Corrective Action Plans

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We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. 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 ...
We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting. 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.
Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s...
Finding 2023-002 – Financial Reporting of Federal Expenditures Condition: Internal controls over financial reporting lacked oversight and thorough review of federal expenditures being included within the SEFA during fiscal year 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: We have reviewed current procedures regarding SEFA preparation and have implemented necessary changes to ensure accuracy. We have also established procedures to ensure a timely reconciliation of federal revenues and expenses.
Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report ...
Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report to the FAC within nine months from year ending June 30, 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines in order to remain compliant with the requirements. Management has made Professional Services changes to ensure timely audit compliance moving forward.
Finding 2023-004 – Reporting Compliance Requirements of Federal Funds Condition: The City’s internal controls over reporting compliance requirements were not thoroughly monitored and were not timely, and reports were not accurately submitted. In conjunction with our FY2023 single audit, please see t...
Finding 2023-004 – Reporting Compliance Requirements of Federal Funds Condition: The City’s internal controls over reporting compliance requirements were not thoroughly monitored and were not timely, and reports were not accurately submitted. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: We have reviewed current procedures regarding report preparation and have implemented necessary changes to ensure accuracy. We have also established procedures to ensure a timely reconciliation of federal revenues and expenses.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Malden January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Town of Malden January 1, 2023 through December 31, 2023 This schedule presents the corrective action the Town is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-002 Finding caption: The Town did not have adequate internal controls and did not comply with federal wage rate requirements. Name, address, and telephone of Town contact person: Dan Harwood, Mayor PO Box 248, Malden, Washington 99149 (509) 569-3771 Corrective action the auditee plans to take in response to the finding: We agree with the SAO staff as far as the Town staff being new to federal grants and the requirements of recordkeeping associated with it. It is obvious that the Town staff can not handle the workload of administering all the grants that the town has obtained since the 2020 Babb Road Fire. We are in the process of contracting an outside party that will handle most of the current grants. The Town staff thought they processed all the certified payroll information that was received. We were surprised that there were some missing. The State Department of Commerce has been working with the staff on making sure that the certified payroll process was complete. With any future grants we will make sure that Town staff will pursue training on Certified Payroll to make sure all papers are received. Anticipated date to complete the corrective action: These actions will be done when we receive future federal grants.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
2023-003: SFSAC Submission Contact Person – Julie Ketterling, Director Corrective Action Plan – This finding is noted together with the Board. The Unit will work to ensure timely submission of the data collection form in the future. Completion Date – The Unit will work to submit timely for the June ...
2023-003: SFSAC Submission Contact Person – Julie Ketterling, Director Corrective Action Plan – This finding is noted together with the Board. The Unit will work to ensure timely submission of the data collection form in the future. Completion Date – The Unit will work to submit timely for the June 30, 2025 audit.
Finding 2023-2 –Reporting Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over grant reporting to ensure all required Reconciliation of Cash on Hand Quarterly Reports and final expenditure reports are prepared accurate...
Finding 2023-2 –Reporting Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over grant reporting to ensure all required Reconciliation of Cash on Hand Quarterly Reports and final expenditure reports are prepared accurately and submitted timely in accordance with grant requirements. The District should implement a formal review and monitoring process and provide training to staff responsible for grant reporting to ensure ongoing compliance. Action: The District Office will work directly with the Federal Programs Coordinator to ensure more timely submissions of Reconciliation of Cash on Hand Quarterly Reports and Final Expenditure Reports are prepared accurately and submitted timely in accordance with grant requirements. The Business Manager will do this by creating reminders on the Business Manager’s calendar that include due dates each quarter and reminding the Federal Programs Coordinator when their respective reports are due. The District will implement and form a review and monitoring process and provide any necessary training to staff responsible for grant reporting to ensure ongoing compliance. Date for Completion: These steps have already been put into place and will continue to be built upon.
The City has engaged an independent accountant and works with its financial advisors to ensure future audits are completed in a timely manner.
The City has engaged an independent accountant and works with its financial advisors to ensure future audits are completed in a timely manner.
Finding 2023-001: Uniform Guidance Audit Requirement Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will work to complete future audits timely. Anticipated Completion Date: Future federal programs.
Finding 2023-001: Uniform Guidance Audit Requirement Responsible Individuals: Jeannie Walters, Finance Officer Corrective Action Plan: The Association will work to complete future audits timely. Anticipated Completion Date: Future federal programs.
Response to finding 2023-005 – Reporting Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-005. During the audit period, recordkeeping was not centrally maintained, and key docu...
Response to finding 2023-005 – Reporting Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-005. During the audit period, recordkeeping was not centrally maintained, and key documents were often stored under individual employee drives rather than within a shared, organization-controlled system. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization had limited capacity to implement formal reporting controls; however, foundational corrective steps were initiated in 2025 to support full compliance during the 2026 operating year. Corrective Action taken in 2025: The Operations Manager conducted a full triage of existing accounts and transferred organizational documents into centralized CSforALL Drives. Files were reorganized by year and subject matter to ensure accessibility, consistency, and proper retention. This restructured system now provides a unified location for all grant-related documents, reporting records, and compliance materials, establishing a baseline for future Uniform Guidance reporting requirements. Corrective Action Planned for 2026: Beginning in 2026, CSforALL will implement formalized policies and procedures to ensure records are maintained in accordance with applicable compliance requirements and that all Uniform Guidance reports are submitted timely. The Operations Manager and Accounting team will oversee ongoing documentation, retention, and periodic internal review to ensure the reporting structure remains organized, accessible, and compliant throughout the 2026 operating year and beyond. Page
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the award...
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the awarding agency as required. Corrective Action: The Tribe has hired a full-time bookkeeper along with a new fiscal consultant to assist the bookkeeper in journal entries, bank statements, etc. on a monthly basis. All required reporting will be done within 30 days of the end of reporting date. Anticipated date of completion: April 1, 2026.
Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, Pass-Through Entit...
Federal Program: Assistance Listing #'s 93. 778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP-4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available; 21.027, COVI D-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury; 93.558, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available. Criteria: The tracking and matching of grant revenues and expenditures and the related grant receivable and unearned revenue amounts is necessary to assist in making management decisions and for the proper reporting and use of those funds in accordance with each of the individual grant requirements. In addition, this information is essential in preparing the County's Schedule of Expenditures of Federal Awards (SEFA}. Condition/Context: The County's system of tracking its grants and matching revenues with expenditures lacks the necessary level of sophistication, given the number and complexities of the County's grant activities, which hampers the County's ability to maintain an accurate general ledger and prepare a complete and accurate SEFA. The current year SEFA also required the restatement of beginning accrued revenue balances. Effect: Grants receivable and unearned revenue amounts are not readily ascertainable to assist in making management decisions or for use in the timely preparation of the County's SEFA. The County did not prepare a complete and accurate SEFA in a timely manner to comply with its financial reporting requirements. Cause: The County has not prioritized a formal system for tracking its grant activities. Recommendation: We recommend that the County develop and implement a formal system for tracking its grant related activities and in doing so require that all departments with responsibility for federal award programs provide periodic reconciliations of their grant reports to the general ledger to a responsible management official. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the restatement of the beginning accrued revenue balances on the SEFA and is working to realign staff responsibilities to provide a dedicated business office staff member to oversee, track, report and manage all of the County's grant awards. Designated Member responsible for Corrective Action Plan: Kayla E. Herman Expected Complete Date: 06/30/2026
Federal Program: Assistance Listing #'s 93.778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP- 4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity...
Federal Program: Assistance Listing #'s 93.778, Medical Assistance Program, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: 13-1415MATP- 4-2; 93.658, Foster Care Title IV-E, Passed Through Pennsylvania Department of Human Services, PassThrough Entity Identifying Number: not available; 21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury; 93.558, Temporary Assistance for Needy Families, Passed Through Pennsylvania Department of Labor and Industry, Pass-Through Entity Identifying Number: not available. Criteria: Pursuant to the provisions of the Uniform Guidance, under Section 200.512(a), the County is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (September 30) of the following year. Condition/Context The County's Single Audit and reporting package was delayed for the year ended December 31, 2022 beyond the nine-month due date. Effect: The County is not in compliance with certain requirements of the Uniform Guidance, including the Single Audit reporting requirements. Questioned Costs: None. Cause: Reconciliations and reports were not completed on a timely basis, and therefore, the completion and filing of its December 31, 2022 Single Audit and reporting package was not prioritized. Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Views of Responsible Officials and Planned Corrective Actions: The County plans to have information ready for the auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the County hopes to have cleared by the 2025 audit. Designated Member responsible for Corrective Action Plan: Kayla E. Herman Expected Complete Date: 06/30/2026
PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO
PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO
Finding 1167725 (2023-010)
Material Weakness 2023
We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be ...
We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be easily reconciled to the underlying accounting records.
Name of Auditee: City of Beacon, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Susan Tucker, CPA, Director of Finance Phone: (845) 838-5006 (2) Audit Finding 2023-002 - The City did not submit its audited financial info...
Name of Auditee: City of Beacon, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2023 CAP Prepared by: Susan Tucker, CPA, Director of Finance Phone: (845) 838-5006 (2) Audit Finding 2023-002 - The City did not submit its audited financial information for the year ended December 31, 2023, to the FAC by the required deadlines. (a) Implementation Plan of Actions - The City will reconcile its balance sheet accounts at year-end. (b) Implementation Date - This will be implemented for the year ending December 31, 2026. (c) Persons Responsible for Implementation - The Director of Finance and the City Council.
Views of responsible officials: 6 days The Company will establish a clear and organized calendar for the submission of all required reports. This calendar will serve as a reference to ensure that all deadlines are met, helping to improve overall efficiency. By outlining specific dates for each repor...
Views of responsible officials: 6 days The Company will establish a clear and organized calendar for the submission of all required reports. This calendar will serve as a reference to ensure that all deadlines are met, helping to improve overall efficiency. By outlining specific dates for each report will avoid delays and ensure that all required reports and documentation are submitted on time, contributing to a more effective report delivery process. Names of the contact persons responsible for the corrective action plan: Nilsa Rodríguez Rivera (CFO -2025) Anticipated complete date: This corrective action was implemented as of December 31, 2024.
The Chief Financial Officer (CFO) is responsible for this task. The overview includes reviewing and submitting the information and data collected during the month. To ensure timely compliance, the CFO has implemented a shared calendar system with the administrative personnel that establishes clear d...
The Chief Financial Officer (CFO) is responsible for this task. The overview includes reviewing and submitting the information and data collected during the month. To ensure timely compliance, the CFO has implemented a shared calendar system with the administrative personnel that establishes clear deadlines and reminders to prevent delays and improve efficiency, ensuring all submissions are received within the required timeframe. In addition to timeliness, the CFO will implement enhanced internal controls and quality assurance measures to guarantee that all data submitted is accurate, complete, and in full compliance with federal reporting requirements. This process will include: • Conducting a pre-submission review of all documents by the finance and compliance team to verify accuracy and consistency. • Establish a checklist of federal regulatory requirements to be applied before final submission of reporting packages. • Assigning a secondary reviewer independent of the preparer to ensure an additional level of oversight. • Documenting all reviews and approvals to create an audit trail that supports transparency and accountability. • Holding monthly coordination meetings with responsible personnel to address potential delays, clarify requirements, and provide corrective guidance in real time. By combining timely submission mechanisms with strengthened review and compliance controls, the CFO ensures that reporting packages meet the highest standards of accuracy, reliability, and federal regulatory compliance. Names of the contact persons responsible for the corrective action plan: Nilsa Rodríguez Rivera (CFO -2025) Anticipated completion date: This corrective action will be in place no more than November 30, 2025.
Finding 2023-007: This is for Pohnpei Community Health Centers. The FFR (SF425’s) were submitted after the due dates. Root Cause Analysis The State’s monitoring controls over FFR reporting deadlines were ineffective Corrective Actions 1) Establish a tracking schedule for grant reporting deadlines up...
Finding 2023-007: This is for Pohnpei Community Health Centers. The FFR (SF425’s) were submitted after the due dates. Root Cause Analysis The State’s monitoring controls over FFR reporting deadlines were ineffective Corrective Actions 1) Establish a tracking schedule for grant reporting deadlines upon award or extension and 2) Retain copies of all submissions and supporting expenditure reports for audit purposes Responsible Parties For CAP 1, Executive Director of CHC and the Administrative officers For CAP 2, Director of DOTA and the Chief of Finance Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Hale County Health Care Authority respectfully submits the following corrective action plan for the year ended September 30, 2023. The finding from the September 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in t...
Hale County Health Care Authority respectfully submits the following corrective action plan for the year ended September 30, 2023. The finding from the September 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Significant Deficiency (2023-001) - Reporting (Late Filing) Recommendation: We recommend that the Authority complete its audit and submit the required by the deadline. Planned Corrective Action: We are continuining to institute processes and procedure to complete timely reconcilations to allow for future filings to be made prior to deadline. Contact Person: Shay Cherry
Action Item Title 2023-006 – Federal Award Findings Status (Open: In-process) Condition Single Audit Reporting Package Submission The Corporation did not comply with the Single Audit Reporting Package submission date requirement for the years ended June 30, 2023, and 2022. Identified root cause Due ...
Action Item Title 2023-006 – Federal Award Findings Status (Open: In-process) Condition Single Audit Reporting Package Submission The Corporation did not comply with the Single Audit Reporting Package submission date requirement for the years ended June 30, 2023, and 2022. Identified root cause Due to the Commonwealth of Puerto Rico's (the Commonwealth) filing for Title III under PROMESA, most of its instrumentalities were required to reduce staff as part of the Fiscal Plan to lower expenditures. This staff reduction resulted in a lack of personnel, which impacted key internal controls. Grantee resolution plan The Corporation will submit the outstanding Single Audit Reporting Packages Completion date 2022 2023 Submitted and accepted by the Federal Audit Clearinghouse on August 20, 2024. May 2025 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
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