assistance Listing #93.301 Program Name COVID 19 Small Rural Hospital Improvement Grants Finding Summary Eide Bailly assisted in the preparation of our draft consolidated schedule of expenditures and federal awards and accompanying notes to the consolidated schedule of expenditures and federal awards. Corrective Action Plan It is not cost effective to have an internal control system designed to provide for a complete and accurate schedule of expenditures and federal awards. We requested that our auditors, Eide Bailly LLP, assist in the preparation of the schedule of expenditures. We have designated a member of management to review the drafted schedule of expenditures. Responsible Individuals Judy Monson, CFO; Nikki Lindsey, CEO Anticipated Completion Date Ongoing
First Step of Wichita Falls, Inc. agrees with this recommendation and is implementing the following actions to address it: 1. Development of a Grant Monitoring System o We are implementing a centralized grant tracking system to record key grant requirements, reporting timelines, and deliverables. o ...
First Step of Wichita Falls, Inc. agrees with this recommendation and is implementing the following actions to address it: 1. Development of a Grant Monitoring System o We are implementing a centralized grant tracking system to record key grant requirements, reporting timelines, and deliverables. o The Executive Director and Finance Director will oversee the development and maintenance of this system. 2. Creation of a Compliance and Reporting Calendar o A detailed compliance calendar will be developed to track all financial and progranunatic reporting deadlines for each grant. o The calendar will be reviewed monthly by program and finance staff to ensure all deliverables are submitted on time. 3. Staff Training and Accountability o Staff responsible for grant management will receive training on Uniform Guidance requirements and the use of the new tracking system. o Roles and responsibilities related to compliance and reporting will be clearly defined in updated internal procedures. We believe these corrective actions will strengthen our internal controls, improve oversight of grant activities, and ensure compliance with all Uniform Guidance reporting requirements.
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued ...
Reference Number: 2023-012 Finding: Recordkeeping and Documentation for the HOME Investment Partnerships Program Name of Contact Person: Lara Auclair Corrective Active Plan: In the past year, the City has worked to develop an updated record of all HOME assisted projects. Staff thoroughly catalogued all program files creating separate documents for files that are discharged or still active. The documents can be reviewed to add monitoring information. The document contains the period of affordability and the amount due at payoff. Proposed Completion Date: 3/31/26
Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAP...
Reference Number: 2023-010 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Lorina Esposito Corrective Active Plan: In the past year, the City has fully staffed the division of housing and community development which has led to the successful submission of the 2024 CAPER. The staff worked diligently to find all required data for the report and participated in training courses to prepare for future CAPERs. Proposed Completion Date: 3/31/26
Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evalu...
Reference Number: 2023-008 Finding: Improve Controls and Compliance with Reporting Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement formal written procedures for preparing, submitting, and retaining all required quarterly performance and evaluation reports in compliance with program requirements. Designated staff will be responsible for tracking reporting deadlines, ensuring timely submissions, and maintaining thorough documentation of all reports. Management will conduct regular reviews to monitor compliance and address any deficiencies promptly. Proposed Completion Date: 6/30/26
Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is ...
Reference Number: 2023-004 Finding: Improve Internal Controls over the Preparation of the Schedule of Expenditures of Federal Awards (SEFA) Name of Contact Person: James Lathrop, CPA Corrective Active Plan: The City will implement comprehensive procedures and internal controls to ensure the SEFA is both complete and accurate. This will include establishing a formal process for reconciling all reported federal expenditures with supporting documentation such as the general ledger and grant reports. Additionally, the SEFA will undergo a documented review by a qualified individual who was not involved in its preparation prior to finalization and submission. Proposed Completion Date: 3/31/26
Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) – Assistance Listing No. 21.027 Recommendation: The County should implement enhanced review procedures to ensure accurate and timely reporting of CSLFRF expenditures. This includes reconciling reported amounts with actual expenditures record...
Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) – Assistance Listing No. 21.027 Recommendation: The County should implement enhanced review procedures to ensure accurate and timely reporting of CSLFRF expenditures. This includes reconciling reported amounts with actual expenditures recorded in the financial system prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: At this time, all funds have been spent however, our new financial system will help track future expenditures. Name(s) of the contact person(s) responsible for corrective action: Stephanie Hranac Planned completion date for corrective action plan: July 1, 2024
Finding 1174193 (2023-001)
Material Weakness 2023
Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustme...
Description of Finding: GBAPP, Inc. was unable to prepare financial statements, a schedule of federal awards and a schedule of state financial assistance that complied with Generally Accepted Accounting Principles (GAAP) and governmental professional standards on a timely basis. Significant adjustments, subsequent to year end, were required to conform the financial statements and schedules to professional standards in all material respects. Accordingly, the Federal Data Collection Form and the Connecticut EARS filings were not submitted timely. Statement of Concurrence or Nonconcurrence: GBAPP, Inc. concurs with this audit finding. Corrective Action: Management has since retained additional personnel to assist in performing these duties and is in the process of implementing additional policies and procedures. GBAPP supplemented its accounting personnel with an external CPA with extensive experience in accounting and reporting for non-profit organizations that receive federal and state funding, and who also possesses the suitable skills, knowledge and experience in financial, government and grants management reporting to ensure that this finding will not be repeated. Name of Contact Person: Nancy Kingwood President/Executive Director 203-366-8255 nkingwood@gbapp.org Projected Completion Date: Immediately
Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification sinc...
Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification since 2024 and has been reporting since receiving notification. Anticipated Completion Date: 1/1/2024
Management has strengthed both financial reporting controls and ovesight procedures. Sage Intacct ERP system was implemented in 2024 to enhance grant level reporting accurary and reconciliation capabilities. In addition, a comprehensive reporting tracker that monitors deadlines were implemented to i...
Management has strengthed both financial reporting controls and ovesight procedures. Sage Intacct ERP system was implemented in 2024 to enhance grant level reporting accurary and reconciliation capabilities. In addition, a comprehensive reporting tracker that monitors deadlines were implemented to improve timeliness of submission of financial and programmatic reports. All federal financial reports are now reconciled with the general ledger and verifying that grant deliverables are met in accordance with the Uniform Guidance. These measures are designed to prevent future late or missing reports and to ensure that funds are properly expended and documented. In addition, all federal financial reports are reconciled to the general ledger prior to submission. A grant reporting reconciliation form is completed and signed by both the Grants Director and Finance staff verifying agreement between accounting records and submitted reports. Reports may not be submitted until the reconciliation documentation is completed and retained.
Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess
Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess
We agree with the finding as stated and the corrective action plan follows. 1. Person responsible for the corrective action: Terry Terry, Chief Financial Officer 2. Corrective Action: a. Policies and procedures have been modified to ensure that reports are complete and accurate. b. Additional proced...
We agree with the finding as stated and the corrective action plan follows. 1. Person responsible for the corrective action: Terry Terry, Chief Financial Officer 2. Corrective Action: a. Policies and procedures have been modified to ensure that reports are complete and accurate. b. Additional procedures have been implemented to reconcile and verify all details prior to submission of reports 3. The Corrective Action has been implemented and will be reviewed no less than annually to ensure that no additional procedures are needed for compliance.
Coryell County Memorial Hospital Authority implemented enhanced financial reporting procedures effective November 1, 2024. These procedures include the use of more detailed reports with sub-categories of expenses rather than reliance solely on the Authority’s summarized income statement when aggrega...
Coryell County Memorial Hospital Authority implemented enhanced financial reporting procedures effective November 1, 2024. These procedures include the use of more detailed reports with sub-categories of expenses rather than reliance solely on the Authority’s summarized income statement when aggregating data. Although corrective action was implemented prior to issuance of the audit report, the finding is reported because the condition existed during the audit period. Management believes these procedures have been operating effectively since implementation and will prevent recurrence.
2023 – 006: Reporting - Preparation of the Schedule of Expenditures of Federal Awards (SEFA) (Repeat Finding: 2021-007 and 2022-006) Condition: During fiscal year 2023, the Organization did not have adequate controls in place to ensure the SEFA accurately reflected each award's federal agency and as...
2023 – 006: Reporting - Preparation of the Schedule of Expenditures of Federal Awards (SEFA) (Repeat Finding: 2021-007 and 2022-006) Condition: During fiscal year 2023, the Organization did not have adequate controls in place to ensure the SEFA accurately reflected each award's federal agency and assistance listing number. There were differences between the SEFA and the grant agreements/compliance supplements, requiring adjustments to the SEFA. 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 now reconciled monthly. Each grant will have its own folder and required information to assure an accurate SEFA can be completed will be included. Management will reconcile SEFA amounts to the general ledger and review federal agency names and assistance listing numbers against grant documentation.
2023 – 005: Reporting (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-005 and 2022-005) 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, ...
2023 – 005: Reporting (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-005 and 2022-005) 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. Management has implemented procedures and training to assure financial report, activity narrative, third-party income report, GPRA/GPRAMA, urban data standards, and property inventory are completed and retained.
2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) Material Weakness – 93.U01 Title V Condition: The Organization’s general ledger did not allow for sufficient identification of ...
2023 – 003: Activities Allowed and Unallowed, Allowable Costs, Period of Performance (Compliance; Internal Controls Over Compliance) (Repeat Finding: 2021-003 and 2022-003) 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. Management is strengthening documentation and recordkeeping procedures to ensure compliance with federal record retention requirements, including improved tracking of Title V expenditures and retention of transaction-level support.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – The Cooperative will reconcile any grant reimbursements prior to submission. Completion Date – This is a current process.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – The Cooperative will reconcile any grant reimbursements prior to submission. Completion Date – This is a current process.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – The Cooperative has no plans to own any property going forward. However, should this situation occur in the future training will be provided for all employees involved with the grant. Completion Date – As needed.
Contact Person – Benjamin Schafer, Executive Director Corrective Action Plan – The Cooperative has no plans to own any property going forward. However, should this situation occur in the future training will be provided for all employees involved with the grant. Completion Date – As needed.
The School has hired a consultant to train and assist school personnel in internal controls and processing transactions. The School has hired a Business Manager and Human Resource Manager.
The School has hired a consultant to train and assist school personnel in internal controls and processing transactions. The School has hired a Business Manager and Human Resource Manager.
Finding 2023-004 – Single Audit Reporting Requirements Condition: Repeat finding from prior year 2022-004. Single Audit reporting packages must be submitted to the Federal Audit Clearinghouse within required timeframes. The FY 2023 submission deadline was September 30, 2024. The audit cited risk of ...
Finding 2023-004 – Single Audit Reporting Requirements Condition: Repeat finding from prior year 2022-004. Single Audit reporting packages must be submitted to the Federal Audit Clearinghouse within required timeframes. The FY 2023 submission deadline was September 30, 2024. The audit cited risk of penalties and potential loss of current or future funding due to delayed filing. Issued Federal Awards 12-31-2023 Corrective Action Plan: TLCHB has implemented a formal audit submission compliance process to ensure timely completion of future Single Audits and federal reporting. Corrective actions include: • Establishment of a formal annual audit timeline with required milestones for financial closeout, draft review, board approval, and submission. • Ongoing coordination with independent auditors to ensure timely fieldwork and audit completion. • Internal assignment of audit preparation responsibilities, including compilation of grant documentation and reconciled schedules. • Board oversight of audit progress through scheduled Finance Committee updates. • Immediate tracking of Federal Audit Clearinghouse submission requirements to ensure submission within required timeframes. Responsible Staff: Executive Director; Finance Manager; Board Treasurer/Finance Committee. Anticipated Completion Date: Implemented as of audit conclusion; audit timeline monitored annually.
Finding 2023-003 – Reporting Requirements Condition: Repeat finding from prior year 2022-003. TLCHB had policies identifying grant reporting requirements and deadlines, but reports were not submitted timely for multiple grants/contracts due to lapses in operational implementation. Issued Federal Awa...
Finding 2023-003 – Reporting Requirements Condition: Repeat finding from prior year 2022-003. TLCHB had policies identifying grant reporting requirements and deadlines, but reports were not submitted timely for multiple grants/contracts due to lapses in operational implementation. Issued Federal Awards 12-31-2023 Corrective Action Plan: TLCHB has implemented a structured reporting compliance system to ensure all required reports are submitted accurately and on time. Corrective actions include: • Development and maintenance of a centralized grant reporting calendar with deadlines for all funding sources. • Use of automated reminders and tracking logs for quarterly, annual, and reimbursement reporting requirements. • Monthly internal review meetings between finance and operations staff to confirm upcoming deadlines and submission readiness. • Quarterly reporting updates to the Finance Committee and Board to ensure governance-level oversight. • Documentation of reporting submission dates and retention of confirmation records for audit trail purposes. Responsible Staff: Grants Administrator; Finance Manager; Operations Manager; Executive Director. Anticipated Completion Date: Implemented as of audit conclusion; ongoing monthly monitoring.
Finding 2023-002 – Control Activities, Information and Communication, Monitoring (Federal Awards) Condition: Repeat finding from prior year 2022-002. Similar deficiencies impacted compliance for major federal programs due to untimely reconciliations, delayed reimbursement activity, and lack of timel...
Finding 2023-002 – Control Activities, Information and Communication, Monitoring (Federal Awards) Condition: Repeat finding from prior year 2022-002. Similar deficiencies impacted compliance for major federal programs due to untimely reconciliations, delayed reimbursement activity, and lack of timely reporting tied to federal award requirements. Issued Federal Awards 12-31-2023 Corrective Action Plan: TLCHB has strengthened internal controls specific to federal awards to ensure timely and accurate compliance. Corrective actions include: • Monthly reconciliation of grant revenue and expenditures to supporting documentation. • Timely preparation of reimbursement requests to ensure full utilization of available federal funding. • Improved internal oversight and segregation of duties to reduce risk of error or misstatement. • Finance Committee oversight of federal drawdowns, reporting schedules, and cash flow impacts. • Quarterly compliance check-ins to verify that all federal reporting and grant management requirements are met. Responsible Staff: Finance Manager; Grants Administrator; Executive Director; Compliance Specialist. Anticipated Completion Date: Implemented as of 2022 audit conclusion; ongoing quarterly review.
SOP will be developed in alignment with contract terms and conditions, assigning responsible parties for each type of reporting, including SF-270 and SF-425 and others. A tracking system will be implemented and strictly monitored to ensure timely submission of these reports. Automated notifications ...
SOP will be developed in alignment with contract terms and conditions, assigning responsible parties for each type of reporting, including SF-270 and SF-425 and others. A tracking system will be implemented and strictly monitored to ensure timely submission of these reports. Automated notifications will be issued to responsible parties 60 days and 30 days in advance of each reporting deadline to prevent delays and maintain compliance.
Audit Finding: 2023-002 – Lack of Documentation of Review and Approval Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital ...
Audit Finding: 2023-002 – Lack of Documentation of Review and Approval Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures adopted in 2025 address these requirements and are being fully implemented. Anticipated Completion Date ● March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director
2023 - 007: Reporting: Preparation of the Schedule of Expenditures and Federal Awards (SEFA) (Repeat Finding:2019-007 and 2020-007, 2021-006 and 2022-008) Condition: During fiscal year 2023, the Governmental Department did not have sufficient controls to ensure the SEFA accurately reflected each awa...
2023 - 007: Reporting: Preparation of the Schedule of Expenditures and Federal Awards (SEFA) (Repeat Finding:2019-007 and 2020-007, 2021-006 and 2022-008) Condition: During fiscal year 2023, the Governmental Department did not have sufficient controls to ensure the SEFA accurately reflected each award’s federal expenditures. There were differences noted in reconciling expenditures from the original SEFA to the trial balance. These errors were corrected through adjustments proposed as part of the audit, and the final version of the SEFA reconciles to the Governmental Department’s general ledger. Corrective Action Plan: Management of the Tribe realizes the importance of the SEFA and will be sure that the SEFA matches the general ledger and accurately reflects each awards federal expenses. With moving reconciliation processes to monthly from annual this will greatly increase the accuracy of the SEFA.
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