Corrective Action Plans

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Benjie Read CFO and Felecia Read Staff Accountant, will update the policies and procedures for all program reports and the review of each before submission. We will also negotiate with the grantors for appropriate time frams as some of these time frames are impossible for us to meet in an accurate m...
Benjie Read CFO and Felecia Read Staff Accountant, will update the policies and procedures for all program reports and the review of each before submission. We will also negotiate with the grantors for appropriate time frams as some of these time frames are impossible for us to meet in an accurate manner. These policies will be done within 90 days of audit completion.
Benjie Read CFO and Felecia Read Staff Accountant, will update procedures for documented review of the program reports prior to submission to the grantors. Also see 2023-013 for timely submission. These updates will be completed within 90 days of audit submission.
Benjie Read CFO and Felecia Read Staff Accountant, will update procedures for documented review of the program reports prior to submission to the grantors. Also see 2023-013 for timely submission. These updates will be completed within 90 days of audit submission.
Finding: 2023-003 – Grant Compliance and Related Reporting. Action Taken: The National Harm Reduction Coalition (NHRC) leadership takes the findings seriously and concurs with the critical importance of timely and accurate financial reports. NHRC acknowledges that significant turnover and vacancies ...
Finding: 2023-003 – Grant Compliance and Related Reporting. Action Taken: The National Harm Reduction Coalition (NHRC) leadership takes the findings seriously and concurs with the critical importance of timely and accurate financial reports. NHRC acknowledges that significant turnover and vacancies within the finance department, including the Senior Finance & Compliance Lead and other key leadership positions within the organization is the primary cause of the finding. NHRC also acknowledges the impact of the trickle-down effect of delays in prior fiscal year and continues to diligently address and improve the performance shortfall. In response to the audit finding, we have initiated corrective actions to address the identified deficiency as follows: 1. NHRC Hired a Senior Finance and Compliance Lead 2. Developed and implementing a closing process to ensure timely financial reporting, supporting NHRC’s ability to adhere to timely compliance reporting requirements. 3. We hired consultants to support the processing and review of financial records to ensure / improve timely and accurate financial reporting until we can hire additional staff.
We agree with the recommendation and understand the required compliance responsibility to provide audited financial statements and major Federal program compliance reporting timely each fiscal year, in accordance with the Federal Single Audit Act. Because of past misunderstandings and incorrect assu...
We agree with the recommendation and understand the required compliance responsibility to provide audited financial statements and major Federal program compliance reporting timely each fiscal year, in accordance with the Federal Single Audit Act. Because of past misunderstandings and incorrect assumptions about major Federal program compliance requirements for fiscal 2019, 2020, 2021, 2022, and 2023, management failed to provide for timely audits. One critical assumption was that the Organization’s subrecipient, responsible for over ninety percent (90%) of grant distributions, fulfilled the audit requirement for the required Federal grant reporting under the Single Audit Act. However, upon recognizing this error, the Organization promptly engaged for the financial statement and major Federal program compliance audits spanning multiple years including up to last fiscal year and is on track to provide for timely filing with the current year. With this understanding and the expectation of financial statement and major Federal program compliance audits, the Organization replaced its contracted accountants by hiring its first Chief Financial Officer (CFO) in January of 2021 and a number of additional support accountants beginning in November of 2021 through January of 2024. Upon hire, and with the growth of the programming, the CFO and the accounting team focused extensively on enhancing the Organization’s financial reporting framework and data management systems to ensure continued compliance with federal and state guidelines and reporting requirements. This effort has been crucial in expediting the more recent audits and improving overall efficiencies in the day-to-day and monthly financial reporting and budgeting requirements. Further, the Organization must acknowledge the challenges posed by the transition of multiple Chief Executive Officers in a 2-year period as well as the impact of the pandemic on operations and reporting. These two factors affected operations and time lines as well as access to data files as many were in paper form. While the timeliness of reporting has improved significantly, some delays remain as a result of the historical backlog. However, the Organization is on track to achieve timely reporting for fiscal 2025. We affirm that timely external financial reporting is a critical internal control feature to support effective Board and management oversight, as well as to meet the accountability requirements of various grants and contracts. Despite the aforementioned difficulties, management’s commitment to timely financial reporting and program compliance remains steadfast and are working diligently to get its timing back on track going forward.
2023-001: Data Collection Form and Single Audit Reporting Package VIEDA Response: The Authority recognizes the importance of timely Single Audit submissions to maintain compliance and low-risk auditee status. Delays in completing the audit process affected the FY2022, FY2023, and FY2024 cycles, and ...
2023-001: Data Collection Form and Single Audit Reporting Package VIEDA Response: The Authority recognizes the importance of timely Single Audit submissions to maintain compliance and low-risk auditee status. Delays in completing the audit process affected the FY2022, FY2023, and FY2024 cycles, and residual timing challenges may impact the FY2025 deadline. However, process improvements including a formal Single Audit calendar, monthly progress monitoring, and cross-training of staff are now in place and are expected to ensure full compliance beginning with the FY2026 audit cycle. Estimated Completion Date: Ongoing Contact: Kelly Thompson Webbe, Chief Financial Officer
With the support of a new leadership team, Jefferson Parish is committed to strengthening oversight and monitoring federal grants financial and compliance activities. To enhance reliability, the Parish has engaged Deloitte & Touche LLP as a consultant to assist with improving documentation procedure...
With the support of a new leadership team, Jefferson Parish is committed to strengthening oversight and monitoring federal grants financial and compliance activities. To enhance reliability, the Parish has engaged Deloitte & Touche LLP as a consultant to assist with improving documentation procedures and strengthen internal controls supporting financial and compliance activities going forward. As part of this effort Jefferson Parish and Deloitte are working across Finance, Accounting, and programmatic departments to establish improved federal grants governance and policy. This includes quarterly oversight and review processes and procedures to monitor the use of federal funds and confirm that compliance activities are occurring. This also includes improved preventative controls to require the performance of due diligence activities for each federal fund sub-recipient or individuals receiving federal assistance prior to the awarding or disbursement of federal funds. The Parish will also develop a policy and communicate annually to all departments the requirements to report to the appropriate authorities, including the Louisiana Legislative Auditor's Office and the Jefferson Parish District Attorney's Office. Community Development Director Stephanie Brumfield, Interim Finance Director Victor LaRocca and Risk Management Director Maria Leon will develop and communicate the policy for reporting fraud which should be enacted by January of 2026.
View Audit 370431 Questioned Costs: $1
With the support of a new leadership team, Jefferson Parish is committed to strengthening grants and financial management and enhancing the reliability of grants reporting. The Parish has engaged Deloitte & Touche LLP as a consultant to assist in establishing regular review practices, policies, proc...
With the support of a new leadership team, Jefferson Parish is committed to strengthening grants and financial management and enhancing the reliability of grants reporting. The Parish has engaged Deloitte & Touche LLP as a consultant to assist in establishing regular review practices, policies, procedures, and internal controls with the goal of improving audit readiness, refine documentation procedures, and strengthen internal controls to support accurate and complete financial data going forward. As part of this effort Jefferson Parish and Deloitte are working across Departments to re-define organizational structure, to establish governance and oversight between finance, accounting, and programmatic departments. Jefferson Parish and Deloitte are also working to implement data quality improvement measures, including the establishment of quarterly grants reconciliation and review processes. Jefferson Parish has also engaged Infor in the implementation of new financial and reporting technology to support improved financial processing and controls. Community Development Director Stephanie Brumfield will develop process to monitor the submission of timely reports in compliance with federal requirements. This process should be enacted by January of 2026.
With the support of a new leadership team, Jefferson Parish is committed to strengthening grants and financial management and enhancing the reliability of grants reporting. The Parish has engaged Deloitte & Touche LLP as a consultant to assist in establishing regular review practices, policies, proc...
With the support of a new leadership team, Jefferson Parish is committed to strengthening grants and financial management and enhancing the reliability of grants reporting. The Parish has engaged Deloitte & Touche LLP as a consultant to assist in establishing regular review practices, policies, procedures, and internal controls with the goal of improving audit readiness, refine documentation procedures, and strengthen internal controls to support accurate and complete financial data going forward. As part of this effort Jefferson Parish and Deloitte are working across Departments to re-define organizational structure, to establish governance and oversight between finance, accounting, and programmatic departments. Jefferson Parish and Deloitte are also working to implement data quality improvement measures, including the establishment of quarterly grants reconciliation and review processes. Jefferson Parish has also engaged Infor in the implementation of new financial and reporting technology to support improved financial processing and controls. Chief Administrative Assistant Nichole Thompson will develop process to monitor the submission of timely reports in compliance with federal requirements. This process should be enacted by January of 2026.
The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected as of December 2024.
The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected as of December 2024.
PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission.
PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission.
Management’s Response and Corrective Action: The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documen...
Management’s Response and Corrective Action: The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the annual financial reporting. The City has also struggled with vacancies in key positions, as well as challenges in completing successful recruitments to fill the positions; staff exploring options for third party assistance with financial reporting functions.
Setting a process up for getting federal wage requirement when projects are being completed. The district will also make sure that the proper training and time will go into allowable cost.
Setting a process up for getting federal wage requirement when projects are being completed. The district will also make sure that the proper training and time will go into allowable cost.
View Audit 370309 Questioned Costs: $1
Niagara Area Management Corporation is recruiting a new Chief Financial Officer and has a new Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse w...
Niagara Area Management Corporation is recruiting a new Chief Financial Officer and has a new Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months after year-end.
We will allocate shared costs appropriately among federal awards
We will allocate shared costs appropriately among federal awards
View Audit 370269 Questioned Costs: $1
We will get physical signatures on submitted timesheets.
We will get physical signatures on submitted timesheets.
The Organization acknowledges the delay in completing the 2023 audit and compliance reporting. To prevent recurrence, the Organization has engaged its auditors earlier in the fiscal year and established an internal timeline that includes interim fieldwork, earlier preparation of supporting documenta...
The Organization acknowledges the delay in completing the 2023 audit and compliance reporting. To prevent recurrence, the Organization has engaged its auditors earlier in the fiscal year and established an internal timeline that includes interim fieldwork, earlier preparation of supporting documentation, and regular check-ins with the audit firm. The Finance Department will monitor progress against this schedule and report status updates to the Audit/Finance Committee of the Board. These steps are intended to ensure all future audits and compliance filings are completed within required deadlines.
2023-009- Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: American Rescue Plan Act / Coronavirus State Fiscal Recovery Fund (ARPA) Assistance Listing Number: 23.027 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of H...
2023-009- Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: American Rescue Plan Act / Coronavirus State Fiscal Recovery Fund (ARPA) Assistance Listing Number: 23.027 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ARPA expenditures, multiple transactions were identified as 2022 fiscal year expenditures that were included in the 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025
View Audit 370214 Questioned Costs: $1
2023-008 – Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Emergency Rental Assistance Program (ERAP) Assistance Listing Number: 23.023 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass...
2023-008 – Reporting Federal Agency: U.S. Department of the Treasury Federal Program Name: Emergency Rental Assistance Program (ERAP) Assistance Listing Number: 23.023 Federal Award Identification Number and Year: Various Pass-Through Agency: Pennsylvania Department of Health and Human Services Pass-Through Number(s): Not Available Award Period: 1/1/2023 – 12/31/23 Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: Policies and controls in place regarding the completeness of the SEFA were not properly functioning. Within the supporting listing of expenses relating to ERAP expenditures, six transactions were identified as prior fiscal-year expenditures that were included in the unadjusted 2023 expenditure total. The County revised the 2023 SEFA to exclude the 2022 expenditures. Recommendation: We recommend management should review the process of recording federal expenditures to determine expenditures are being included in the appropriate fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the finding’s recurrence is in part a result of the timing of when the finding was issued. For example, the 2022 Single Audit was issued in August 2024. At this point, the 2023 fiscal year was already complete. Additionally, the implementation of corrective actions are in progress, including providing training, oversight and guidance to departments administering the grants, but these efforts take time to complete and/or are ongoing. A Deputy Controller of Grant Accounting was hired in February 2023, and a Manager-Grant Accounting was hired in July 2024, after working in this capacity as a temporary staff member since mid-2023. The County approved an additional full-time grant accounting position in May 2025 and will begin recruiting for this position in June 2025. These positions are responsible for establishing accounting policies based on best practices for grant-related activities, developing and providing training and resources to grant- funded departments, reviewing grant-related accounting in the Infor system, preparation of the annual SEFA, and assisting in the facilitation and preparation of documents needed for the Single Audit. The work performed by these positions had been vacant since the departure of Internal Audit Staff who helped General Accounting prior to the 2021 audit as well as the SEFA. Several changes have been made since the grant accounting team was created including the following: The grant accounting team is developing streamlined and standardized SEFA templates for each department for SEFA preparation. The expenditures reported on each SEFA are being compared to the financial information in the GL where possible to ensure all appropriate expenditures are included. Additionally, we are incorporating tracking of lifetime grant expenditures into the SEFA process to ensure no expenditures are missed due to cut off or timing issues. In 2023, the grant accounting team created a Montgomery County Grant Repository. This repository is used to store all grant agreements awarded to the County. Departments submit grant information to the repository upon notification of grant award. The grant accounting team reviews the Grant Repository when preparing the SEFA to ensure no grant programs are inadvertently left off of the SEFA. Additionally, the availability of the Grant Repository enables members of the accounting, finance and grant departments to quickly access grant award information when needed for audits, reporting, or other requirements. The grant accounting team is continuing to review and update the County’s Grant Accounting policies and is working closely with departments to understand their utilization of Infor to account for grant- related activities. As these policies are formalized, we will continue to provide training and resources; in late 2023, the County hired an outside trainer to provide an in-depth training on the accrual method of accounting, grant accruals, and the treatment of grant revenue. The Grant Accountant provided training in April 2024 to explain and outline the SEFA and Single Audit processes. Grant-funded departments received a two-day training on utilization of the Grant Management components of Infor in February 2024. We are also providing guidance and education to departments on the differences in timing of various grant fiscal years and how these impact the financial audit, SEFA and Single Audit. For example, departments must understand how to report expenditures and receipts in the correct period regardless of the fiscal year associated to the contract (State: July-June; Federal: October-September; County: January-December) and understand how these amounts reconcile to the amounts reported to the funding agencies. The accounting department continues to work with departments to emphasize the importance of submitting financial documentation timely and reviewing what is in the General Ledger promptly at the end of each month. The Finance department is performing quarterly reviews with departments to go over financial status, including grant financials. Departments are continuing to utilize Project Codes and other components of Infor’s Grant Management System to ensure the proper accounting of grant-related expenses, receipts, and revenues in the GL. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025
View Audit 370214 Questioned Costs: $1
2023-007 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services and U.S. Department of Homeland Security Federal Program Name: Various Assistance Listing Numbers: 17.258, 17.259,...
2023-007 – Completion and Submission of the Annual Single Audit Federal Agency: U.S. Department of Labor, U.S. Department of Transportation, U.S. Department of Health and Human Services and U.S. Department of Homeland Security Federal Program Name: Various Assistance Listing Numbers: 17.258, 17.259, 17.277, 17.278, 17.283, 20.205, 21.023, 21.027, 93.558, 93.959, 93.778, 97.036 Federal Award Identification Number and Year: Various Pass-Through Agency: Various Pass-Through Number(s): Various Award Period: 1/1/2023 – 12/31/23 Type of Finding: Other Matters and Significant Deficiency in Internal Control Over Compliance Condition: The County’s single audit and reporting package was delayed for the year ended December 31, 2023, beyond the due date. Recommendation: The County should evaluate its procedures around timely submission of the single audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The reason for the recurrence of the finding is in part a result of the timing of when the finding was issued. The 2023 ACFR was issued on February 14, 2025. The Single Audit began after that in late February 2025. At that point the 2023 Single Audit was already past the submission deadline. The County prioritized completion of the 2023 Single Audit and has allocated staff time from the Controller’s department and hired outside temporary professional staffing to complete the audit. Throughout the process, the Grant Accountant and Controller staff have facilitated communication and information between grant-funded departments and CLA resulting in a quick turnaround and completion of the Single Audit. Continued use of Infor’s grant management system and Project codes are increasing efficiency in accurately completing the SEFA and providing documentation as requested for programs being audited. The County began implementing a grant accounting system as part of our implementation of Infor in mid-2021 and are continuing to work with departments to refine their use of the systems. The County is working to compile information required for the 2024 ACFR, and the 2024 SEFA preparation is underway. To expedite this process, the County has engaged additional contract professional staff and is also in the process of hiring an additional full-time employee in the Grant Accounting area. Depending on external auditor availability and other Financial Audits being conducted, the 2024 SEFA will be complete and ready for review by August 2025, with a goal of timely completion of the 2024 Single Audit by the due date of September 30, 2025. Name(s) of the contact person(s) responsible for corrective action: Thomas Landauer and Fonta Reilly Planned completion date for corrective action plan: September 2025
To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-003 Federal Agency: U.S. Department of Treasury U.S. Department of Homeland Security ALN: 21.027 / 97.036 Grady...
To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-003 Federal Agency: U.S. Department of Treasury U.S. Department of Homeland Security ALN: 21.027 / 97.036 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: We have restated 2023 SEFA totals based on updates to the project funded within ALN 21.027 and for the project funded within 97.036. Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reporting
To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-002 (REVISED) Federal Program: Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 93.778 / 93...
To: FY2023 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding 2023-002 (REVISED) Federal Program: Medicaid Assistance Program HIV Emergency Relief Project Grants ALN: 93.778 / 93.914 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: Going forward the SEFA will be reviewed to ensure that all related expenses for the audit period are incorporated. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2024 Financial Audit Reportin
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memori...
To: FY2023 Uniform Guidance Reporting Package From: Gina Smith, VP, Fiscal Service/Controller RE: 2023 Uniform Guidance Audit Corrective Action Plan Date: 9/27/2024 Finding 2023-001 – Reporting Federal Program: Provider Relief Fund and American Rescue Plan Rural Distribution ALN: 93.498 Grady Memorial Hospital Corporation’s (Grady) CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will revamp our controls and processes to include additional management review of the SEFA to include the prior of any submission and to provide evidence of the related review Grady’s corrective action plan: Grady Memorial Hospital Corporation has implemented a new review policy for the submissions of PRF reports which also includes a new reporting and review procedure that are performed by the Controller and Tax & Technical Accounting Manager. GMHC will implement controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained within the timeline it was signed. Contact person/s responsible for the correction action: Gina Smith, VP, Fiscal Service/Controller Anticipated Completion Date: Grady Memorial Hospital Corporation has implemented controls and processes to ensure grant reports are reviewed prior to submission and that evidence of review is maintained
Finding 2023-005 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material Noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and formalize policies and procedures: • ...
Finding 2023-005 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material Noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and formalize policies and procedures: • Action: Conduct a comprehensive review and update of the Administrative Manual Systems, Chapter III: Financial Management, focusing specifically on all sections related to Uniform Guidance (UG) reporting. This includes procurement, reporting, and subrecipient monitoring requirements. • Details: o Develop and document detailed, step-by-step procedures for each UG reporting requirement. o Ensure all policies reflect the most current version of the UG, including the 2024 revisions. o Secure formal approval of the revised manual from tribal leadership. 2. Standardize and conduct mandatory staff training: • Action: Develop and implement a structured, mandatory training program for all staff involved in federal grant management, including finance, administrative, and program personnel. • Details: o Content: The training will cover the revised UG policies, focusing on reporting deadlines, documentation requirements, and proper internal controls. o Onboarding: The Executive Director will meet with all new permanent staff within their first two weeks of employment to review these protocols and emphasize the importance of compliance. o Ongoing Training: Conduct annual refresher training for all relevant staff to address any new changes or best practices. 3. Enhance monitoring and oversight: • Action: Establish a robust system of internal oversight to ensure continuous compliance with UG reporting requirements. • Details: o Regular Reviews: The Executive Director will implement a schedule of regular reviews of financial records to confirm that all supporting documentation for federal awards is correctly attached and reports are filed accurately and on time. o Reporting Checklist: Create and use a standardized checklist for each federal award to ensure all specific reporting requirements are met prior to submission. o Audit Readiness: Perform periodic internal compliance checks or "mock audits" to identify and correct potential issues before an external audit. 4. Strengthen documentation and audit trail: • Action: Improve the organization and accessibility of all documentation required for UG reporting to facilitate a clear and defensible audit trail. • Details: o Centralized Record-keeping: Establish a centralized, secure digital location for all federal award documents, including grant agreements, financial reports, and supporting records. o Documentation Protocol: Implement a protocol requiring all relevant personnel to upload and correctly label all necessary documentation immediately after a transaction is completed. 5. Designate responsibility and accountability: • Action: Clearly assign responsibility for each UG compliance task to specific individuals to eliminate confusion and ensure accountability. • Details: For each grant, a lead financial staff member will be designated as the primary point of contact responsible for ensuring all UG reporting and documentation requirements are met. The Executive Director will oversee this process. Proposed Completion Date: Ongoing, starting in early 2026.
Finding 2023-004 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and formalize policies and procedures: • ...
Finding 2023-004 Late Reporting and Noncompliance with Reporting Requirements Type of Finding: Material weakness in internal control over compliance and material noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and formalize policies and procedures: • Action: Conduct a comprehensive review and update of the Administrative Manual Systems, Chapter III: Financial Management, focusing specifically on all sections related to Uniform Guidance (UG) reporting. This includes procurement, reporting, and subrecipient monitoring requirements. • Details: o Develop and document detailed, step-by-step procedures for each UG reporting requirement. o Ensure all policies reflect the most current version of the UG, including the 2024 revisions. o Secure formal approval of the revised manual from tribal leadership. 2. Standardize and conduct mandatory staff training: • Action: Develop and implement a structured, mandatory training program for all staff involved in federal grant management, including finance, administrative, and program personnel. • Details: o Content: The training will cover the revised UG policies, focusing on reporting deadlines, documentation requirements, and proper internal controls. o Onboarding: The Executive Director will meet with all new permanent staff within their first two weeks of employment to review these protocols and emphasize the importance of compliance. o Ongoing Training: Conduct annual refresher training for all relevant staff to address any new changes or best practices. 3. Enhance monitoring and oversight: • Action: Establish a robust system of internal oversight to ensure continuous compliance with UG reporting requirements. • Details: o Regular Reviews: The Executive Director will implement a schedule of regular reviews of financial records to confirm that all supporting documentation for federal awards is correctly attached and reports are filed accurately and on time. o Reporting Checklist: Create and use a standardized checklist for each federal award to ensure all specific reporting requirements are met prior to submission. o Audit Readiness: Perform periodic internal compliance checks or "mock audits" to identify and correct potential issues before an external audit. 4. Strengthen documentation and audit trail: • Action: Improve the organization and accessibility of all documentation required for UG reporting to facilitate a clear and defensible audit trail. • Details: o Centralized Record-keeping: Establish a centralized, secure digital location for all federal award documents, including grant agreements, financial reports, and supporting records. o Documentation Protocol: Implement a protocol requiring all relevant personnel to upload and correctly label all necessary documentation immediately after a transaction is completed. 5. Designate responsibility and accountability: • Action: Clearly assign responsibility for each UG compliance task to specific individuals to eliminate confusion and ensure accountability. • Details: For each grant, a lead financial staff member will be designated as the primary point of contact responsible for ensuring all UG reporting and documentation requirements are met. The Executive Director will oversee this process. Proposed Completion Date: Ongoing, starting in early 2026.
Finding 2023-007 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material Noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and ...
Finding 2023-007 Lack of Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Material weakness in internal control over compliance and material Noncompliance. Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Update and Disseminate Financial Management Policies: • Action: Formally update and reissue Chapter III (Financial Management) of the Administrative Manual to specifically include the following requirements for all payroll-related actions. o Mandatory use of the payment authorization form for all employee pays rate changes, bonuses, or other non-standard payments. o Verification of all signatories against a current, board-approved signatory list. o A documented review step during each payroll run where the personnel action recommendation form is compared against the actual pay rate being processed. • Responsible Party: Executive Director and Financial Specialist. 2. Implement a Structured Payroll Review Process: • Action: Establish a mandatory, documented two-step review process for every payroll cycle. o Step 1: The Financial Specialist will review all payment authorization forms and verify signatories. o Step 2: The Financial Specialist will compare the pay rates in the payroll system to the approved rates on the personnel action recommendation forms and initial the review for the record. • Responsible Party: Financial Specialist. 3. Conduct Mandatory Training for Staff: • Action: Provide comprehensive and mandatory training for all relevant staff (e.g., payroll clerks, program managers) on the updated financial management policies and payroll review protocols. This training will cover: o Proper use and routing of payment authorization forms. o Verification procedures for pay rates. o The importance of maintaining proper documentation. • Responsible Party: Executive Director, in coordination with the Financial Specialist 4. Transition to New Permanent Administration: • Action: As part of the onboarding process for the new permanent Administration, the following will occur: o The Executive Director will hold a comprehensive "sit-down" session to review and reinforce all financial management and payroll protocols. o The new team will be provided with the updated Administrative Manual and all relevant training materials. o A transition checklist will be used to ensure all key financial controls are properly handed over and understood. • Responsible Party: Executive Director. 5. Verification of Effectiveness: • Action: After the new procedures are implemented, the Executive Director and Tribal Council will perform a periodic review of a sample of payroll records to ensure compliance with the new internal controls. • Responsible Party: Tribal Council and Executive Director. Proposed Completion Date: Ongoing, starting in early 2026.
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