Corrective Action Plans

Finding 481151 (2022-015)

Significant Deficiency 2022

MD

Questioned Costs Reporting Internal Control / Segregation of Duties

Management Response #2022-015: Due to staff turnover in prior years and inadequate handover procedures, the reporting requirements under the WIC program was not done as required. Corrective Action Plan: • Training will be provided for the WIC staff that clearly delineates roles and responsibilities...

Management Response #2022-015: Due to staff turnover in prior years and inadequate handover procedures, the reporting requirements under the WIC program was not done as required. Corrective Action Plan: • Training will be provided for the WIC staff that clearly delineates roles and responsibilities for each position in the WIC Dept. This training will separate the tasks of income verification and medical risk assessments under different job titles. Job descriptions and policy/procedures manuals will be updated to memorialize this update. • The Grants program management team will expand upon our current process to ensure eligibility determination is verified and documented. Responsible Party: Tracy Harrison, COO

View Audit 317252

Finding 481138 (2022-008)

Significant Deficiency 2022

Unity Health Care, Inc.

MD

Reporting

Management Response #2022-008: Staff turnover in FY2020-2021, saw a departure of key personnel that calculated and filed the SF-425 Federal Financial Report for the reporting period end date of December 31, 2021. In addition, the staff that was responsible for reviewing and approving the reports lef...

Management Response #2022-008: Staff turnover in FY2020-2021, saw a departure of key personnel that calculated and filed the SF-425 Federal Financial Report for the reporting period end date of December 31, 2021. In addition, the staff that was responsible for reviewing and approving the reports left the company in FY2021. Corrective Action Plan: In FY2022, the following steps were implemented to ensure there is proper support for the program income calculation and it is reviewed and approved prior to submission of the SF-425 reports. • The Vice President of Grants Management and Senior Director of Finance will work collaboratively with their teams to ensure that the program income calculation is supported and accurate. • Nitro or a similar tool to document their review and approval of the calculation and the supporting documentation. • The evidence of review and approval will be stored in a central repository. Responsible Party: Tamara Barnes, CFO

View Audit 317252

Finding 481131 (2022-012)

Significant Deficiency 2022

Unity Health Care, Inc.

MD

Questioned Costs Reporting Internal Control / Segregation of Duties

Management Response #2022-012: Due to staff turnover in prior years and inadequate handover procedures, the Federal Funding Accountability and Transparency Act (FFATA) reports were not filed with the granting agencies as required. Corrective Action Plan: The Grants program department will develop p...

Management Response #2022-012: Due to staff turnover in prior years and inadequate handover procedures, the Federal Funding Accountability and Transparency Act (FFATA) reports were not filed with the granting agencies as required. Corrective Action Plan: The Grants program department will develop procedures to ensure that we are compliant in the timely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports. This will be monitored and audited by the Vice President of the grants program at regular intervals. In additional the grants program staff will provide monthly updates to the Finance grants team as to the status of submission as well as copying the team on all submission. Responsible Party: Erin Flior, CSDO

View Audit 317252

Finding 481116 (2022-007)

Significant Deficiency 2022

Unity Health Care, Inc.

MD

Reporting

Management Response #2022-007: The pandemic and subsequent shift to remote work saw a disruption on the previous workflow of reviewing and approval of federal programs financial reports prior to submission to the granting agency. Staff turnover in key financial positions also contributed to the depa...

Management Response #2022-007: The pandemic and subsequent shift to remote work saw a disruption on the previous workflow of reviewing and approval of federal programs financial reports prior to submission to the granting agency. Staff turnover in key financial positions also contributed to the departure in following the processes that were in place and I sufficiently documented. This practice continued into FY2021 which also had similar issues. Corrective Action Plan: In FY2022, the following steps were implemented to ensure there is proper review and approval of reports required under the federal programs prior to submission. • The Vice President of Grants Management and Senior Director of Finance, which reside in two different departments, will work collaboratively with their teams to ensure that federal financial and programmatic reports are accurate and have adequate support and thereby strengthen the internal controls. • All federal and programmatic reports will go through an approval process requiring the signature of a senior programmatic leader and a senior finance leader. Responsible Party: Tamara Barnes, CFO

View Audit 317252

Finding 481113 (2022-004)

Material Weakness 2022

Unity Health Care, Inc.

MD

Reporting § 200.512

Management Response #2022-004: Due to staff shortages and turnover in FY2020-21 and continuing into FY2022, the company did not have adequate personnel in place to properly monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Corrective Action Pla...

Management Response #2022-004: Due to staff shortages and turnover in FY2020-21 and continuing into FY2022, the company did not have adequate personnel in place to properly monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Corrective Action Plan: The following action items have been established. • In 2022, the finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • In 2022 Project Budget Reports have been created for each federal award. These reports include the budget, expenses foreach month and the revenue (drawdown) incurred foreach month. The reports will be reviewed and reconciled by the grants administration staff and finance monthly to ensure all agree with the allocated costs and that costs follow compliance and grant regulations. This will allow timely reconciliation of grants before year end for FFRs, SEFA preparation, audit, reporting package and data collection for FAC. Responsible Party: Tamara Barnes, CFO

View Audit 317252

Finding 481107 (2022-009)

Significant Deficiency 2022

National Casa Association

WA

Subrecipient Monitoring Reporting § 200.303

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 Explanation: Management c...

Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 Explanation: Management concurs that although it already enhanced policies to comply with an OJJDP/OCFO recommendation resolved in 2023, which included a two-step review and approval process for subrecipient awards involving the Executive Team, grantor procedures will be updated as recommended to include a third step to specify review and approval of subrecipient FFATA data prior to submission. The Supervisor or member of the Executive Team will capture review and approval of FFATA data with an email including the approved list attached. When FFATA reporting is submitted by staff, the list will be updated with the date submitted and returned to the Supervisor to confirm timeliness. Regarding the 12 subrecipient awards for Court Appointed Special Advocates selected for testing FFATA submission requirements, 9 out of 12 reports were submitted by the last day of the month following the start of the grant period.

View Audit 317239

Finding 481099 (2022-007)

Significant Deficiency 2022

National Casa Association

WA

Questioned Costs Subrecipient Monitoring Reporting § 200.512

Responsible: Thomas Hoover, CFO Corrective Actions: Upload the 2022 reporting package to the Federal Audit Clearinghouse. Completion Date: August 14, 2024 Explanation: Management concurs that the reporting package was not submitted to the Federal Award Clearinghouse within the deadline due to t...

Responsible: Thomas Hoover, CFO Corrective Actions: Upload the 2022 reporting package to the Federal Audit Clearinghouse. Completion Date: August 14, 2024 Explanation: Management concurs that the reporting package was not submitted to the Federal Award Clearinghouse within the deadline due to the completion of the closeout of a joint OJJDP/OCFO October 2022 monitoring visit report that resulted in a delay in the FY22 Single Audit being conducted and completed.

View Audit 317239

Finding 481085 (2022-003)

Material Weakness 2022

National Casa Association

WA

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking Questioned Costs § 200.430

Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to document and maintain the documentation of Supervisory review and approval of journal entries charging payroll costs to federal grants; 2) Update Finance policies to review estimates of accrued costs charged to feder...

Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to document and maintain the documentation of Supervisory review and approval of journal entries charging payroll costs to federal grants; 2) Update Finance policies to review estimates of accrued costs charged to federal grants at calendar/fiscal year end to determine whether true-ups to actual costs are necessary. Completion Date: March 29, 2023 Explanation: 1) Review of allocated payroll costs: Payroll processing and recording of costs charged to federal grants has in practice, consistently involved multiple review and approval steps by at least two employees. Detailed records of these steps are maintained in Finance records for each payroll, including the allocated grant costs. However, Management acknowledges that an additional step be added to capture the documentation of review and approval of the payroll journal entries that allocate payroll costs to federal grants. This step was put in place in 2023 to resolve a recommendation from OJJDP/OCFO. Supervisor review and approval is captured directly in the general ledger system. Finance policies have been updated to codify this additional step as recommended. 2) Procedure for trueing up estimates: Three of sixty transactions tested showed that payroll costs were accrued at year end based on the approved grant budget but were not trued up in the new accounting period based on actual costs. The total variance of the three transactions was $6.20. Finance policies have been updated to include evaluating year-end accruals to determine whether a true-up is necessary in the new period as recommended.

View Audit 317239

Finding 481081 (2022-002)

Significant Deficiency 2022

National Casa Association

WA

Questioned Costs Subrecipient Monitoring Reporting

Responsible: Sally Erny, Deputy CEO Corrective Action: Document and maintain documentation of Supervisory review and approval of grant reports. Completion Date: July 10, 2024 Explanation: Since the inception of National CASA/GAL receiving federal funding, procedures and practices were in place f...

Responsible: Sally Erny, Deputy CEO Corrective Action: Document and maintain documentation of Supervisory review and approval of grant reports. Completion Date: July 10, 2024 Explanation: Since the inception of National CASA/GAL receiving federal funding, procedures and practices were in place for the review and approval of performance reports and SF-425s (FFRs). This practice includes the involvement of multiple staff in the organization participating in the development and review of these documents and a knowledgeable staff member with appropriate authority approving the document. There are many points of approval through the development of the reports. In terms of the FFRs, the Accounting Director is responsible for preparing a Pivot table showing the expenses for the grant for both the quarterly and inception to date periods and to update the data worksheet for the quarterly FFR report. The Controller confirms that the cumulative expenses indicated on the quarterly FFR report data worksheet match the inception to date information in the accounting ledger and then approves the report. The Accounting Director submits the FFR report through the Grants Management System. In 2023 a policy, as part of the Operations SOPs, was put in place that in addition to the various staff who work on developing the performance report, OJJDP performance reporting would be reviewed and approved and documented as such, by the Project Manager and appropriate Chief Officer. This policy formalized what had been happening in practice over many years. While we acknowledge that this policy of documentation was not in place in 2022, the practice of review and approval was. In 2023 and going forward, we have improved documenting the approval processes for the FFRs and performance reports.

View Audit 317239

Finding 481028 (2022-001)

Significant Deficiency 2022

American Baptist Theological Seminary

TN

Reporting

The College does not dispute this finding. The finding pertains to the College’s efforts to renovate its historic library to make it more accessible and user-friendly. To fund the project's initial phase, the renovations required the aggregation and carry-over of Title IIIB funds over multiple fisca...

The College does not dispute this finding. The finding pertains to the College’s efforts to renovate its historic library to make it more accessible and user-friendly. To fund the project's initial phase, the renovations required the aggregation and carry-over of Title IIIB funds over multiple fiscal year periods. Before the commencement of construction, the Title IIIB program officer was informed of the College’s intent to dedicate the aggregated funds to the project. There was no indication from the Department of Education that such use would be an inappropriate practice. Because no blueprints or other construction documents were available for the mid-1950s era building, the College, and the construction professionals it utilized, anticipated that the project would experience unknown conditions and unanticipated material and equipment supply delays during the construction period that would increase the cost of the project. Some unknown conditions included a significant floor height discrepancy between building sections and extensive rock formations in the excavation area. The recording and reconciliation errors noted by the auditor above reflect the College’s attempt to ensure that it had sufficient cash on hand during the project to meet both anticipated and unanticipated expenses. Additionally, a second phase of the library modernization project involving HVAC, window system, and flooring upgrades was planned even before the beginning of the initial phase of construction. While few of the second-phase improvements were ultimately included in the initial stage, the College has proceeded with the remaining second-phase enhancements, including replacing existing windows and flooring. These items will be expensed in the next quarter (October-December 2022). The College now recognizes that the approach described above is unallowable, and will confine its future drawdowns of federal funds to actual, not speculative, expenditures. The Board will implement the above procedure immediately.

View Audit 317146

Finding 481007 (2022-004)

Significant Deficiency 2022

City of Groton

SD

Internal Control / Segregation of Duties Questioned Costs Reporting

Finding 2022-004 Finding Summary: In our testing of reporting, we did not have a documented control in place to review reports prior to submission for reporting directly to Department of Treasury. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will adopt contro...

Finding 2022-004 Finding Summary: In our testing of reporting, we did not have a documented control in place to review reports prior to submission for reporting directly to Department of Treasury. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will adopt controls to have a review process added before the required reports for federal programs are submitted to federal or state agencies. Anticipated Completion Date: December 31, 2024

View Audit 317109

Finding 480993 (2022-002)

Material Weakness 2022

Brookfield Local School District

OH

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.414 § 200.502 § 200.510

All future federal expenditures will be reconciled to the disbursement ledger.

View Audit 317104

Finding 480963 (2022-002)

Material Weakness 2022

Town of Southampton

MA

Internal Control / Segregation of Duties Questioned Costs Material Weakness

Planned Corrective Action: The Town will adopt policies pertaining to federal awards, specifically ARPA, that have been effective and useful in other municipalities. Using established policies from other municipalities will expedite bringing Southampton into compliance. The new policies will esta...

Planned Corrective Action: The Town will adopt policies pertaining to federal awards, specifically ARPA, that have been effective and useful in other municipalities. Using established policies from other municipalities will expedite bringing Southampton into compliance. The new policies will establish controls setting responsibilities and deadlines for timely and accurate submissions. With ARPA funding moving towards an expiration date, these policies will be important to finalize and close-out any awards.

View Audit 317084

Finding 480923 (2022-002)

Significant Deficiency 2022

Healthalliance, Inc.

NY

Reporting

Due to staff turnover in 2022, reports submitted to the PRF Portal were not properly reconciled to the Corporations general ledger and accounting records. However, the amounts submitted were underreported and thus conservative in nature to actual expenses and revenue losses incurred. Corporation M...

Due to staff turnover in 2022, reports submitted to the PRF Portal were not properly reconciled to the Corporations general ledger and accounting records. However, the amounts submitted were underreported and thus conservative in nature to actual expenses and revenue losses incurred. Corporation Management ensured amounts reported for future periods reconciled to the underlying accounting records.

View Audit 317022

Finding 480922 (2022-001)

Significant Deficiency 2022

Healthalliance, Inc.

NY

Reporting § 200.512

Due to staff turnover in 2022, we did not meet the reporting deadline. We have sufficient staffing during 2023 and are actively working to complete the 2023 Uniform Guidance audit of the Corporation’s federal awards for the year ended December 31, 2023 by the due date of September 30, 2024.

View Audit 317022

Finding 480842 (2022-002)

Material Weakness 2022

Casita Park Housing Development Fund Corporation

NY

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Finding 2022-002 Unauthorized loans from project assets Comments on the Finding and Each Recommendation Statement of Condition During the year ended September 30, 2022, the project paid expenses in the amount of $81,886 on behalf of an affiliate from project cash without HUD approval. The amount due...

Finding 2022-002 Unauthorized loans from project assets Comments on the Finding and Each Recommendation Statement of Condition During the year ended September 30, 2022, the project paid expenses in the amount of $81,886 on behalf of an affiliate from project cash without HUD approval. The amount due to the project as of September 30, 2022 is $81,886. Criteria Loans are not permitted to be made from project cash without prior authorization from HUD. Cause Procedures were not in place to ensure that cash disbursements of project funds were limited to project operating costs. Effect or Potential Effect The payments of $81,886 were unauthorized loans and therefore considered to be questioned costs. Questioned Costs $ 81,886. Recommendation Management should immediately reimburse the amount due to the project and establish procedures to ensure payments of this nature are not made in the future. Auditor Noncompliance Code B – Allowable Cost/Costs Principles Reporting Views of Responsible Officials The Corporation agrees with the finding and the auditor's recommendations have been adopted. Upon finalizing the audits and submitting to HUD, management intends to request funds from the replacement reserve to enable them to pay down the due from affiliates..

View Audit 316972 Questioned Costs: $1

Finding 480841 (2022-002)

Material Weakness 2022

Lucille Clark Housing Development Corporation

NY

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

2- Finding No. 2022-002; Unauthorized loans from project assets Statement of Condition During the year ended September 30, 2022, the project paid expenses in the amount of $32,736 on behalf of an affiliate from project cash without HUD approval. The amount due to the project as of September 30, 2022...

2- Finding No. 2022-002; Unauthorized loans from project assets Statement of Condition During the year ended September 30, 2022, the project paid expenses in the amount of $32,736 on behalf of an affiliate from project cash without HUD approval. The amount due to the project as of September 30, 2022 is $32,736. Criteria Loans are not permitted to be made from project cash without prior authorization from HUD. Cause Procedures were not in place to ensure that cash disbursements of project funds were limited to approved project operating costs. Effect or Potential Effect The payments of $32,736 were unauthorized loans and therefore considered to be questioned costs. Questioned Costs $32,736. Recommendation Management should immediately reimburse the amount due to the project and establish procedures to ensure payments of this nature are not made in the future. Auditor Noncompliance Code B – Allowable Cost/Costs Principles Reporting Views of Responsible Officials The Corporation agrees with the finding and the auditor's recommendations have been adopted. Upon finalizing the audits and submitting to HUD, management intends to request funds from the replacement reserve to enable them to pay down the due from affiliates.

View Audit 316971 Questioned Costs: $1

Finding 480817 (2022-001)

Material Weakness 2022

Houston Housing Authority

TX

Internal Control / Segregation of Duties HUD Housing Programs Material Weakness

The Houston Housing Authority agrees with this finding and related recommendations. During this audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In...

The Houston Housing Authority agrees with this finding and related recommendations. During this audit, as these issues arose, notes were taken, evaluation of what had happened was made so that we could make the necessary adjustments to our procedures to prevent the continuation of these issues. In addition, we hired a firm to come in and undertake a review of the finance department. The purpose of this review was to review our existing staffing levels, workloads, experience, etc., for purposes of proposing a reorganization of the finance department to address any deficiencies. We have reviewed the recommendations from this consultant and are in the process of implementing many of the recommended changes. We are in the process of bringing in additional staff to expand the capacity of the Finance department. As we had fallen behind on our audits we anticipated the weaknesses noted in prior audits would continue to be present in future audits. We have been working very diligently to address the issues within the finance department that gave rise to this finding. We fully expect this finding or a similar finding to be present for the 2023 audit as many of the departmental improvements and changes were only recently made and would not have been in place for the majority of 2023.

View Audit 316962

Finding 480702 (2022-004)

Material Weakness 2022

Humboldt Park Health, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles Material Weakness

Condition: The Organization’s controls in place for reporting submissions did not identify that the General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to expense amounts reported in the Organization’s period 2 portal submissions. P...

Condition: The Organization’s controls in place for reporting submissions did not identify that the General and Targeted Distribution Post-Payment Notice of Reporting Requirements guidelines were not followed related to expense amounts reported in the Organization’s period 2 portal submissions. Planned Corrective Action: The Organization will review its processes surrounding the quantification of expenses reported and will implement additional levels of review to ensure that the expense amounts are validated for future reporting periods. Contact person responsible for corrective action: Tom Garvey, Interim CFO Anticipated Completion Date: 9/30/2023

View Audit 316928 Questioned Costs: $1

Finding 480701 (2022-003)

Material Weakness 2022

Humboldt Park Health, Inc.

IL

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs

Condition: The Organization’s lacked effective controls to ensure documentation for expenses reported within the Organization’s period 2 portal submission were retained. The Organization was able to produce documentation for total expenses of $7,516,920, while the Organization had reporting to HRSA ...

Condition: The Organization’s lacked effective controls to ensure documentation for expenses reported within the Organization’s period 2 portal submission were retained. The Organization was able to produce documentation for total expenses of $7,516,920, while the Organization had reporting to HRSA that it had incurred $8,509,978 of expenses. As a result, the Organization was unable to provide support for $993,058 of the total expenses reported. Planned Corrective Action: The Organization will review its processes surrounding the retention of documentation used to report expenses and will implement additional levels of review to ensure that the proper documentation is retained for future reporting period portal submissions. Contact person responsible for corrective action: Tom Garvey, Interim CFO Anticipated Completion Date: 9/30/2023

View Audit 316928 Questioned Costs: $1

Finding 480641 (2022-002)

Significant Deficiency 2022

Mobridge Housing and Redevelopment Commission

SD

Reporting Significant Deficiency § 200.512

Findings Related to Major Federal Award Program Finding 2022-002 Reporting (Compliance; Internal Control Over Compliance) Condition as Noted in Auditor’s Finding: The Commission did not complete and submit their audit to the Federal Audit Clearinghouse by the due date of September 30, 2023. Resp...

Findings Related to Major Federal Award Program Finding 2022-002 Reporting (Compliance; Internal Control Over Compliance) Condition as Noted in Auditor’s Finding: The Commission did not complete and submit their audit to the Federal Audit Clearinghouse by the due date of September 30, 2023. Responsible Individuals: Board of Commissioners and Management Correction Action Plan: The Commission will implement procedures to begin audit preparation work earlier in the calendar year to ensure reports are filed within the nine-month reporting deadline set forth by Uniform Guidance. Anticipated Complete Date: September 30, 2024 Very truly yours, MOBRIDGE HOUSING AND REDEVELOPMENT COMMISSION Rich Galbraith Executive Director

View Audit 316835

Finding 480640 (2022-003)

Material Weakness 2022

Community Coordinated Child Care

IA

Reporting Material Weakness

Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance. In addition, management will prepare information on federal awards to determine whether...

Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance. In addition, management will prepare information on federal awards to determine whether a Single Audit is necessary and prepare a Schedule of Expenditures of Federal Awards as part of preparation for future audits.

View Audit 316830

Finding 480639 (2022-002)

Significant Deficiency 2022

Community Coordinated Child Care

IA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance.

View Audit 316830

Finding 480546 (2022-002)

Significant Deficiency 2022

National Indian Women's Health Resource Center

OK

Reporting Internal Control / Segregation of Duties § 200.502 § 200.510

CORRECTIVE ACTION PLAN: DEVELOP AND IMPLEMENT PROCEDURES TO MAINTAIN ADEQUATE ACCOUNTING RECORDS THAT ACCURATELY TRACK EXPENDITURES BY INDIVIDUAL FEDERAL PROGRAMS, ENSURING COMPLIANCE WITH REPORTING REQUIREMENTS AND TRANSPARANCY IN FUND UTILIZATION. 1. IMMEDIATE ASSESSMENT: CONDUCT A COMPREHENSIVE A...

CORRECTIVE ACTION PLAN: DEVELOP AND IMPLEMENT PROCEDURES TO MAINTAIN ADEQUATE ACCOUNTING RECORDS THAT ACCURATELY TRACK EXPENDITURES BY INDIVIDUAL FEDERAL PROGRAMS, ENSURING COMPLIANCE WITH REPORTING REQUIREMENTS AND TRANSPARANCY IN FUND UTILIZATION. 1. IMMEDIATE ASSESSMENT: CONDUCT A COMPREHENSIVE ASSESSMENT OF CURRENT ACCOUNTING PRACTICES AND RECORDS TO IDENTIFY DEFICIENCIES IN TRACKING EXPENDITURES BY FEDERAL PROGRAMS. DETERMINE THE SCOPE AND EXTENT OF INACCURACIES OR GAPS IN DOCUMENTATION. 2. ENGAGE ACCOUNTING EXPERTISE: ENGAGE A THIRD-PARTY CPA FIRM EXPERIENCED IN GOVERNMENTAL ACCOUNTING AND FEDERAL GRANT COMPLIANCE TO ASSIST IN RESOLVING THE ISSUE. 3. REVIEW FEDERAL PROGRAM REQUIREMENTS: REVIEW THE REQUIREMENTS OF EACH FEDERAL PROGRAM UNDER WHICH FUNDS ARE RECEIVED. IDENTIFY SPECIFIC REPORTING AND EXPENDITURE TRACKING REQUIREMENTS MANDATED BY EACH PROGRAM. 4. DEVELOP CHART OF ACCOUNTS: DEVELOP OR REVISE A DETAILED CHART OF ACCOUNTS THAT CLEARLY DISTINGUISHES EXPENDITURES BY EACH FEDERAL PROGRAM. ASSIGN UNIQUE CODES OR IDENTIFIERS TO TRANSACTIONS ASSOCIATED WITH EACH PROGRAM. 5. IMPLEMENT SEGREGATION OF EXPENDITURES: IMPLEMENT PROCEDURES TO SEGREGATE EXPENDITURES BY FEDERAL PROGRAM AT THE TIME OF RECORDING. ENSURE ALL TRANSACTIONS ARE ALLOCATED ACCURATELY TO THE APPROPRIATE PROGRAM BASED ON THE CHART OF ACCOUNTS. 6. DOCUMENT EXPENDITURE ALLOCATION: DOCUMENT THE ALLOCATION OF EXPENDITURES TO SPECIFIC FEDERAL PROGRAMS CLEARLY AND COMPREHENSIVELY. MAINTAIN SUPPORITNG DOCUMENTATION SUCH AS INVOICES, RECEIPTS, AND PAYROLL RECORDS THAT SUBSTANTIATE THE ALLOCATION. 7. TRAINING AND CAPACITY BUILDING: CONDUCT TRAINING SESSIONS FOR ACCOUNTING STAFF INVOLVED IN RECORDING AND REPORTING EXPENDITURES. TRAIN THEM ON THE NEW PROCEDURES, CHART OF ACCOUNTS, AND THE IMPORTANCE OF ACCURATELY TRACKING EXPENDITURES BY FEDERAL PROGRAM. 8. REGULAR RECONCILIATION AND REPORTING: IMPLEMENT A PROCESS FOR REGULAR RECONCILIATION OF EXPENDITURES WITH FEDERAL PROGRAM REQUIREMENTS. ENSURE RECONCILIATION IS PERFOMRED MONTHLY OR QUARTERLY TO IDENTIFY DISCREPANCIES PROMPTLY. 9. INTERNAL CONTROLS AND MONITORING: STREGTHEN INTERNAL CONTROLS TO PREVENT FUTURE INACCURACIES IN EXPENDITURE TRACKING. ASSIGN RESPONSIBILITY FOR OVERSIGHT AND MONITORING OF COMPLIANCE WITH THE NEW PROCEDURES. - TIMELINE FOR IMPLEMENTATION: ONGOING: MAINTAIN VIGILANCE OVER COMPLIANCE AND ADJUST AS NEEDED. - CONCLUSION: BY IMPLEMENTING THIS CORRECTIVE ACTION PLAN, WE AIM TO ESTABLISH ROBUST ACCOUNTING PRACTICES THAT ACCURATELY TRACK EXPENDITURES BY INDIVIDUAL FEDERAL PROGRAMS. THIS WILL ENSURE COMPLIANCE WITH REPORTING REQUIREMENTS, ENHANCE TRANSPARENCY IN FUND UTILIZATION, AND MITIGATE RISKS ASSOCIATED WITH INACCURATE FINANCIAL REPORTING. THIS PLAN OUTLINES OUR COMMITMENT TO ADDRESSING THE CURRENT DEFICIENCIES AND ESTABLISHING A SUSTAINABLE FRAMEWORK FOR FUTURE OPERATIONS. - RESPONSIBLE PARTY: KIMBERLEY CHAFFIN, EXECUTIVE DIRECTOR- DATE OF IMPLEMENTATION: OCTOBER 1, 2023.

View Audit 316748

Finding 480516 (2022-002)

Material Weakness 2022

Virginia Commonwealth University Health System

VA

Questioned Costs Reporting Matching / Level of Effort / Earmarking

Corrective action plan over control environment over lost revenue COVID – 19 – Provider Relief Funding (Assistance Listing #93.498) Recommendation: The Authority’s procedures for calculating lost revenues for the purposes of PRF reporting should be designed to ensure that audited year end numbers ar...

Corrective action plan over control environment over lost revenue COVID – 19 – Provider Relief Funding (Assistance Listing #93.498) Recommendation: The Authority’s procedures for calculating lost revenues for the purposes of PRF reporting should be designed to ensure that audited year end numbers are reported and/or tied back to amounts that are reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: As of July 2024, there is no further lost revenue reporting that is required to be reported. Management will implement more robust internal controls in preparation for similar future grant reporting. For lost revenues that have been submitted for PRF that do not tie back to an audited financial statement, a reconciliation will be completed and documented. Name(s) of the contact person(s) responsible for corrective action: Min Cummings, VP of Finance and Accounting, 703-629-8155 Planned completion date for corrective action plan: July 31, 2024 and going forward.

View Audit 316712

Corrective Action Plans

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