Corrective Action Plans

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Significant Deficiency 2022-003 Financial Reporting for Federal and State Assistance. Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Common Council will continue to designate competent staff to oversee and review the finan...
Significant Deficiency 2022-003 Financial Reporting for Federal and State Assistance. Management Views – Management agrees with the finding and the recommendation. Corrective Action Planned – Management and the Common Council will continue to designate competent staff to oversee and review the financial reports and approve them before issuance. However, it is not feasible or cost effective to add staff with the competence to prepare these reports. Anticipated Completion Date – This action will be on going.
Penelope House, Inc. and CLAY Foundation, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Wilkins Miller, L.L.C. 41 West Interstate 65 Service Rd. North, Suite 400, Mobile, Alabama 36608. Aud...
Penelope House, Inc. and CLAY Foundation, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Wilkins Miller, L.L.C. 41 West Interstate 65 Service Rd. North, Suite 400, Mobile, Alabama 36608. Audit period: January 1, 2022 to December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - COMBINED FINANCIAL STATEMENT AND FEDERAL AWARD FINDING 2022-001: Condition: The Organization reconciled significant accounts in the accounting system for December 31, 2022, with assistance by the auditing firm. The auditing firm’s assistance was overseen by an individual with the requisite skills, knowledge, and experience. However, reconciliations were not timely in that some reconciliations were not finalized until late September 2023. In addition, material adjustments were proposed and recorded by management during the audit to adjust accounts such as investments, grants and accounts receivable, accounts payable, and accrued expenses, and the related revenues and expenses, including adjustments of $80,942 to prior period balances and net assets. Additionally, errors in coding of transactions to the correct classes in the general ledger accounting software prevented the Organization from consistently implementing the control of comparing the grant draws and support to the general ledger detail. Criteria: Uniform Guidance 200.302(b)(4) states each non-federal entity must provide for “effective control over, and accountability for, all funds, property, and other assets.” Cause: Turnover in the CFO position twice during the year ended December 31, 2022, resulted in a time period where account reconciliations were not being maintained. The former CFO resigned effective March 2022, and her replacement resigned effective December 2022. This required extensive transition of knowledge that contributed to financial reporting delays. Effect: A material weakness in internal control over financial reporting and over compliance exists due to failure to properly code transactions and to timely reconcile and adjust accounts which led to material adjusting journal entries being identified during the audit process. Where the Organization maintained adequate documentation to support costs allowable for substantially the full amount of the budget for grant number HESG-CV-20-003 (CFDA 14.231), there was an isolated incident of errors in developing and communicating support for $78,932 of the draws.Recommendation: We recommend the Organization implement systems, procedures and training to ensure accounts are reconciled timely and accurately with the reconciliations completed entirely by the Organization’s accounting staff or by third party professionals prior to provision of the trial balance and supporting documentation to the auditor. Views of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has developed and begun implementation of a corrective action plan. To address this finding, the Organization has implemented processes whereby the CFO compares profit and loss detail statements from the general ledger for each grant to the draw requests and investigates any differences. If the governing organization has questions regarding this plan, please contact me at 251-459-6665. Sincerely, Tonie Ann Coumanis Torrans Executive Director Penelope House, Inc. and CLAY Foundation, Inc.
Finding 293 (2022-004)
Significant Deficiency 2022
City staff are aware of this responsibility and will plan to prepare the SEFA annually in future years.
City staff are aware of this responsibility and will plan to prepare the SEFA annually in future years.
September 29, 2023 U.S. Department of Health and Human Services Triad Health Systems, Inc. respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisvill...
September 29, 2023 U.S. Department of Health and Human Services Triad Health Systems, Inc. respectively submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisville, Kentucky 40223 Audit period: Year ended December 31, 2022. The findings from the schedule of findings and questioned costs for the year ended December 31, 2022, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS 2022-001 Condition: Improper reporting of lost revenues on Phase 4 PRF submission: When submitting information related to Phase 4 of the Provider Relief Fund (“PRF”) program to the Health Resources and Services Administration (“HRSA”), various quarters were not corrected from the incorrect prior year submission, resulting in an overstatement of lost revenues reported in the THS’s official filing. Action: Management will implement internal control procedures by December 31, 2023, to ensure the proper reporting of any potential lost revenues on future PRF program submission to HRSA. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Adam Craft, CEO, at (859) 567-1591. Sincerely, Adam Craft Chief Executive Officer
Hire a person with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. Knowledge in accounting and auditing procedures. In addition, must have experience in federal compliance that can monitor an execute the college po...
Hire a person with legal knowledge of federal grant regulations to report any situations directly to the attention of the Governing Board of PR College. Knowledge in accounting and auditing procedures. In addition, must have experience in federal compliance that can monitor an execute the college policies.
View Audit 475 Questioned Costs: $1
Finding 2022-003: Emergency Rental Assistance Program (ERAP) Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Hum...
Finding 2022-003: Emergency Rental Assistance Program (ERAP) Contact Person: Michael R. Baker, Director of Fiscal Affairs Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Human Services Director and Human Services Financial Manager to revise and, where necessary, establish procedures to insure proper approval by all required parties prior to submission of said reports. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the Human Services Director and Human Services Financial Manager all upcoming reporting requirement, and implement reporting procedures that require multiple signatures and approvals, including those required under the reporting guidelines and requirements, and the initials of the County Director of Fiscal Affairs, prior to submission of the subject reports. Date for Completion: December 31, 2023
Finding 2022-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with this recommendation. Initially Nulato Tribal Council thought that the audit was completed and ready for review in March 2023....
Finding 2022-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Martha Turner, Tribal Administrator Corrective Action Plan: We concur with this recommendation. Initially Nulato Tribal Council thought that the audit was completed and ready for review in March 2023. In April the unrecorded liabilities identified in Finding 2022-001 were discovered, which took some time with the parties involved to agree the actual balances owed. With the tying out of internal transactions monthly this should not be an issue in the future. Proposed Completion Date: June 30, 2024
Finding #2022-005 Housing Voucher Cluster Special Tests and Provisions – Rolling Forward Equity Balances Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 a...
Finding #2022-005 Housing Voucher Cluster Special Tests and Provisions – Rolling Forward Equity Balances Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Financial Assessment Sub-System (FASS-PH) so that the Authority can meet the reporting requirement. Responsible Party: Frances Danieli, Controller Anticipated Date of Completion: Ongoing effort with HUD
Finding #2022-004 Housing Voucher Cluster Reporting Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Fina...
Finding #2022-004 Housing Voucher Cluster Reporting Views of Responsible Officials and Planned Corrective Action Responsible accounting personnel will coordinate and prioritize with HUD to resolve the submission of its audited Fiscal Year 2020 and 2021 financial information as required in the Financial Assessment Sub-System (FASS-PH) so that the Authority can meet the reporting requirement. Responsible Party: Frances Danieli, Controller Anticipated Date of Completion: Ongoing effort with HUD
Finding #2022-001 CDBG – Entitlement Grants Cluster Reporting Views of Responsible Officials and Planned Corrective Action The Integrated Disbursement and Information System (IDIS) accounts for transactions using the cash basis method of accounting (real-time) while GHURA’s trial balance reflects ...
Finding #2022-001 CDBG – Entitlement Grants Cluster Reporting Views of Responsible Officials and Planned Corrective Action The Integrated Disbursement and Information System (IDIS) accounts for transactions using the cash basis method of accounting (real-time) while GHURA’s trial balance reflects transactions using the accrual basis method of accounting. Due to the differing accounting methods, variances are expected between reports extracted from IDIS and GHURA’s accounting system. The responsible party will prepare a reconciliation between GHURA’s trial balance and the IDIS reports to ensure the completeness and accuracy of the reported amounts. GHURA agrees with the recommendation to monitor subawards for reporting in FSRS. Responsible Party: Katherine Taitano, Chief Planner, and Jerricho Garcia, General Accounting Supervisor Anticipated Date of Completion: September 30, 2024
2022-001 – Reporting of Provider Relief Fund (“PRF”) Lost Revenues Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration Award Name: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistanc...
2022-001 – Reporting of Provider Relief Fund (“PRF”) Lost Revenues Cluster: Not applicable Federal Granting Agency: Health Resources and Services Administration Award Name: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Assistance Listing #: 93.498 Assistance Listing Title: COVID-19 - Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution – Period 4 Award Year: January 1, 2020 – December 31, 2022 Management of Maimonides Midwood Community Hospital have reached out to HRSA on September 5, 2023 to determine if any corrective action related to the reporting error is necessary. HRSA responded and advised that the reporting portal is closed and changes can no longer be made to the report. HRSA also advised to maintain all records that pertain to expenditures and other data related to the PRF payment for three (3) years. Management will review any future PRF submissions to ensure that HRSA instructions are appropriately followed. Responsible Individual: Robert Palermo, Executive Vice President Chief Financial Officer
Contact Person: Rhonda Zastoupil, Business Manager, Planned Corrective Action: The District will implement the auditor's recommendation. Planned Completion Date: March 31, 2024
Contact Person: Rhonda Zastoupil, Business Manager, Planned Corrective Action: The District will implement the auditor's recommendation. Planned Completion Date: March 31, 2024
2022-004 Late Submission of 2021 Data Collection Form to Federal Audit Clearinghouse Condition: The 2021 data collection form for the County was submitted after the prescribed nine month due date, as required by the Federal Audit Clearinghouse for the year ended December 31, 2021. Criteria: The Fe...
2022-004 Late Submission of 2021 Data Collection Form to Federal Audit Clearinghouse Condition: The 2021 data collection form for the County was submitted after the prescribed nine month due date, as required by the Federal Audit Clearinghouse for the year ended December 31, 2021. Criteria: The Federal Audit Clearinghouse requires that organizations submit their annual audit and the annual data collection form within nine months after the fiscal year-end. Cause: The delay in submitting the 2021 data collection form and the 2021 annual audit was primarily due to audit was completed late. Effect: This delay in submission may hinder timely access to accurate financial information for decision-making and reporting. Auditor’s Recommendation: We recommend that the County establishes a formalized process to track regulatory filing deadlines and responsibilities and conduct periodic reviews to ensure timely compliance with regulatory requirements. Management Response: The County acknowledges the audit finding and commits to implementing the recommended actions promptly to enhance compliance with regulatory requirements regarding data collection form submissions. Contact Person: Derek Kalish Anticipated Completion: Ongoing
FINDING 2022-001 PROVIDER RELIEF FUND REPORTING Condition: During the audit, we noted that management did not complete the reporting portion on the Provider Relief Fund Reporting Portal for one of the facilities that received PRF money during 2021. RESPONSE AND CORRECTIVE ACTION PLAN PREPARED BY: Sc...
FINDING 2022-001 PROVIDER RELIEF FUND REPORTING Condition: During the audit, we noted that management did not complete the reporting portion on the Provider Relief Fund Reporting Portal for one of the facilities that received PRF money during 2021. RESPONSE AND CORRECTIVE ACTION PLAN PREPARED BY: Scott Fisher PERSON RESPONSIBLE FOR IMPLEMENTING THE CORRECTIVE ACTION: Scott Fisher ANTICIPATED COMPLETION DATE OF CORRECTIVE ACTION: December 31, 2023 PLANNED CORRECTIVE ACTION: Management will review all the EINs associated with each facility to ensure the PRF funding received has been accounted for and properly reported in the Provider Relief Fund Reporting Portal.
View Audit 82 Questioned Costs: $1
Finding 73 (2022-002)
Material Weakness 2022
Response and corrective action plan: Baker Places, Inc. concurs with the finding. Agency has hired additional financial staff and consulting resources in order to complete its annual audit and submission to the Federal Audit Clearinghouse (FAC) in a timely fashion. We anticipate that the FY 2022-23 ...
Response and corrective action plan: Baker Places, Inc. concurs with the finding. Agency has hired additional financial staff and consulting resources in order to complete its annual audit and submission to the Federal Audit Clearinghouse (FAC) in a timely fashion. We anticipate that the FY 2022-23 audit will be submitted to the FAC within the March 31, 2024 deadline (nine months after the end of our fiscal year). Anticipated completion date: March 31, 2024. Responsible person: Leo Levenson, Consulting CFO.
With recent changes in Leadership, the Board of Directors has established committees for financial policy and a robust internal control system, and as a result, an initiative is underway for the establishment of expenditure policies. We expect to have the new expenditures policy and Financial Manual...
With recent changes in Leadership, the Board of Directors has established committees for financial policy and a robust internal control system, and as a result, an initiative is underway for the establishment of expenditure policies. We expect to have the new expenditures policy and Financial Manual approved by the Board at the next Board Meeting in October.
The prior audit (for FY 2021) had been delayed, and the Board determined that it was time to issue an RFP to consider other auditors. With the late completion of the prior audit, and the selection of a new auditor, there was insufficient time to engage the new firm to commence the audit and complete...
The prior audit (for FY 2021) had been delayed, and the Board determined that it was time to issue an RFP to consider other auditors. With the late completion of the prior audit, and the selection of a new auditor, there was insufficient time to engage the new firm to commence the audit and complete it and submit the Single Audit prior to the deadline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Finding Number 2021-009: No Internal Review of SEFA Prior to Submission (Internal Controls), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not complete an internal review of SEFA prior to submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler...
Finding Number 2021-009: No Internal Review of SEFA Prior to Submission (Internal Controls), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not complete an internal review of SEFA prior to submission PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  PCOA has instituted an internal review and approval process for the Schedule of Expenditures of Federal Awards (SEFA), which now requires sign-off by the Finance Director prior to submission to the auditors.  The third-party accounting firm prepared and reconciled the SEFA in collaboration with internal staff  Technical hires are being made to ensure continued compliance and review capacity during year-end closing. Completion Date: July 31, 2025
Finding Number 2021-008 : Noncompliance with Federal Reporting Requirements (Reporting), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not comply with Federal Reporting Requirements PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Directo...
Finding Number 2021-008 : Noncompliance with Federal Reporting Requirements (Reporting), July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not comply with Federal Reporting Requirements PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan:  PCOA, with the assistance of DES, has created a grant compliance tracking system.  PCOA has also implemented oversight procedures to ensure all federal reports are submitted accurately and on time.  The Finance Director will assist in structuring these controls around the training program and finance staff.  The Finance Director oversees this process, and their capacity to do so has been strengthened through targeted hiring of experienced finance professionals.
Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting correcti...
Finding Number 2021-003: Lack of Review of Meal Sign-In Sheets (Allowable Costs/Cost Principles) , July 1, 2020 through June 30,2021. Statement of Condition: The Meal Sign-in Sheets were not regularly and consistently attached to proper documentation. PCOA personnel responsible for enacting corrective action plan: Francine McGetrick, Contracts Director, Fmcgetrick@pcoa.org The corrective action plan: 1. PCOA has implemented procedures requiring internal review of all client sign-in sheets related to meals billed for reimbursement. 2. While the required sign-in documentation was completed and retained, it was stored in the contracts area and not submitted with the DES files. A new process has been established to ensure that sign-in sheets are filed along with the corresponding summary information at the time of submission. 3. PCOA has designed the updated process and trained staff to ensure proper documentation is verified prior to billing. 4. Ongoing compliance is now overseen by the Director of Contracts, and operational staff have been re-trained to ensure consistent execution. Completion Date: June 30th, 2025
Finding Number 2021-002: – Late Filing of Uniform Guidance Audit, July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not file the Uniform Guidance Audit before the established deadline PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director,...
Finding Number 2021-002: – Late Filing of Uniform Guidance Audit, July 1, 2020 through June 30,2021. Statement of Condition: PCOA did not file the Uniform Guidance Audit before the established deadline PCOA personnel responsible for enacting corrective action plan: Jay Huffstutler, Finance Director, jhuffstutler@pcoa.org The corrective action plan: Background: Prior to fiscal year 2021, PCOA consistently completed and submitted its Uniform Guidance audits on time. The delay in filing for fiscal year 2020–2021 was primarily due to a change in executive leadership, which significantly impacted internal capacity and oversight during that period. PCOA acknowledges the missed filing deadline and has since taken corrective action, including hiring a new Finance Director and engaging a third-party accounting firm to support the finance team during the transition and assist in bringing all outstanding audits current. These measures have been implemented to ensure timely and compliant audit submissions moving forward. 1. A finance compliance calendar has been established, and oversight of reporting deadlines will be completed by the newly hired Finance Director. 2. The third-party accounting firm supports timely preparation and review of audit materials. 3. New accounting staff are also being hired to ensure workload coverage and continuity during critical reporting periods. 4. In addition, ongoing training and cross-training of staff will continue under the direction of the Finance Director to strengthen internal capacity and mitigate future risks. Completion Date: June 30, 2025
November 10,2025 Clallam County Public Hospital District No. 2, dba Olympic Medical Center (OMC) Corrective Action Plan Year Ended December 31,202I Finding 2021-001 Responsible Official: Dennis Stillman, Interim CFO Correction Action and Timing: With the volume of COVID-19 federal programs and the r...
November 10,2025 Clallam County Public Hospital District No. 2, dba Olympic Medical Center (OMC) Corrective Action Plan Year Ended December 31,202I Finding 2021-001 Responsible Official: Dennis Stillman, Interim CFO Correction Action and Timing: With the volume of COVID-19 federal programs and the related complexities associated with the evolving guidance, it was challenging to prepare the Schedule of Expenditures of Federal Awards (SEFA) and related support completely and accurately for the single audit by the required due dates. Before the COVID-19 pandemic, grant expenditures related to federal programs rarely surpassed the single audit threshold, and the single audit threshold for OMC is unlikely to be surpassed in the future. To prepare for the possibility of future federal grant awards, all applications and contracts for federal awards will require review and approval by OMC's Contracts department. All applications for federal awards will be forwarded to the Chief Financial Officer for evaluation, acceptance, and record-keeping for Schedule of Expenditure of Federal Awards, SEFA. The recordkeeping for SEFA will be for accuracy, completeness, and reconciliation with accounting records. These records will support the performance of the single audit. OMC will implement this Corrective Action Plan effective November I,2025 Stillman Interim CFO Contracts Manager Controller cc
Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA...
Corrective Action Plan: PREMA will establish and document formal procedures for the preparation, review, reconciliation, and timely submission of SF-425 Federal Financial Reports for EMPG grants by implementing a report reconciliation checklist requiring agreement of reported data to PRIFAS and SEFA records, ensuring each report includes federal and recipient share, drawdown activity, and unliquidated obligations, designating an official responsible for report review and approval prior to submission with evidence of filing retained, and providing staff training on federal reporting requirements under 2 CFR 200.327–200.329 to improve accuracy, completeness, and compliance in federal financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports...
Corrective Action Plan: PREMA will establish and enforce procedures to ensure that quarterly SF-425 or equivalent COR3 financial reports are prepared, reviewed, reconciled to PRIFAS and SEFA records, and submitted within required deadlines; PREMA will create reconciliation checklists, ensure reports include federal and recipient share, drawdown activity, and unliquidated obligations, designate responsible personnel for review and approval prior to filing with evidence of submission retained, and provide staff training on federal reporting requirements under 2 CFR 200.327–200.329 to strengthen compliance and accuracy in financial reporting. Lead Person: Maritza Torres, Fiscal Area Director, and Contractors (Robles & Assoc.). Anticipated Completion Date: December 2025.
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