Corrective Action Plans

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The hospital staff member – reimbursement analyst- who no longer works for the hospital - submitted PRF reports in the portal within timelines, but he did not save copies of the reports. We were only able to get the blank templates from his company folder. I confirmed with the then chief compliance ...
The hospital staff member – reimbursement analyst- who no longer works for the hospital - submitted PRF reports in the portal within timelines, but he did not save copies of the reports. We were only able to get the blank templates from his company folder. I confirmed with the then chief compliance officer for Sheridan Community Hospital that she signed the reports in the portal before they were submitted. During the audit, we were unable to produce these reports, however, we are in the process of retrieving these reports from the HRSA portal to keep with our records as proof that it was completed per the auditor’s recommendation above.
The audit report on the financial statements for the year ended June 30, 2022 was issued on April 15, 2026, The Data Collection form and reporting package will be submitted within 5 business days thereafter.
The audit report on the financial statements for the year ended June 30, 2022 was issued on April 15, 2026, The Data Collection form and reporting package will be submitted within 5 business days thereafter.
Item 2022.004 - Reporting Recommendation The Center should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that financial statement audit is submitted on a timely basis to the Federal government. The Center should also ensure that a...
Item 2022.004 - Reporting Recommendation The Center should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that financial statement audit is submitted on a timely basis to the Federal government. The Center should also ensure that all reporting requirements are monitored and met on a timely basis. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Ensure proper analysis and support of accounting records through a monthly financial close process that enforces standards for supporting documentation, and internal review and approval • Ensure timely submission of financial statement audit by establishing a Master Calendar for the organization's required submissions. Depending on the required submission deadline, we would ensure that we properly allocate time and tasks into a schedule that would assist us in making our submission on a timely basis
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to ...
Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.
Reimagining Justice Inc. Corrective Action Plan Federal Single Audit Finding Auditors’ Recommendation Reimagining Justice Inc. should ensure that financial records, reconciliations, and reporting documentation are completed in a timely manner so that the Single Audit can be performed and finalized o...
Reimagining Justice Inc. Corrective Action Plan Federal Single Audit Finding Auditors’ Recommendation Reimagining Justice Inc. should ensure that financial records, reconciliations, and reporting documentation are completed in a timely manner so that the Single Audit can be performed and finalized on schedule and required reporting can be submitted before applicable deadlines. Corrective Action Plan Management acknowledges that the Single Audit reporting package and Data Collection Forms for the 2022 audit were not submitted by the required deadlines. To correct this issue and prevent recurrence, the organization has implemented the following actions:• Enhanced monitoring and tracking• Hired an internal accountant to strengthen financial oversight and reconciliation processes.• Assignment of oversight responsibility.• Staff Training.• Formalized workflows and fiscal coordination protocols with St. Joseph’s University Medical Center (fiscal sponsor) including submission timelines, approval processes, and reporting requirements.• Established external filing deadlines. Anticipated Completion Date These corrective actions were initiated in autumn 2025, and will be fully in place for the audit of the fiscal year ended September 30, 2025, ensuring timely submission by June 30, 2026. Management Statement Management believes the corrective actions implemented will ensure full compliance with federal and state reporting requirements and prevent recurrence of late audit submissions. Responsible Individual Dr. Liza Chowdhury Executive Director Date: March 17, 2026
Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Antici...
Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2026
Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit pr...
Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit progress and submission deadlines can help prevent future delays.
Judge Lucas Response: This was an oversight on our part. Steps have been taken to fully comply with all SEFA reporting in the future.
Judge Lucas Response: This was an oversight on our part. Steps have been taken to fully comply with all SEFA reporting in the future.
Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a...
Name: Community Services Office of Hot Springs and Garland County Arkansas Contact: Leslie P. Barnes Contact Phone Number: (501) 538-5626 Audit Period Ending: 05/31/2022 Anticipated Completion Date: May 5, 2025 Finding 2022-004: Management concurs with the finding. The Organization has implemented a process where a staff accountant will prepare the necessary reports and the chief financial officer will review such reports. Alternatively, if the chief financial officer must prepare such reports, the review will be performed by the executive director.
Condition and Context: As noted in finding 2022-002, ITCN had cash deficit in the amount of $35,398, while also reporting a total deferred revenue of $1,187,084 and a due to grantor agency of $269,375. At September 30, 2022, the WIC program is reporting deferred revenues of $289,963 while reflecting...
Condition and Context: As noted in finding 2022-002, ITCN had cash deficit in the amount of $35,398, while also reporting a total deferred revenue of $1,187,084 and a due to grantor agency of $269,375. At September 30, 2022, the WIC program is reporting deferred revenues of $289,963 while reflecting an amount loaned to other funds relating to these restricted sources totaling $60,455. Also, at September 30, 2022, the Child Care and Development Block Grant program is reporting deferred revenues of $198,541 while reflecting an amount loaned to other funds relating to these restricted sources totaling $828,529. As a result, ITCN is not in compliance with their contracts governing the use of these restricted funds. Recommendation: The auditors recommended that we implement the recommendations noted in finding 2022-002. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: ITCN has adopted the corrective actions under Finding 2022-002, with fiscal contractors monitoring compliance. The CFO provides monthly restricted fund reviews. MIP/Microix will add automated cash tracking and prohibit interfund borrowing. Staff training will reinforce cash management best practices. Anticipated Completion Date: The policy was adopted in March 2024. ITCN began to request for reconsideration, including supporting documentation, with grantor agencies with expected completion by December 31, 2025.
Condition and Context: ITCN did not file Form ACF-696T reports, required by the Child Care and Development Block Grant within the required timeframe. ITCN also did not file Form SF-429(A), required by the Head Start program within the required timeframe. Also, ITCN’s single audit reporting package f...
Condition and Context: ITCN did not file Form ACF-696T reports, required by the Child Care and Development Block Grant within the required timeframe. ITCN also did not file Form SF-429(A), required by the Head Start program within the required timeframe. Also, ITCN’s single audit reporting package for the fiscal year ended September 30, 2022, was not submitted to the Federal Audit Clearinghouse within nine months after ITCN’s year-end. Recommendation: The auditors recommended that ITCN devote the necessary resources to the financial reporting process and establish a system of monitoring for the filing of all required reporting and that the executive director review the monitoring list on a regular basis consistent with the timing of report filings. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: ITCN has created a federal reporting compliance calendar with automated reminders. Fiscal contractors continue to support timely submission of required reports. MIP/Microix will allow automated report generation and tracking. The training plan includes modules on reporting compliance and deadline monitoring. Anticipated Completion Date: The calendar was implemented in March 2024, with full automation and staff training to be completed by March 2026.
Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommenda...
Condition and Context: As noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007, ITCN’s internal control over financial reporting and grants management was insufficient to provide the level of assurance necessary to demonstrate compliance with the federal awards. Recommendation: The auditors recommended that ITCN implement the recommendations noted in findings 2022-001, 2022-003, 2022-004, 2022-005, 2022-006 and 2022-007. Contact Name: Deserea Quintana, Executive Director Corrective Action Planned: This broad finding is being addressed by the corrective actions above. Fiscal contractors are providing quarterly compliance monitoring. ITCN’s Compliance Officer has initiated quarterly internal monitoring reviews. Migration to MIP/Microix will enhance reporting and compliance tracking. Training will ensure fiscal staff maintain compliance standards long-term. Anticipated Completion Date: The additional monitoring began in June 2024, with integration and staff training to be fully complete by June 2026.
The agency has created new policies and implmented fail safes to ensure the deadline for all required filiings.
The agency has created new policies and implmented fail safes to ensure the deadline for all required filiings.
Corrective Action Plan Finding: Finding 2022-006-Late Filing of Audit Report-Reporting and Special Tests Condition: This audit report is past-due. Corrective Action Planned We are aware of the filing deadlines. Person responsible for corrective action: Charles Unsell, Executive Director Telephone: (...
Corrective Action Plan Finding: Finding 2022-006-Late Filing of Audit Report-Reporting and Special Tests Condition: This audit report is past-due. Corrective Action Planned We are aware of the filing deadlines. Person responsible for corrective action: Charles Unsell, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026
Corrective Action Plan Finding: Finding 2022-005-Board Minutes-Reporting Condition: We do not have access to any board minutes between the minutes of the January 28, 2022 and December 26, 2023. Current management represents that they are not aware of any board minutes for that period, or if the boar...
Corrective Action Plan Finding: Finding 2022-005-Board Minutes-Reporting Condition: We do not have access to any board minutes between the minutes of the January 28, 2022 and December 26, 2023. Current management represents that they are not aware of any board minutes for that period, or if the board met. Corrective Action Planned As noted above, the Authority now holds regular board meetings and the minutes are generated. Person responsible for corrective action: Charles Unsell, Executive Director Telephone: (918) 367-5558 Housing Authority of Bristow, Oklahoma Fax: (918) 367-2341 1110 S. Chestnut Bristow, OK 74010 Anticipated Completion Date- June 30, 2026
Finding 1175571 (2022-009)
Material Weakness 2022
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
The County will make sure that all federal documentation is maintained by each district for inspection and will ensure it is accurately reported on the SEFA.
Finding 1175570 (2022-008)
Material Weakness 2022
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
The County will include discussion of all required compliance requirements for each federal program presented in our Officers’ meetings.
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to documen...
Finding: The Company was not able to evidence the review and approval of non-payroll expenses incurred in connection with the Coronavirus State and Local Fiscal Recovery Funds grant program. Corrective Actions Taken or Planned: During the testing there was one invoice Insight was not able to document that it had been approved by management to pay. During this period of 2022 we were on a manual accounts payable system. Invoices were approved before payment was made by email and the email was to be printed and attached. In September of 2022 we implemented a new ERP system. This system requires electronic approval by management for the invoice to be paid. Ferrick Jones, Controller, is responsible for ensuring this is remediated.
This was a simple mistake in reporting the SEFA revenue instead of the expenditures. Since discovering expenditures are required this will not be an issue going forward.
This was a simple mistake in reporting the SEFA revenue instead of the expenditures. Since discovering expenditures are required this will not be an issue going forward.
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action...
Condition: Costs charged to ALN 97.036 – Disaster Grants: Public Assistance were also charged to ALN 93.498, U.S. Department of Health and Human Services, Provider Relief Fund in a prior fiscal year, as reported in the Period 1 submission to the Provider Relief Fund portal. Planned Corrective Action: Management agrees and has revised existing internal control processes and policies to implement review and approval procedures to ensure expenditures submitted were not already reimbursed under a separate grant. Contact person responsible for corrective action: Kevin Riley Anticipated Completion Date: 12/31/2025
Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monit...
Response: Management concurs with the finding. Corrective Action Plan: Management will establish a documented SF-425 preparation procedure requiring reconciliation of all reported amounts to the general ledger and supporting schedules. The Financial Analyst will prepare the SF-425 based on the monitored running budget, and the Executive Director will review and approve each report prior to submission to AFRL. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst — by March 31, 2023.
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