Corrective Action Plans

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Beneficiary Reporting Auditor’s Recommendation: We recommend that a responsible employee review and approve all HOME Program Housing Beneficiary Reports for accuracy prior to their submission to the applicable oversite agency. The review should be documented with the initials of the reviewer and th...
Beneficiary Reporting Auditor’s Recommendation: We recommend that a responsible employee review and approve all HOME Program Housing Beneficiary Reports for accuracy prior to their submission to the applicable oversite agency. The review should be documented with the initials of the reviewer and the date reviewed on each report. Action Taken: In order to ensure the accuracy of the HOME Program Housing Beneficiary Reports, the reports are now routed to our director of Low-Income Housing Tax Credit and Compliance, who reviews each report in detail. Once she has approved the reports, she initials and dates the reports and then they are sent to either the City of Las Vegas or Clark County, as required. These procedures were implemented in mid-2023.
Serenity House has followed up with corrective actions to include – Personnel changes in the Bookkeeping role. In addition, we have upgraded our Quick Books to better help with reporting. We have upgraded to Quick Books Online.
Serenity House has followed up with corrective actions to include – Personnel changes in the Bookkeeping role. In addition, we have upgraded our Quick Books to better help with reporting. We have upgraded to Quick Books Online.
Finding #2023-002- Material Adjustments Condition: Johnson Block and Company, Inc. proposed adjusting journal entries during the audit process. We deem these entries to be material in relation to the financial statements. Since the Village did not make these adjustments in its accounting system prio...
Finding #2023-002- Material Adjustments Condition: Johnson Block and Company, Inc. proposed adjusting journal entries during the audit process. We deem these entries to be material in relation to the financial statements. Since the Village did not make these adjustments in its accounting system prior to the audit, a material weakness exists in the Village’s internal controls. Criteria: Material adjusting journal entries not prepared by the Village before the audit are considered an internal control weakness. Cause: The Village does not have policies and procedures in place to ensure that all transactions are properly recorded on the general ledger prior to the audit. Effect: This means that the proper recording and reporting of financial information may not occur within a timely manner. Recommendation: Policies and procedures should be implemented to ensure account balances are properly recorded in a timely manner. Response: The Village will work to establish policies and procedures to reduce the number of adjusting journal entries proposed by the auditor. Contact Person: Amy Barnes, Village Clerk/Treasurer, 608-523-4521, Email: clerk@blanchardvillewi.gov Anticipated Completion: December 31, 2024
Policies and procedures have been implemented to ensure compliance with reporting requirements, and to ensure proper documentation is available from the State reporting system (AccuFund) for all fiscal reporting.
Policies and procedures have been implemented to ensure compliance with reporting requirements, and to ensure proper documentation is available from the State reporting system (AccuFund) for all fiscal reporting.
Finding 497547 (2023-003)
Significant Deficiency 2023
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
Finding 497544 (2023-005)
Significant Deficiency 2023
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
Finding 497539 (2023-002)
Significant Deficiency 2023
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
Finding 497537 (2023-003)
Significant Deficiency 2023
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
Finding 497533 (2023-003)
Significant Deficiency 2023
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
We will ensure that going forward, processes are in place to allow for the timely submission of the financial reporting requirements. Further, we request that this finding be removed as the late filing occurred in 2024 and should be given in 2024 pursuant to AU-C 935.
Finding Reference Number: 2023-001   Description of Finding:As required by 2 CFR 200.328, the auditee failed to submit the required Federal Financial Report (“SF425”) for two of their awards by the required due date of January 31, 2024.  Corrective Action: The Organization concurs with this find...
Finding Reference Number: 2023-001   Description of Finding:As required by 2 CFR 200.328, the auditee failed to submit the required Federal Financial Report (“SF425”) for two of their awards by the required due date of January 31, 2024.  Corrective Action: The Organization concurs with this finding and recognizes that the required SF425 reports for two awards were not submitted by the due date of January 31, 2024.   SEMI constantly communicates with the program managers for these awards and meets weekly to discuss project progress. The Organization has commonly received extensions for these reporting deadlines; however, this has not been documented in writing.   SEMI will evaluate process improvements to provide accounting information to the SEMI R&D team two weeks after the reporting period end date. This will help ensure sufficient time for the reports to be prepared and submitted 30 days after the reporting end date. If additional time is needed, SEMI will obtain prior written approval for report submission extension.   Name of Responsible Person: Kevin Bauer (Chief Financial and Business Operations Officer)  Melissa Grupen-Shemansk (Vice President, Technology Communities)  Anticipated Completion Date: The Organization anticipates completing the corrective action by Q4 2024.
Finding 497528 (2023-001)
Significant Deficiency 2023
Oregon Tilth, Inc. respectfully submits the following corrective action plan for the year ending December 31, 2023. Audit: January 1, 2023 to December 31, 2023. The finding from the schedule of findings is discussed below. The finding is numbered with the number assigned in the schedule. FINDING - F...
Oregon Tilth, Inc. respectfully submits the following corrective action plan for the year ending December 31, 2023. Audit: January 1, 2023 to December 31, 2023. The finding from the schedule of findings is discussed below. The finding is numbered with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department Agriculture 2023-001 Market Protection and Promotion – Assistance Lising #10.163 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: The issue with late Federal Funding Accountability and Transparency Act Subaward Reporting was identified by the auditors during the testing and review of documents during our first Single Audit. Management understood the importance of Immediate action and steps were taken to create and implement appropriate procedures, policies and controls. Action Plan: In order to prevent further tardiness with the submission of the obligated sub-recipient funding, a recurring Asana task item was created that reminds the Grant Finance Manager to submit the report 10 days before the end of the month following the obligation of funds. In addition, the Finance & Administration Director has also created a calendar task and reminder to be the stop gap check, and to approve the pdf of submitted reports before the close of the month. An addendum to the Fiscal Policies and Controls guide was sent to the board Finance Committee on Sept. 9th, 2024 that immediately implements the policy and details the oversight procedure for the submission and approval of reports. The sub-recipient FSRS FFATA excel worksheet schedule has been enhanced to include a page that details the month of the award, number of subrecipients and date the report was filed for that month. There is now a self-reporting column that indicates if the report was filed late. And lastly, the Grants Financial Manager has been ordered to insert written procedures into the Grant Internal Controls guide. Name(s) of the contact people responsible for correction action: Renee Kempka, Finance & Administration Director Abigail Soto, Grants Financial Manager Plan completion date for corrective action plan: September 30, 2024
Finding 497522 (2023-001)
Significant Deficiency 2023
Nā Puʻuwai agrees with the Auditor's advice and as a result, in June of 2024, we began the transition process to our new accounting team, Accumulus, and are confident that moving forward, we will comply fully with timely financial reporting requirements.
Nā Puʻuwai agrees with the Auditor's advice and as a result, in June of 2024, we began the transition process to our new accounting team, Accumulus, and are confident that moving forward, we will comply fully with timely financial reporting requirements.
Adventist Health implemented an action plan and established internal controls last year, following the conclusion of 2022 UG audit. Since the program has ended, no action is required at this time. We have also worked with HRSA to address any issues and findings from previous years. In the future,...
Adventist Health implemented an action plan and established internal controls last year, following the conclusion of 2022 UG audit. Since the program has ended, no action is required at this time. We have also worked with HRSA to address any issues and findings from previous years. In the future, similar programs will be managed by the Grants Management team, utilizing the established internal controls.
Finding 497516 (2023-005)
Significant Deficiency 2023
o As of June 30, 2024, LifeWire has implemented a new software package called VELA in which direct services staff enter their actual time worked to contracts, which is then reviewed and approved by their supervisors and reported to Finance staff for payroll processing. By December 31, 2024, the Fina...
o As of June 30, 2024, LifeWire has implemented a new software package called VELA in which direct services staff enter their actual time worked to contracts, which is then reviewed and approved by their supervisors and reported to Finance staff for payroll processing. By December 31, 2024, the Finance staff will ensure all 2024 actual hours worked toward contracts have been reviewed and approved by all direct services staff whose time is billed and approved by their supervisors. o Name of Responsible Individual: Jeannette Biffle, Controller
Finding 497504 (2023-001)
Significant Deficiency 2023
o LifeWire’s Senior Accountants, Controller and Co-EDs carefully review all costs charged to contracts to ensure they fall within the appropriate contract period. As of September 9, 2024, all 2024 contract charges are captured in the correct periods. o If the staff of LifeWire has any question about...
o LifeWire’s Senior Accountants, Controller and Co-EDs carefully review all costs charged to contracts to ensure they fall within the appropriate contract period. As of September 9, 2024, all 2024 contract charges are captured in the correct periods. o If the staff of LifeWire has any question about the permissibility of a given charge, we will reach out to the contract manager, obtain clarification and/or permission in writing, and ensure that documentation is filed and maintained appropriately. If we are unable to obtain this permission, we will find another funding source for the charge or find alternate methods of supporting survivors’ needs. o Name of Responsible Individual: Jeannette Biffle, Controller
The Project is relatively small with only one administrative staff. Further the Board of Directors is a volunteer board and not a managing board. It does not have the time nor expertise to provide the necessary services to correct the internal control deficiencies noted. The Board of Directors has r...
The Project is relatively small with only one administrative staff. Further the Board of Directors is a volunteer board and not a managing board. It does not have the time nor expertise to provide the necessary services to correct the internal control deficiencies noted. The Board of Directors has reviewed this issue, and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies. As such, the Board of Directors accepts this finding.
Management understands the recommendations and is actively addressing the deficiencies identified by the auditors. Management has implemented improved internal processes over the past year to better track and allocate staff time across all grants, including federal grants, and maintain detailed tim...
Management understands the recommendations and is actively addressing the deficiencies identified by the auditors. Management has implemented improved internal processes over the past year to better track and allocate staff time across all grants, including federal grants, and maintain detailed time tracking for all staff that determine payroll allocations. Management recognizes there is further need to directly link time tracking to payroll allocation, and that we need more standardized bi-monthly supervisory approval processes for staff time tracking, and management approval of payroll allocations on a consistent basis. Management is implementing a new, significantly more robust financial accounting system that will standardize time tracking, payroll allocation and approval processes all within one system. This system was determined as a need at the beginning of 2024, and we have conducted a multi-month review and analysis process to identify the best system for our organizational needs. The system will be in place and fully operational within six (6) months and we expect it will directly address and remediate current challenges in all of the areas identified by the auditors. Anticipated Completion Date: December 2024
Finding 497432 (2023-005)
Significant Deficiency 2023
2023-005: Subaward Reporting Requirements for Federal Funding Accountability and Transparency Act (FFATA), Significant Deficiency and Noncompliance The City will implement monitoring procedures to ensure timely reporting of subaward information in line with the requirements of the Federal Funding Ac...
2023-005: Subaward Reporting Requirements for Federal Funding Accountability and Transparency Act (FFATA), Significant Deficiency and Noncompliance The City will implement monitoring procedures to ensure timely reporting of subaward information in line with the requirements of the Federal Funding Accountability and Transparency Act. The City’s Grants Manager will monitor the status of the subaward reporting on a quarterly basis to ensure effectiveness of the reporting procedures. The corrective action will be fully implemented during the Fiscal Year 2024/2025 audit. The contact persons for this corrective action are Sara Cortes‐dePavon (Grants Manager) and Michele Ogawa (Director of Economic Development and Housing Department) of City of Perris.
All assets will be checked after entry into the inventory system to ensure that the correct account code is input into the inventory system. We will compare the coding on the inventory item to the purchase order that ties to the item. The person checking the code will place a check mark and initia...
All assets will be checked after entry into the inventory system to ensure that the correct account code is input into the inventory system. We will compare the coding on the inventory item to the purchase order that ties to the item. The person checking the code will place a check mark and initial the inventory item packet once complete. This will also ensure the proper management of the inventory asset for disposition and deletion.
Finding 497413 (2023-006)
Significant Deficiency 2023
Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reports be reviewed by a supervisory-level person who is not the preparer of the report. Explanation of disagreement with audit finding: There is no disagreeme...
Staffing for Adequate Fire and Emergency Response (SAFER) - Assistance Listing No. 97.083 Recommendation: It is recommended that SAFER grant reports be reviewed by a supervisory-level person who is not the preparer of the report. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have established a mandatory review process where all reimbursement requests and performance reports must be reviewed and approved by a designated supervisory-level staff member who did not prepare the report before submission to the granter. We have communicated the importance of this review process in ensuring compliance, completeness and accuracy. We will monitor the process to prevent recurrence. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: August 7, 202
Finding 497408 (2023-003)
Significant Deficiency 2023
Airport Improvement Program - Assistance Listing No. 20.106 Recommendation: The City should review its process for identifying and tracking Federal Aviation Administration reporting requirements to ensure that all required reports are submitted timely. Explanation of disagreement with audit finding:...
Airport Improvement Program - Assistance Listing No. 20.106 Recommendation: The City should review its process for identifying and tracking Federal Aviation Administration reporting requirements to ensure that all required reports are submitted timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To prevent future occurrences, we are revising internal review procedures and establishing automated calendar reminders, to ensure that in the future, SF-425 reports will be submitted for all reporting periods. We are fully committed to maintaining compliance with all federal reporting requirements and will continue to improve our processes to prevent such issues in the future. Name of the contact person responsible for corrective action: Janie Rodriguez Planned completion date for corrective action plan: September 30, 2024
USHCC management has always evaluated the capabilities and resources of the audit firms and their auditors prior to engagement. Unfortunately, USHCC management had no control over internal issues within the audit firm that caused the audit FY2022 reports to be delayed. USHCC management has addressed...
USHCC management has always evaluated the capabilities and resources of the audit firms and their auditors prior to engagement. Unfortunately, USHCC management had no control over internal issues within the audit firm that caused the audit FY2022 reports to be delayed. USHCC management has addressed the issue and contracted with a different firm establishing a timeline and maintaining frequent communication to ensure that the FY2023 reports are submitted in a timely manner.
2023-001 Internal Control over Financial Reporting - Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The small size of the Authority’s office staff does not allow for adequate segregation of duties. Standard practice regarding the design of a good system of internal con...
2023-001 Internal Control over Financial Reporting - Lack of Segregation of Duties – Significant Deficiency Condition & Criteria: The small size of the Authority’s office staff does not allow for adequate segregation of duties. Standard practice regarding the design of a good system of internal controls relies at least in part on a system of checks and balances accomplished by having different employees performing various functions within the accounting cycle. These checks and balances are not possible when the same person performs all of an interrelated series of tasks. Although the Authority does have some compensating controls in place, there are still a number of situations where one person is responsible for all aspects of a transaction. Planned Action: The Authority acknowledges the potential effects of this condition. However, for such a small organization as we are, the Authority believes that it would not be cost beneficial to hire additional personnel in order to provide for adequate segregation of duties. As a compensating control, the Board intends to continue its close involvement in, and oversight over, the financial transaction process.
Finding 497392 (2023-004)
Significant Deficiency 2023
LACONIA SCHOOL DISTRICT CORRECTIVE ACTION PLAN Audit Finding Reference MW-2023-04 Planned corrective action: All prepared Journal Entries will be reviewed and approved by the preparer and one other business office individual (Payroll Accounting specialist or Accounts Payable coordinator) Name o...
LACONIA SCHOOL DISTRICT CORRECTIVE ACTION PLAN Audit Finding Reference MW-2023-04 Planned corrective action: All prepared Journal Entries will be reviewed and approved by the preparer and one other business office individual (Payroll Accounting specialist or Accounts Payable coordinator) Name of Contact person: Diane Clary, Business Administrator dclary@laconiaschools.org Anticipated completion date: September 30, 2024 Example of Planned Corrective Action: Journal entries will be printed by the preparer and reviewed and initialed by another business office employee.
RE: Finding 2023-002 – Significant Deficiency – Compliance with Accurate Records of Meal Preparation and Ordering Response During the TDA audit, the CE provided meal production records as supporting documentation for meal preparation. Although the meal production record shows the number of meals pre...
RE: Finding 2023-002 – Significant Deficiency – Compliance with Accurate Records of Meal Preparation and Ordering Response During the TDA audit, the CE provided meal production records as supporting documentation for meal preparation. Although the meal production record shows the number of meals prepared, the quantity prepared is insufficient for the number of participants the sites anticipate serving per the Food Buying Guide. The meal Production record dated 07/07/2023, shows that the central kitchen prepared 40 lunches for a site. Per the meal production record, the kitchen used 2 #10 cans of sliced peaches to prepare 40 meals, which is not enough to ensure that 40 participants received the correct quantity. Meal Production Records are prepared daily and presented to the kitchen staff in preparation for the meal service. All calculations are done using the food-buying guide on www.squaremeals.org. It was brought to our attention that there were a few calculations that were off on the meal production sheet at the time of the Review. The circumstances that caused this error was simply wrong human calculations that needed to be reviewed by additional staff to ensure the errors were corrected. We pride ourselves in knowing our kids we serve receive quality meals and enough meals are prepared to ensure all children receive the proper quantities. A. To ensure any calculation error does not occur the following steps, process and procedures were updated and implemented effective December 2023 after receiving additional training from Region IV ESC when three staff members attended Meal Production Records training—4 hours. B. Training certificates for the three staff members that attended Meal Production Records training were provided to TDA. Although the training was for CACFP, the process and results are the same for SFSP. This was the most recent training provided and we attended it in order to make the appropriate changes necessary for our program. POLICY: Daily Meal Production (Updated Nov 2023) “With Helping Hands” (WHH) must ensure that its central kitchen and sponsored facilities prepare a meal production record for each meal service each day. The center/facility (ies) must record the food items used, and quantities on a daily basis on H1530, Daily Meal Production Record, or H1530-A. PROCEDURE: All SFSP Program meals prepared by WHH will follow the TDA standard/established guidelines for proper meal pattern servings. Form H1530, Daily Meal Production Record will be completed prior to meal preparation as follows for reimbursement under the SFSP Program. 1) All areas of the form (listed below) need to be completed in entirety: a) Name of contractor b) Name of facility (only required for multiple facilities or if the facility name differs from contractor) c) Agreement number (this is the same as the TX number) d) Dates covered e) Day of meal service f) Food components g) Menu(s) h) Food items used i) Quantity used j) CN Labels used k) Special Diets l) USDA Recipe Numbers m) Whole grains n) Planned participation program meals o) Planned participation non-program meals 2) Meal Calculations are completed by the office staff using the food-buying guide via www.squaremeals.org. These calculations will be verified and checked at random within the month from Administrative Staff to ensure the accuracy of the calculations. 3) The Administrative Staff will check Meal Productions at the end of each week to ensure accuracy and completion. 4) Meal production records must be completed by office and kitchen staff on a daily basis and submitted to the Administrative Staff by the 5th of every month for processing the claim. 5) If there are any findings such as: a. Missing components b. Unallowable food items c. Not enough food prepared d. Uncompleted or Missing Completely e. Wrong Calculations Staff will be given corrective action and review of policy and procedures will be enforced by the Executive Director. 6) If more findings occur, Production Record training will be conducted on-site or via web. 7) Meal Production Training will be taken annually by the Region IV ESC Center annual training INSPO or other training options offered by the ESC and/or TDA SFSP Training Sessions.
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