Corrective Action Plans

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The County will enhance its internal controls over reporting and review federal guidance for reporting under the Coronavirus State and Local Fiscal Recovery Funds.
The County will enhance its internal controls over reporting and review federal guidance for reporting under the Coronavirus State and Local Fiscal Recovery Funds.
Finding 2024-01 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in material audit adjustments across key financial statement accounts, including revenue, accounts payable, accrued exp...
Finding 2024-01 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in material audit adjustments across key financial statement accounts, including revenue, accounts payable, accrued expenses, deferred revenue, nets assets, and related activity accounts. These adjustments were proposed by the auditors and subsequently recorded by management in order to fairly present the financial statements in accordance with generally accepted accounting principles. The extent and materiality of the adjustments indicate that the Organization's existing closing procedures were insufficient to identify and correct errors prior to the audit. Corrective Actions Taken or Planned: The Organization acknowledges this finding and agrees with the auditor’s assessment regarding the need for a more robust financial close and review process. We recognize that the absence of such a process contributed to the material audit adjustments noted during the engagement. Management and the Board are committed to strengthening internal controls and financial oversight to ensure that future financial statements are materially accurate and compliant with GAAP prior to audit. We are confident that the measures underway will address the deficiency and prevent recurrence. To address this finding, the Organization will implement a comprehensive monthly and quarterly financial close and review process to ensure accuracy, timeliness, and compliance with GAAP prior to the annual audit. Specific actions include: 1. Monthly Close Procedures - Develop and document a formal month-end closing checklist. - Reconcile all key accounts monthly (cash, accounts payable, receivables, accrued expenses, deferred revenue, and net assets). - Require dual review and sign-off from the Accountant (FTM) and Co-Executive Director. 2. Quarterly Financial Review - Conduct quarterly reviews of financial statements and reconciliations with the Treasurer of the Board. - Compare actual results against budget and prior-year trends to identify anomalies early. - Engage an external accountant (FTM) quarterly (if feasible) for review and guidance. 3. Training & Capacity Building - Provide finance staff with training in GAAP reporting and nonprofit accounting best practices. - Implement cross-training to ensure continuity if staffing changes occur. 4. Documentation & Controls - Maintain detailed documentation of all reconciliations and adjusting entries. - Establish a clear approval hierarchy for journal entries, ensuring all significant entries are reviewed by leadership prior to posting. 5. Audit Readiness - By implementing these processes, management will be positioned to present materially accurate financial statements prior to auditor review. - The goal is to minimize, if not eliminate, material audit adjustments in future years. Progress will be tracked by requiring the Finance Committee to review and approve quarterly financial packages. Any discrepancies or deficiencies will be documented and corrective steps taken promptly.
Management has implemented enhanced review processes to ensure accuracy in key accounts and prevent discrepancies. A formal review procedure is now in place to examine journal entries before they are posted.
Management has implemented enhanced review processes to ensure accuracy in key accounts and prevent discrepancies. A formal review procedure is now in place to examine journal entries before they are posted.
Management will ensure that the books are closed within 45 days of the end of each reporting period. To support this timeframe, we have put a dedicated team in place. Additionally, a month-end checklist has been established to confirm that all tasks are completed on schedule.
Management will ensure that the books are closed within 45 days of the end of each reporting period. To support this timeframe, we have put a dedicated team in place. Additionally, a month-end checklist has been established to confirm that all tasks are completed on schedule.
Finding 1160353 (2024-001)
Material Weakness 2024
Recommendation: We recommend the Organization establish policies and procedures to ensure adequate internal controls over the drawdown process of federal awards. Prior to submission of drawdown, supporting schedules and reports are reviewed by the Executive Director or appropriate management personn...
Recommendation: We recommend the Organization establish policies and procedures to ensure adequate internal controls over the drawdown process of federal awards. Prior to submission of drawdown, supporting schedules and reports are reviewed by the Executive Director or appropriate management personnel. Plan: All federal draw down requests will be preceded by a revenues and expenses report provided to the Executive Director and the program manager for their review prior to draw down of the funds through any related portals. Person Responsible: Program Manager and Executive Director Plan Implementation: 9/30/2025 Status: Implemented
Finding 2024-002 Management Response: The Business Manager has year-end procedures in place to ensure year end adjusting entries are performed prior to the audit. Individual Responsible: Corrina Lesko Anticipated Completion Date: October 1, 2025
Finding 2024-002 Management Response: The Business Manager has year-end procedures in place to ensure year end adjusting entries are performed prior to the audit. Individual Responsible: Corrina Lesko Anticipated Completion Date: October 1, 2025
Finding 2024-002 Material Weakness in Internal Control Over Reporting Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources a...
Finding 2024-002 Material Weakness in Internal Control Over Reporting Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2024 Criteria FFHC is responsible for preparing and submitting its annual Universal Report and Federal Financial Reports in a timely manner. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist.• The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • All grant related year-end audit procedures have been transitioned to the Grant Accountant who has experience with financial audits and compliance and reporting for City, State, and Federal grants. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the Federal Financial Reports and the Universal Report. The target date for full implementation of these corrective actions is December 30, 2025. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. • To ensure timely submission of Federal Financial Reports (FFR) to HRSA, Friend Health will implement a robust internal calendar that includes all HRSA reporting deadlines along with earlier internal due dates for preparation and review. Designated financial and grants management staff will be responsible for compiling and verifying the required data well in advance of the submission deadline. Friend Health will conduct regular internal reviews to ensure accuracy, completeness, and compliance with HRSA guidelines. Additionally, staff will be provided with ongoing training on HRSA reporting requirements and utilizing reporting tools or software that streamline the FFR preparation process. These proactive measures will help maintain compliance and prevent future delays. • The Organization will document accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies.
Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.224 Health Centers Program 93.527 Affordable Care Act Grants (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services Pass...
Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.224 Health Centers Program 93.527 Affordable Care Act Grants (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services Passthrough Agency N/A Award Number/Year 2024 Criteria Uniform Guidance requires that single audits be completed, and the reporting package submitted to the Federal Audit Clearinghouse within the earlier of thirty (30) calendar days after receipt of the auditor’s report or nine (9) months after the end of the audit period. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. • The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan, and will oversee all related finance activities. To ensure compliance with timely submission of financial and Single audit reports, Friend Health will implement a structured timeline that aligns with all regulatory deadlines and includes internal checkpoints to monitor progress. The audit engagement will begin within sixty (60) days of fiscal year-end. Key staff members will be assigned clear responsibilities, and regular status meetings will be held to track report preparation and address any issues promptly. Friend Health will also enhance coordination with its external auditors by providing them with all necessary documentation in advance to avoid delays. Additionally, further investment will be made to train relevant team members on audit requirements and reporting standards to improve accuracy and efficiency. These steps will ensure that all deadlines are met and full compliance is maintained moving forward. • The Organization has implemented procedures for staff accountants to prepare balance sheet reconciliations monthly with a monthly review performed by the CFO. All balance sheet accounts are reconciled to external data for verification on a monthly basis. All revenue accounts will be reconciled to external data for verification on a monthly basis. • The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • The Organization has implemented a month-end checklist for all monthly entries to be completed by assigned finance personnel. We are ensuring that all staff are trained adequately to handle any assigned task. All monthly entries are required to be reviewed and approved by the CFO prior to posting to the general ledger within our new accounting software. All appropriate backup documentation will be saved and stored within the accounting software. • All grant related year-end audit procedures have been transitioned to the Grant Accountant who has experience with financial audits and compliance and reporting for City, State, and Federal grants. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the financial statements and supplementary information. The target date for full implementation of these corrective actions is December 30, 2025. The presponsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 340 E. 51st St., Chicago, IL 60615.
Recommendation: We recommend that management timely submit annual audit report to the Federal Audit Clearinghouse. To do this, management should develop and implement a clear timeline with internal milestones for completing audit preparation and review. Management should also establish internal cont...
Recommendation: We recommend that management timely submit annual audit report to the Federal Audit Clearinghouse. To do this, management should develop and implement a clear timeline with internal milestones for completing audit preparation and review. Management should also establish internal control procedures that assign specific responsibilities to staff to ensure that all federal reporting deadlines are met. Views of Responsible Official: Management of the Organization concurs with the audit finding and will immediately implement the auditors’ recommendations. Internal control procedures will be put into place to establish milestones and overseen by the Executive director
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the Security Deposit account in 2025...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the Security Deposit account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account i...
FINDING No. 2024-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
FINDING No. 2024-002: Recommendation: The Project’s management should redeposit the funds into the Security Deposit bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the security account in 2025.
Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertif...
Action Taken: Housing Authority of the County of Chester agrees with the above recommendations and has already instituted policies and procedures designed to address the findings. Please see the list of procedures. HACC Recertification & Documentation Checklist (Quick Reference – 1 Page) 1. Recertification Timeline • Annual: Start process 120 days before due date. • Interim: Complete within 30 days of household change. • Missed/Delayed: Notify Program Manager immediately and document reason. 2. Required Documentation • Income verification (pay stubs, benefits, child support). • Asset verification (bank/retirement statements). • Family composition docs (birth certificates, SSNs). • HUD-required forms. • Use EIV when available; seek third-party verification first. • All docs must be collected within 60 days of effective date. 3. File Standards • Use Resident File Checklist for each household. • Files must include all signed forms & verifications. • Store in approved secure system (electronic or paper). • Retain files 3 years after end of participation (longer if litigation/audit pending). 4. Internal Controls • Supervisory Review: 10% of files checked monthly. • Maintain clear audit trail (date notices, interviews, verifications). • Correct any deficiencies within 30 days. 5. Staff & Training • Staff handling certifications = annual HUD/HACC compliance training. • Document training completion in personnel file. 6. Monitoring • Quarterly compliance report on timeliness & file completeness. • Issues shared with Executive Director and Board. • Policies reviewed annually for updates. Roles • Housing Specialists: Complete recerts & file docs. • Supervisors: Monitor timeliness & review files. • Compliance Officer: Audit & reporting. • Executive Director: Oversight & resources. n Follow this checklist to ensure timely recertifications, complete documentation, and avoid audit findings.
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: The grants administrator has been developi...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: The grants administrator has been developing a master calendar and will ensure the departments file the required reports within the required timeframes of their funders and maintain copies in a centralized file.
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs o...
Personnel Responsible for Corrective Action: Dr. Shelley Kneuvean Chief Financial Officer Unified Government of Wyandotte County & Kansas City, Kansas Anticipated Completion Date: October 1, 2025 Views of Responsible Officials and Planned Corrective Action: All subrecipients for all grant programs over $30,000 will be reported in the FSRS system. Departments will enter the subrecipients into this system, and our grant administrator will audit the files to ensure proper documentation is maintained to ensure compliance.
The Health Department agrees with the finding and will implement the following corrective actions: Grant Monitoring Procedures: Develop and implement procedures to identify and monitor grant agreement changes and their potential impacts on established grant requirements and internal procedures. Repo...
The Health Department agrees with the finding and will implement the following corrective actions: Grant Monitoring Procedures: Develop and implement procedures to identify and monitor grant agreement changes and their potential impacts on established grant requirements and internal procedures. Reporting Procedures: Establish specific procedures to track grant reporting deadlines, review submission progress, and confirm status of upcoming reports. Staff Training and Oversight: Assign responsibility for the report preparation and submission as well as management review and confirmation of report submission.
Condition Found: Per 2 CFR § 200.512(a), the auditee must submit the data collection form (DCF) and reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the auditee’s fiscal year. The aud...
Condition Found: Per 2 CFR § 200.512(a), the auditee must submit the data collection form (DCF) and reporting package to the Federal Audit Clearinghouse within the earlier of 30 calendar days after receipt of the auditor’s report(s), or nine months after the end of the auditee’s fiscal year. The audit for the year ended December 31, 2023, was not submitted to the Federal Audit Clearinghouse until DATE, which is after the required submission deadline of September 30, 2024. Individual(s) Responsible for Corrective Action: Lynda P. Goldthwaite, Executive Director and Stacey Matott, Director of Finance Planned Corrective Action: With the debt work out in place, management should continue to follow procedures in place to ensure the timely completion of future audits and submission of the reporting package to the Federal Audit Clearinghouse. Anticipated Completion Date: September 30, 2025
ASPIRA will put in place a process for monitoring the certification of the audit reporting package and ensure to submit the audit reporting package before the deadline.
ASPIRA will put in place a process for monitoring the certification of the audit reporting package and ensure to submit the audit reporting package before the deadline.
The Company does not have the resources and/or staff to prepare the financial statements and notes but will continue to oversee the auditor’s services and review and approve the financial statements and notes.
The Company does not have the resources and/or staff to prepare the financial statements and notes but will continue to oversee the auditor’s services and review and approve the financial statements and notes.
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