Corrective Action Plans

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Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is...
Management agrees with the recommendation and has added this report filing requirement to the grant onboarding checklist. The FFATA report was submitted and uploaded by the Director of Grants & Compliance on August 28 2024. This process will be overseen by the Director of Grants & Compliance and is in place as of the date of this corrective action plan.
Material Weakness ? Internal Control over Compliance & Compliance Testing The Organization will reach out to HUD again to seek assistance to resolve the REAC system technical issues in order to move forward.
Material Weakness ? Internal Control over Compliance & Compliance Testing The Organization will reach out to HUD again to seek assistance to resolve the REAC system technical issues in order to move forward.
Finding 499861 (2023-003)
Significant Deficiency 2023
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do...
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor
Finding 2023-003: Emergency Rental Assistance Program (ERAP). Contact Person: Jenaya L. Mellinger, Director of Fiscal Affairs. Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Hum...
Finding 2023-003: Emergency Rental Assistance Program (ERAP). Contact Person: Jenaya L. Mellinger, Director of Fiscal Affairs. Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Human Services Director and Human Services Financial Manager to revise and, where necessary, establish procedures to insure proper approval by all required parties prior to submission of said reports. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the Human Services Director and Human Services Financial Manager all upcoming reporting requirement, and implement reporting procedures that require multiple signatures and approvals, including those required under the reporting guidelines and requirements, and the initials of the County Director of Fiscal Affairs, prior to submission of the subject reports. Date for Completion: December 31, 2024.
Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor t...
Individual Responsible for Corrective Action Plan: Alliance Director – Brian Dennis Corrective Action: The Organization will enhance its procedures and internal controls with respect to monitoring over subrecipient activities and reimbursement payments by working with the State of Montana grantor to ensure local clubs are using subawards for authorized purposes. Anticipated Completion Date: December 31, 2024
Individuals Responsible for Corrective Action Plan: BGCA Fiscal Team – Shelby Mahoney, Senior Accounting Manager Corrective Action: Alliance team will enhance procedures and internal controls with respect to preparation and review of the SEFA by reviewing detail of expenses included in prior year w...
Individuals Responsible for Corrective Action Plan: BGCA Fiscal Team – Shelby Mahoney, Senior Accounting Manager Corrective Action: Alliance team will enhance procedures and internal controls with respect to preparation and review of the SEFA by reviewing detail of expenses included in prior year with current year expenses, to prevent duplicate entries being reported. Anticipated Completion Date: December 31, 2024
Finding 499849 (2023-002)
Significant Deficiency 2023
Subject: 2023-002 Coronavirus State and Local Fiscal Recovery Funds – Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Rec...
Subject: 2023-002 Coronavirus State and Local Fiscal Recovery Funds – Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Recommendation: The Auditor recommends the City implement procedures to ensure reports are being reviewed by an individual or third-party familiar with the grant prior to their submission, including reconciliation of the report to the general ledger system. Planned Corrective Actions: The City made corrections during calendar year 2023 for a corresponding 2022. This current findings is a result of not being able to make edits in the ARPA reporting portal. A 2022 expenditure was overstated, and this 2023 expenditure was understated by the same amount.
Finding: Timely Filing of Required Reports (2023-002) During the period of audit, it was noted that the two reports required by the Agreement were not submitted by the due date noted in the Agreement. Name of contact person responsible for corrective action: Rosie Vanadestine, COO Anticipated comple...
Finding: Timely Filing of Required Reports (2023-002) During the period of audit, it was noted that the two reports required by the Agreement were not submitted by the due date noted in the Agreement. Name of contact person responsible for corrective action: Rosie Vanadestine, COO Anticipated completion date: December 31, 2024 Corrective Action Plan: The Organization takes reporting requirements seriously, filing reports on numerous grants, and attributes the unusual occurrence of late filings to turnover in finance staff as well as the somewhat novel timelines in the Organization’s first federal “earmark.” The Organization will review the process of submitting reports to ensure the reporting deadlines are achieved in a timely manner.
Finding 499840 (2023-007)
Significant Deficiency 2023
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Ide...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) – Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2305MN5ADM, 2305MN5MAP Compliance Requirement Affected: Reporting Award Period: Year Ended December 31, 2023 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review the annual LCTS Collaborative report before submission and document their review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin documenting the review of their annual LCTS Collaborative report. Name(s) of the contact person(s) responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2024
Compliance Finding: Material Weakness U.S. Department of State - Citizen Exchanges – CFDA No. 19.415 Finding 2023-001: Timely Completion of Audit and Data Collection Form (DCF) Recommendation: Internal controls should be in place that provide reasonable assurance that the audit is engaged and co...
Compliance Finding: Material Weakness U.S. Department of State - Citizen Exchanges – CFDA No. 19.415 Finding 2023-001: Timely Completion of Audit and Data Collection Form (DCF) Recommendation: Internal controls should be in place that provide reasonable assurance that the audit is engaged and completed timely and submitted to the Federal Audit Clearinghouse (now FAC.gov) by the applicable deadline (sooner of 30 days from completion of audit or 9 months from year-end). Action Taken: Management of World Link will engage the audit earlier and provide supporting documentation to the auditors based on the agreed-upon schedule for the 2023 audit to facilitate timely completion and submission of the data collection form. Completion Date: September 30, 2024
Views of Responsible Officials and Planned Corrective Actions: AcademyHealth received its first ever U level grant from the Health Resources and Services Administration and was unaware of the FFATA Subaward Reporting System (FSRS) requirement to file information about the grant by the end of the mon...
Views of Responsible Officials and Planned Corrective Actions: AcademyHealth received its first ever U level grant from the Health Resources and Services Administration and was unaware of the FFATA Subaward Reporting System (FSRS) requirement to file information about the grant by the end of the month following the month in which the subaward was awarded. Now that AcademyHealth is aware of the FFATA requirements, the Chief Financial Officer and Director of Grants and Contracts will seek to understand and demonstrate compliance with its submissions’ requirements and deadlines. AcademyHealth’s written processes and procedures will include deadlines to ascertain compliance, and the finance and OGC professionals will attend HRSA compliance seminars and seek resources to better understand the requirements.
Views of Responsible Officials and Planned Corrective Actions: In future, the Chief Financial Officer will submit the indirect cost rate proposal to obtain final rates for the fiscal year just completed and will submit requests for provisional rates for upcoming years within the required timeframe. ...
Views of Responsible Officials and Planned Corrective Actions: In future, the Chief Financial Officer will submit the indirect cost rate proposal to obtain final rates for the fiscal year just completed and will submit requests for provisional rates for upcoming years within the required timeframe. AcademyHealth’s written processes and procedures will include deadlines to ascertain compliance.
Finding 2023-007: Reporting - Significant Deficiency/Noncompliance Recommendation: We recommend that the County revisit its policies and procedures related to reporting to ensure future reports are completed and submitted within the appropriate time period. Explanation of disagreement with audit f...
Finding 2023-007: Reporting - Significant Deficiency/Noncompliance Recommendation: We recommend that the County revisit its policies and procedures related to reporting to ensure future reports are completed and submitted within the appropriate time period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has put safeguards in place to ensure timely filing of reports. Name(s) of the contact person(s) responsible for corrective action: Director of Budget and Finance Planned completion date for corrective action plan: Completed September 2024
Finding 2023-006: Completion and Submission of Annual Single Audit - Significant Deficiency/Noncompliance Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframe...
Finding 2023-006: Completion and Submission of Annual Single Audit - Significant Deficiency/Noncompliance Recommendation: We recommend that County management review its staffing and personnel responsibilities to prioritize the completion of its audit responsibilities within the prescribed timeframes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The information for the 2023 Single Audit was provided in a timely manner and it is expected that the report will be filed on time. Name(s) of the contact person(s) responsible for corrective action: Director of Budget and Finance Planned completion date for corrective action plan: Completed September 2024
FINDING 2023-002 Finding Subject: Airport Improvement Program – Reporting Summary of Finding: Noncompliance. The airport was unable to provide the SF-425: Federal Financial Report, a required report, for the AIP54 grant for audit. Contact Person Responsible for Corrective Action: Kelsey Veatch Conta...
FINDING 2023-002 Finding Subject: Airport Improvement Program – Reporting Summary of Finding: Noncompliance. The airport was unable to provide the SF-425: Federal Financial Report, a required report, for the AIP54 grant for audit. Contact Person Responsible for Corrective Action: Kelsey Veatch Contact Phone Number and Email Address: 812-877-2542 kveatch@huf.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The airport has hired a new Director of Operations and a new on-call airport consultant/engineer which both positions will be properly advised on how to complete and retain all documents related to Airport Improvement Program projects. For this process the on-call airport consultant/engineer will prepare the SF-425 and will submit it to the Executive Director and the Director of Operations for their review and signature of approval. The Executive Director and the Director of Operations will then provide their signed approval to the on-call airport consultant/engineer. Upon receiving the signed approval, the on-call airport consultant/engineer will submit the completed SF-425 to the FAA. Once the submission is made, the oncall airport consultant/engineer will provide documented evidence to the airport showing the submission was made. In summary, the on-call airport consultant/engineer will be responsible for preparing, reporting and submitting the SF-425 upon airport staff’s approval. The Executive Director and the Director of Operations will be responsible for reviewing and providing approval of the SF-425 prior to the final submission, verifying the submission was completed, and maintaining records of the submission in the appropriate AIP binder. Anticipated Completion Date: Effective immediately – 9/24/2024
Finding No. 2023-001 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: All necessary FFATA will be filed within 30 days. Legal Services of Eastern Missouri (LSEM) will develop policies...
Finding No. 2023-001 Personnel Responsible For the Corrective Action: Eric Keith, Director of Finance Anticipated Completion Date December 31, 2024 Corrective Action Plan: All necessary FFATA will be filed within 30 days. Legal Services of Eastern Missouri (LSEM) will develop policies and procedures within 60 days to ensure that all FFATA reports are submitted in a timely manner. LSEM will provide training regarding all grant compliance for all staff involved in grant management and compliance within 90 days.
FINDING 2023-005 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of R...
FINDING 2023-005 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Summary of Finding: Material Weakness Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Explanation and Reasons for Disagreement: Description of Corrective Action Plan: The Town of Upland will implement an oversight system to review the P&E Report before submission to the Federal Government. Anticipated Completion Date: Upon the submission of our next report due April 30, 2025
FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-74...
FINDING 2023-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Activities Allowed and Unallowed. Summary of Finding: Material Weakness, Modified Opinion Contact Person Responsible for Corrective Action: Mary Fletcher Contact Phone Number and Email Address: (765) 998-7439, mfletcher@uplandindiana.com Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Although the funds were transferred to utilities and not paid directly from ARPA Funds, the funds were used to make necessary investments in utility infrastructure during 2023. We have been fully informed of the guidelines for the use of the ARPA funds since this transfer occurred and will use the remaining funds according to the ARPA guidelines. The Clerk-Treasurer has contacted the Department of the Treasury to get guidance on what can be done to rectify our misuse of the funds. Anticipated Completion Date: Unknown- When a resolution is reached with the Federal Government.
View Audit 322658 Questioned Costs: $1
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reonciled with the FDS. Anticipated completion date - Within the next fiscal year.
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reonciled with the FDS. Anticipated completion date - Within the next fiscal year.
Our CCI Trip Report System has been modified to automatically send to USDA-FAS Trip Report/s submitted by the traveler/s in the System.
Our CCI Trip Report System has been modified to automatically send to USDA-FAS Trip Report/s submitted by the traveler/s in the System.
Finding 499785 (2023-004)
Significant Deficiency 2023
Finding 2023-004 Condition The 2023 Project and Expenditure Reports for quarters selected for testing were not reviewed by an independent person before submission of the report. Corrective Action Plan Corrective Action Planned: The reporting process has been updated to ensure proper documentatio...
Finding 2023-004 Condition The 2023 Project and Expenditure Reports for quarters selected for testing were not reviewed by an independent person before submission of the report. Corrective Action Plan Corrective Action Planned: The reporting process has been updated to ensure proper documentation of formal review prior to submission. Name(s) of Contact Person(s) Responsible for Corrective Action: Samantha Fenske, Finance Director Anticipated Completion Date: December 31, 2024
Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, El...
Finding 2023-002: Section 8 Project-Based Cluster Federal Assistance Number: 14.182 and 14.195 U.S. Department of Housing and Urban Development (Repeat of Finding 2022-002) Compliance Requirements: Cash Management, Eligibility, Reporting, Special Tests and Provisions Type of finding: Internal Control Over Compliance (significant deficiency) Recommendation: The Organization should strengthen its internal controls with adopted policies and procedures to ensure a review process is established through adequate segregation of duties. The Organization should consider assessing and realigning the duties and responsibilities of administrative staff allowing the administrator to act in a more supervisory position. Action Taken: The Operation Administrator is overall responsible the operation of Tri-County Senior Center and Housing; working together with the bookkeeping staff and Executive Director as partners to maintain financial records and budgets. The Executive Director will sporadically review tenant eligibility of new certifications and re-certifications, HAP Contracts, samples of monthly HAP Assistance Payment requests, and her presence when auditors are in-house as well any other assistance requested by Administrator. To ensure the health, safety, and well-being of the residents and staff, the Administrator oversees the responsibilities and duties of all other staff in their roles, (Administration Assistant/Program Administrator-Senior Center Activities; Administration Assistant-Membership, monthly newsletters, answer phones and any other duties requested by the Administrator), to guide them in their specific roles so they understand their duties and responsibilities as administrative staff, and ensuring the facility meets all regulatory compliance standards. If there are questions regarding this plan, please call the responsible party at (719) 852-5778. Sincerely yours, Monica Wolfe Executive Director Tri-County Senior Citizens and Housing, Inc.
Columbus Neighborhood Health Center, Inc. dba PrimaryOne Health Corrective Action Plan Year Ended December 31, 2023 Contact Information: Charleta B. Tavares, Chief Executive Officer 614. 859. 1946 ctavares@primaryonehealth.org Audit period: January 1, 2023 – December 31, 2023 Finding 2023-001 –...
Columbus Neighborhood Health Center, Inc. dba PrimaryOne Health Corrective Action Plan Year Ended December 31, 2023 Contact Information: Charleta B. Tavares, Chief Executive Officer 614. 859. 1946 ctavares@primaryonehealth.org Audit period: January 1, 2023 – December 31, 2023 Finding 2023-001 – Allowable Costs (Time and Effort) Recommendation: Management should establish policies and procedures that are consistent with the Uniform Guidance administrative requirements with regards to compensation and allowable costs which includes ensuring time and effort charges are based on records that accurately reflect the work performed. Action planned/take in response to finding: 1. Implementation of Time and Effort Reporting System: The organization has begun to establish and implement a robust time and effort reporting system in compliance with 2 CFR 200.430. This system will: a. Accurately reflect the distribution of employee time across different federal grants. b. Track employee hours worked, allocate wages based on grant activities, and ensure the proper alignment of salaries to the work performed. c. Provide documentation supporting time allocation between different federal and non-federal activities. 2. Training for Payroll and Grants Management Staff: All payroll, human resources, and finance staff will undergo mandatory training on: a. Time and effort reporting requirements under federal guidelines. b. The correct procedures for allocating wages to federal grants, including compliance with Uniform Guidance (2 CFR 200). 3. Updating Policies and Procedures: The organization will update internal policies to reflect compliance with the Uniform Guidance, particularly regarding payroll documentation and time and effort allocation. This will include: a. Establishing written procedures on tracking employee work hours and effort reporting. b. Implementing monthly or quarterly reviews to ensure payroll costs are appropriately charged to federal awards. 4. Periodic Internal Audits: The organization will conduct periodic internal audits to ensure continued compliance with federal requirements, especially as it relates to payroll and time tracking. Any discrepancies will be promptly corrected to avoid future findings. Planned completion date for corrective action plan: December 31, 2024
View Audit 322621 Questioned Costs: $1
Management intended to report the Provider Relief Funding in the HRSA reporting system for subsidiary entities with the parent entity, however, it has now come to our attention that the field did not appropriately populate despite having included the TIN of the subsidiary.  The Organization has indi...
Management intended to report the Provider Relief Funding in the HRSA reporting system for subsidiary entities with the parent entity, however, it has now come to our attention that the field did not appropriately populate despite having included the TIN of the subsidiary.  The Organization has indicated that there is more than enough lost revenue and eligible expenses in the appropriate period to claim this funding in its entirety as was our intention, therefore there is no risk that funding was inappropriately utilized.  The Organization will implement procedures and a responsible party to oversee the preparation of a complete Schedule of Expenditures of Federal Awards that reconciles to the general ledger and other external reporting.
Audit Finding Number: 2023-002 Responsible Person: Carrie Smith, AVP of Regulatory Response to Findings: The Accounting Team performed an internal review and agrees with the Uniform Guidance audit findings. An adjustment was recorded as of 12/31/2023. In addition, the finding was communicated to the...
Audit Finding Number: 2023-002 Responsible Person: Carrie Smith, AVP of Regulatory Response to Findings: The Accounting Team performed an internal review and agrees with the Uniform Guidance audit findings. An adjustment was recorded as of 12/31/2023. In addition, the finding was communicated to the State auditors. Corrective Action to be Taken: 1. VillageCare will continue to utilize project ID when recording grants revenue and grants expenses. 2. Only appropriate, non-duplicative, and verified invoices will be submitted by the Accounts Payable Department for reimbursement. The AVP of Regulatory will receive and review all invoices from AP prior to submission to the funding source. 3. For material reimbursement, the Procurement Department will ensure the goods are received. 4. The Accounting Team will maintain all potential reimbursement schedules and cross check against current and past grants to ensure no prior approved expenditures are resubmitted for reimbursement. 5. The Director of Accounting and Finance and/or Controller will only approve grants receivable accrual based on allowable, confirmed, and validated invoices. Completion Date or Anticipated Completion Date of the Action to be Taken: September 1, 2024.
View Audit 322588 Questioned Costs: $1
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