Corrective Action Plans

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Delaware Parents Association acknowledges the delays in completing audits and data collection forms, which were due to limited staffing and competing demands on available staff time. Delaware Parents Association is committing additional time and effort to getting caught up and anticipates filing its...
Delaware Parents Association acknowledges the delays in completing audits and data collection forms, which were due to limited staffing and competing demands on available staff time. Delaware Parents Association is committing additional time and effort to getting caught up and anticipates filing its 2024 data collection form prior to the September 2025 deadline.
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in ac...
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in accordance with the required deadlines. To address this, we will implement the following corrective actions: 1. Enhanced Internal Timeline: We will establish an internal deadline for audit-related documentation and review, allowing sufficient time for finalization before the official reporting deadline. 2. Increased Coordination: Management will work closely with auditors and key stakeholders throughout the audit process to ensure timely responses and resolution of outstanding items. 3. Resource Allocation: Additional internal resources will be dedicated to supporting the audit process, ensuring that necessary documentation and financial records are prepared in advance. 4. Regular Progress Monitoring: We will implement periodic check-ins during the audit period to track progress and address any potential delays proactively. We are confident that these measures will improve our ability to meet future reporting deadlines and enhance overall efficiency in the audit process.
We agree with the auditor’s comments and the following action will be taken to improve this situation. We are working to organize current contracts and awards for federal programs and other funding sources. Second Harvest staff will review each funding contract and verify which sources include fun...
We agree with the auditor’s comments and the following action will be taken to improve this situation. We are working to organize current contracts and awards for federal programs and other funding sources. Second Harvest staff will review each funding contract and verify which sources include funding and expenditures subject to Uniform Guidance. This corrective action will be implemented by June 1, 2025.
We agree with the auditor’s comments and the following action will be taken to improve this situation. Second Harvest staff are currently engaged with outside resources and support to develop an appropriate cost segregation plan which will address direct costs and indirect costs including salary, f...
We agree with the auditor’s comments and the following action will be taken to improve this situation. Second Harvest staff are currently engaged with outside resources and support to develop an appropriate cost segregation plan which will address direct costs and indirect costs including salary, fringe benefits, and non-salary costs. Through this process a spreadsheet will be developed to better distribute costs appropriately across all federal programs operated by Second Harvest and efforts supported through additional funding sources. This corrective action will be implemented by February 1, 2025.
We agree with the auditor’s comments and the following action will be taken to improve this situation. As of September 2024, the Director of Logistics has established a system to ensure the accurate values of USDA foods are receipted into Primarius, Second Harvest’s inventory software system. At t...
We agree with the auditor’s comments and the following action will be taken to improve this situation. As of September 2024, the Director of Logistics has established a system to ensure the accurate values of USDA foods are receipted into Primarius, Second Harvest’s inventory software system. At the beginning of each year, the Department of Social Services sends our Operations team the USDA Foods valuation chart for the calendar year. This valuation chart lists the food value per pound, net case weight and case value by material code. These material codes are input into our inventory software system and reviewed each month to ensure they match the USDA foods code. In preparing for USDA food deliveries, the Director of Logistics will pre-enter information using the USDA Foods Valuation chart to verify the case values & case net weights match in Primarius. Finally, all USDA food valuations will be reviewed at year-end for accuracy and sent to the State Agency for verification that all monthly receipted quantities and values align between the two systems. This corrective action was implemented as of September 30, 2024.
Finding 2023-004 Noncompliance-Reporting Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: The report for the year ende...
Finding 2023-004 Noncompliance-Reporting Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: The report for the year ended December 31, 2022, was not filed within the required report submission period. Actions Planned in Response to the Finding: Prior to 2022, the Organization barely had the infrastructure to fully run a non-profit organization. The state legislature has been kind to provide funding to build the infrastructure within the organization. The learning curve has been steep but senior management staff and Board members in understanding the federal requirements. With adequate resources, the Organization is on track to accelerate the submission of future audit reports henceforth. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: July 15, 2025
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Emplo...
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Employee time sheets do not identify the hours charged to each federal grant, and do not identify hours worked by employees on non-federal grants. Actions Planned in Response to the Finding: The timeline for hiring an in-house accountant is very compressed. The in-house accountant will undergo various training on Uniform Guidance and federal grant management. These training programs will help the organization to create a system of time and effort reporting that will meet the Standards for Documentation of Personnel Expenses included in OMB Uniform Guidance. Specifically, time sheets will be redesigned to ensure that employees record hours charged to each federal grant, any other projects, and administrative time. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025
View Audit 344524 Questioned Costs: $1
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minn...
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minneapolis, MN 55415 African American Child Wellness Institute submits the following corrective action plan for the year ended December 31, 2023. Please contact Akinyele Akinsanya at 763-522-0100. Finding 2023-001 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Expenses charged to the federal grant cannot be traced into the Organization’s general ledger. Invoices submitted to the pass-through agency for reimbursement also cannot be traced into the general ledger. Actions Planned in Response to the Finding: It is clear to management that the Organization needs to boost its accounting team to fulfil effective reporting that could easily be traced into the organization’s general ledger. As a result, the organization will recruit and hire a full-time accountant to work with the current team. Further steps may be required including replacing the organization’s current accounting software that will identify and record expenditure specific to each cost centers for each federal grant. The in-house accountant will also be required to obtain additional training in Uniform Guidance and federal grant management and create a system of financial reporting to record expenditure directly to each federal grant award. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: March 15, 2025
View Audit 344524 Questioned Costs: $1
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee R...
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Errors in recording and reporting of revenues and expenditures of federal awards may not be detected and/or corrected. Because the Auditee’s SEFA that was presented for audit was completed incorrectly, and not reconciled to the general ledger, the SEFA was materially misstated, prior to auditors’ correction recommendations. Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • Inadequate reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: November 1, 2024 Responsible Person: District Business Manager
Recommendation – We recommend that management ensure that all grant reporting is tracked to ensure future compliance. Views of Responsible Officials and Planned Corrective Actions – Reporting requirements will be tracked to support requirements in the future.
Recommendation – We recommend that management ensure that all grant reporting is tracked to ensure future compliance. Views of Responsible Officials and Planned Corrective Actions – Reporting requirements will be tracked to support requirements in the future.
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and ...
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and retained to support expenses in the future.
Management acknowledged several amendments were made to the UDS tables that support the final calculation that was filed. A lack of document retention resulted in the final amended calculation not being saved in a central shared site that would support the amount filed. In future periods, management...
Management acknowledged several amendments were made to the UDS tables that support the final calculation that was filed. A lack of document retention resulted in the final amended calculation not being saved in a central shared site that would support the amount filed. In future periods, management has processes and procedures in place to require reconciliation and tie-out of supporting documentation to final filings which will alleviate this finding. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Finding 2023-004 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: For certain quarters, the am...
Finding 2023-004 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: For certain quarters, the amounts reported for net patient revenue were based on gross charges. Additionally, amounts did not agree to the supporting documentation provided. Corrective Action Plan: Confluence Health during the next pandemic will confirm reporting requirements before submitting reporting data. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. The 2023 data was reported at net patient revenue as required by the grant. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: Confluence Health selected option ii to calculat...
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: Confluence Health selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to a budget approved before March 27, 2020, for the entire period of availability. The budget used in the calculation of lost revenue for quarters in 2021, 2022 and 2023 was not approved prior to March 27, 2020. Corrective Action Plan: Confluence Health during the next pandemic will issue a budget for the entire period required by the grant. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.
Audit Finding Reference: 2023-013 Management’s Response and Planned Corrective Action: We currently do not have a grant accountant, but a second pair of eyes would make it easier to manage our federal activities fund. Someone to help reconcile and be a second approver on journal entries + adjus...
Audit Finding Reference: 2023-013 Management’s Response and Planned Corrective Action: We currently do not have a grant accountant, but a second pair of eyes would make it easier to manage our federal activities fund. Someone to help reconcile and be a second approver on journal entries + adjusting entries would be a huge source of stability in this area. Management will work with financial support on ensuring our discrepancies are resolved, while we also revamp and complete new grant related procedures – such as monthly reconciliations, timely monthly reporting of expenses/reimbursement, and filing to sure up and make this fund reviewable/auditable. Management has been working to track in an aggregate format – the status of each grant on a live document – which the board has access too so they can see when a grant falls behind. Unfortunately, when management first identified these issues, some grants were behind in reporting to almost a full calendar year, causing issues with getting the fund caught back up to date. Name of Contact Person and Completion Date: Name: Mackenzie Campbell Anticipated Completion Date – 6/30/25
View Audit 344315 Questioned Costs: $1
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.
The District will review its control procedures and attempt to maximize internal control with a limited number of office employees.
The District will review its control procedures and attempt to maximize internal control with a limited number of office employees.
Finding 524581 (2023-001)
Significant Deficiency 2023
Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 3...
Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 30, 2023.
Finding 524563 (2023-001)
Significant Deficiency 2023
Below is Housing Forward’s response to the audit finding for fiscal year 1/1/2023 through 12/31/2023. Federal Award Finding Finding 2023-001: Allowable costs and activities – significant deficiency in internal controls over compliance and compliance finding specific to payroll allocation.  Funding ...
Below is Housing Forward’s response to the audit finding for fiscal year 1/1/2023 through 12/31/2023. Federal Award Finding Finding 2023-001: Allowable costs and activities – significant deficiency in internal controls over compliance and compliance finding specific to payroll allocation.  Funding Source: Coronavirus State and Local Fiscal Recovery Funds ALN 21.027 (CSLFRF).  Condition: During allowable cost and activities testing for the CSLFRF grant, 2 out of 40 timesheets tested did not agree to the number of hours charged to the grant.  Cause: Although the 2 timesheets were filled out completely, signed and reviewed by a supervisor, there was an error in the data entry into the accounting software. Amounts were calculated correctly but inadvertently assigned to the wrong grant. GL detail was provided to the funder as part of the monthly reporting, but neither the funder nor Housing Forward staff noticed this error.  Management’s Response: Management understands the importance of correctly charging time to funders. Housing Forward will continue its timesheet review process and utilize employee timesheets that clearly indicate funding sources and allocate payroll costs based on these records. Housing Forward will implement a second review of the payroll entry at the time it is entered into the accounting system to ensure that errors are corrected before payroll costs are charged to funders. This began in January 2025. The second reviewer will be the VP of Finance/CFO or her designee. In later FY25 the organization also plans to implement a timekeeping software that integrates with the accounting software to prevent future data entry errors. Sincerely, Sarah Kahn Sarah Kahn President & CEO
View Audit 343995 Questioned Costs: $1
Finding 524466 (2023-003)
Significant Deficiency 2023
Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the...
Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the Town of Eagle, Colorado, to follow to ensure that the Town’s books and records are completed and provided to the Town’s independent auditors within 4 ½ months after the Town’s calendar year-end.
Finding 524465 (2023-002)
Significant Deficiency 2023
Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the...
Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the Town of Eagle, Colorado, to follow to ensure that the Town’s books and records are completed and provided to the Town’s independent auditors within 4 ½ months after the Town’s calendar year-end.
Finding 524464 (2023-001)
Significant Deficiency 2023
Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the...
Views of Responsible Officials and Planned Corrective Action: In order to ensure timely submission of future required Single Audit Reports to the Federal Audit Clearinghouse on a timely basis, the Town Manager will establish and issue written procedures for the staff of the Finance Department of the Town of Eagle, Colorado, to follow to ensure that the Town’s books and records are completed and provided to the Town’s independent auditors within 4 ½ months after the Town’s calendar year-end.
The management's company's new CFO has brought the filings up-to-date as of November 2024 and reporting sumbissions will now be filed in a timely manner.
The management's company's new CFO has brought the filings up-to-date as of November 2024 and reporting sumbissions will now be filed in a timely manner.
The District will continue to review procedures and make adjustments as necessary to obtain the maximum internal control possible under the circumstances utilizing current personnel and elected officials.
The District will continue to review procedures and make adjustments as necessary to obtain the maximum internal control possible under the circumstances utilizing current personnel and elected officials.
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to as...
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025
View Audit 343640 Questioned Costs: $1
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