Corrective Action Plans

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Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff reports were not always documented or certified. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administrative positions are staffed. Training will be provided to staff responsible for Federal reporting. Implementation date: June 30, 2025
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limit...
Persons responsible for corrective action: Bob Harmon, Superintendent Corrective Action: For a significant portion of the 2021 fiscal year the Quileute Tribe implemented an emergency order as a result of the COVID-19 pandemic. The School was subject to this emergency order and operations were limited to essential staff and activities. Due to the limited staff not all documentation and certifications were obtained. Further, prior to the emergency order key positions in the finance and administration departments were vacant. Currently all finance and administration departments are staffed. The School has implemented electronic procurement and timekeeping systems. These systems provide clarity in the approval process of procurement and timekeeping transactions. The transition from paper to digital formats provides enhanced internal controls to ensure that transactions are documented and approved. Training relating to the Federal and School procurement and timekeeping requirements will be provided. Implementation date: June 30, 2025
Finding 20201-0001 Responsible Official: Richard E Rico Views of Responsible Officials: With the volume of new COVID-19 federal programs, it was more challenging to completely prepare the SEFA. Processes will be put into place to compile the SEFA, reconcile to support and perform a related review pr...
Finding 20201-0001 Responsible Official: Richard E Rico Views of Responsible Officials: With the volume of new COVID-19 federal programs, it was more challenging to completely prepare the SEFA. Processes will be put into place to compile the SEFA, reconcile to support and perform a related review prior to audit. In addition, any funds with unusual reporting requirements will be reviewed in detail to ensure reporting is complete and accurate. This has been implemented as of January 2025.
Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should inc...
Finding: Under Uniform Grant Guidance (2 CFR 200.303) requires nonfederal entities receiving Federal awards to establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. Effective internal controls should include procedures to ensure that documentation to evidence the operation of internal controls, such as supervisory reviews. The Corporation did not have sufficient documentation that internal controls were in place and operating effectively for control activities required for assessment of activities allowed or unallowed and for allowable costs/cost principles. The Corporation also did not have sufficient documentation that internal controls were in place and operating effectively for monitoring procedures required for cash management and reporting compliance requirements. Corrective Actions Taken or Planned: Due to turnover of key positions responsible for grant submission, supporting documentation that was kept on these individuals’ computers was not saved, passed on, nor stored in a central storage location so that the new hires that were brought in to replace these individual as well as others in the department could view them. In August 2023, the hospital has provided education and training to the staff regarding identifying documentation and files related to the annual SEFA as well as establishing a central departmental drive to store the documentations so that others can locate them when necessary. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance.
Finding: Under the Uniform Guidance, Section 200.512, Report Submission, the audit must be completed and the data collection form and single audit reporting package must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of the auditor’s report...
Finding: Under the Uniform Guidance, Section 200.512, Report Submission, the audit must be completed and the data collection form and single audit reporting package must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. This deadline would have been March 31, 2022 for the Corporation’s reporting for the year ended June 30, 2021. However, because the Corporation received Provider Relief Fund distributions, this deadline was extended by six months to September 30, 2022. The Corporation’s fiscal year 2021 Single Audit package was not submitted to the FAC by the extended deadline of September 30, 2022. Corrective Actions Taken or Planned: The single audit for the year ended June 30, 2021 was completed in January 2025 and the single audit reporting package will be submitted prior to February 15, 2025. The single audit for the year ended June 30, 2022 is expected to be completed by February 28, 2025. The data collection form and single audit reporting package for future single audits will be completed timely and will be sent to the FAC by the prescribed due date. Caralton Brown, Assistant Controller, and Jamie Mack, Vice President of Finance, will be responsible for working with the auditor to complete these on time in the future. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance.
Finding: In accordance with 2 CFR 200 200.510(b), the auditee must prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502. The Corporation’s ...
Finding: In accordance with 2 CFR 200 200.510(b), the auditee must prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502. The Corporation’s Schedule of Expenditures of Federal Awards for the year ended June 30, 2021 was initially prepared without federal expenditures totaling $1,222,859 for the HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance Fund, Assistance Listing number 93.461. Corrective Actions Taken or Planned: In July 2023, the Corporation has provided education and training to the staff regarding how to identify programs and costs that need to be reported on the annual SEFA. This includes a process to enhance internal controls around the timely identification of federal awards and the reconciliation of the SEFA to ensure that it is accurate and complete. Name of contact person responsible for corrective action: Rose Rosario, Director of Patient Financial Services.
Finding: U.S. GAAP requires that the effects of all subsequent events that provide additional evidence about conditions that existed at the date of the balance sheet, including the estimates inherent in the process of preparing financial statements, be recognized in the financial statements. The Co...
Finding: U.S. GAAP requires that the effects of all subsequent events that provide additional evidence about conditions that existed at the date of the balance sheet, including the estimates inherent in the process of preparing financial statements, be recognized in the financial statements. The Corporation identified that subsequent events affecting accounts payable and accrued expenses as of June 30, 2021 were not considered by management. There were subsequent events that were identified which affected accounts payable and accrued expenses as of June 30, 2021 which were not considered by management. Corrective Actions Taken or Planned: A process has been established in July 2022 in which Management performs a detailed review of journal entries that are recorded in the subsequent fiscal year to determine whether any portion of such journal entries should be reflected in the prior fiscal year-end financial statements. Name of contact person responsible for corrective action: Caralton Brown, Assistant Controller and Jamie Mack, Vice President of Finance.
Finding: In order to provide assurance that unauthorized or fraudulent journal entries are not posted within the Corporation’s financial system, journal entries should be subjected to review and approval by an individual independent of the preparer of the journal entry prior to posting. The Corporat...
Finding: In order to provide assurance that unauthorized or fraudulent journal entries are not posted within the Corporation’s financial system, journal entries should be subjected to review and approval by an individual independent of the preparer of the journal entry prior to posting. The Corporation’s system allowed the same individual to approve and post the same entry, and entries were posted with only one level of review. Corrective Actions Taken or Planned: A process has been established effective July 2022 where journal entries are reviewed by an individual with appropriate authority, different than the preparer of the journal entry. Jamie Mack, Vice President of Finance, will approve the journal entries of Caralton Brown, Assistant Controller, and Caralton Brown will review and approve the entries prepared by Jamie Mack and Michael Caddick, outside contractor. Name of contact person responsible for corrective action: Jamie Mack, Vice President of Finance.
Finding 520957 (2021-003)
Significant Deficiency 2021
a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding Management will transfer excess funds from the operating account to the reserve for replacements account and continue to work toward...
a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding Management will transfer excess funds from the operating account to the reserve for replacements account and continue to work toward bringing the delinquent accounts current.
View Audit 340847 Questioned Costs: $1
Finding 520956 (2021-002)
Significant Deficiency 2021
a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding The Corporation will file the December 31, 2021 financial statements as soon as possible and will ensure the annual financial report...
a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding The Corporation will file the December 31, 2021 financial statements as soon as possible and will ensure the annual financial report is filed within 30 days after the date of the auditor’s report and within 9 months of fiscal year end.
Finding 520955 (2021-001)
Significant Deficiency 2021
a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding The Corporation will file the December 31, 2021 financial statements as soon as possible and will ensure the annual financial report...
a. Comments on the Finding and Each Recommendation Management concurs with the finding and agrees with the recommendation. b. Action(s) Taken or Planned on the Finding The Corporation will file the December 31, 2021 financial statements as soon as possible and will ensure the annual financial report is filed within 90 days in future periods or within 9 months of fiscal year end if an owner certified submission was furnished to HUD.
Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task wi...
Finding 2021-003-Reporting, Non-compliance (Material Weakness) Going forward, the hospital will work with an outside consultant with more in-depth understanding of the reporting requirements prior to additional submissions. We are also catching up on the audit submissions and will remain on task with timely submission. Anticipated completion date: 01/31/25.
Finding Reference: 2021-002 Compliance with Reporting to Housing and Urban Development Description: The financial information submission was not submitted timely. Recommendation: The Town should follow federal guidelines by submitting the audited financial statement to HUD through the REAC submi...
Finding Reference: 2021-002 Compliance with Reporting to Housing and Urban Development Description: The financial information submission was not submitted timely. Recommendation: The Town should follow federal guidelines by submitting the audited financial statement to HUD through the REAC submission in a timely manner. Corrective Action: The Town of Guilderland Comptroller’s Office suffered significant turnover in key positions during the fiscal years of 2019 and 2021 including the retirement of the Town Comptroller and Fiscal Officer. In addition, the COVID-19 pandemic had significant impact to the Town, particularly during 2020 when remote work was encouraged. This combination and sequence of events made it impossible to meet the required external audit reporting deadlines. Since these events, the Town has filed the vacant positions and has scheduled all remaining audits. The auditors are working as expeditiously as possible to complete the remaining audits. The Town receives an accepted audited REAC submission from HUD each year and has been submitting timely since 2022. Once the audited financial statements are caught up, they will be included in the REAC submission timely. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The remaining audits that are left to become fully in compliance have been tentatively scheduled with the external auditors since 2022. The Town of Guilderland works as efficiently as possible with the auditors to complete these remaining audits.
Finding Reference: 2021-001 Compliance with Reporting Under the Uniform Guidance Description: The data collection forms for the years 2018 through 2023 have not been submitted timely. Recommendation: The Town should follow federal guidelines by submitting the data collection form to the FAC in a...
Finding Reference: 2021-001 Compliance with Reporting Under the Uniform Guidance Description: The data collection forms for the years 2018 through 2023 have not been submitted timely. Recommendation: The Town should follow federal guidelines by submitting the data collection form to the FAC in a timely manner. Corrective Action: The Town of Guilderland Comptroller’s Office suffered significant turnover in key positions during the fiscal years of 2019 and 2021 including the retirement of the Town Comptroller and Fiscal Officer. The Town also implemented a new accounting software during 2018 that caused significant delays in the monthly and year-end reporting. Lastly, the COVID-19 pandemic had significant impact to the Town, particularly during 2020 when remote work was encouraged. This combination and sequence of events made it impossible to meet the required external audit reporting deadlines. Since these events, the Town has filed the vacant positions and has scheduled all remaining audits. The auditors are working as expeditiously as possible to complete the remaining audits. The required reporting noted in the guidelines above cannot be completed until each prior year audit is finished, therefore causing a delay in each fiscal year’s reporting. Person(s) Responsible for Corrective Action: Darci Efaw, Comptroller & Jessica Gulliksen, Fiscal Officer Anticipated Completion Date for Corrective Action: The data collection forms for years 2018 through 2021 have been filed. The remaining audits that are left to become fully in compliance have been tentatively scheduled with the external auditors since 2022. The Town of Guilderland works as efficiently as possible with the auditors to complete these remaining audits. The remaining data collection forms will be filed upon completion of the audits.
2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienc...
2021-005 - Reporting - Material Weakness Recommendation: Management should ensure timely completion of a Uniform Guidance audit, as required. Action Taken: Historically, Uniform Guidance Data Collection Form submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.
2021-004 - Reporting - Material Weakness Recommendation: Financial statements should be timely filed to REAC. Action Taken: Historically, REAC submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. ...
2021-004 - Reporting - Material Weakness Recommendation: Financial statements should be timely filed to REAC. Action Taken: Historically, REAC submissions were scheduled by the sponsor. In April 2019, the management agent experienced significant staff turnover including the Chief Financial Officer. The Entity's fiscal year fiscal year 2019 closed shortly thereafter. Management Agent Staff were unaware the required fiscal year 2019 and subsequent audit(s) had not been scheduled by the Sponsor; Covid 19 hit shortly thereafter. This issue went unaddressed throughout the pandemic, followed by the resignation of the Management Agent Accounting Manager in 2021, a position that remained vacant for nearly a year. The Management agent engaged with a CPA firm to conduct the 2019, 2020 and 2021 audits.
2021-003 Reporting Federal Program – All federal programs Criteria – The data collection form must be completed and submitted within nine months of the Organization’s fiscal year end. Condition and Context – As a result of a conversion to a new accounting system, the impact of COVID-19, and reco...
2021-003 Reporting Federal Program – All federal programs Criteria – The data collection form must be completed and submitted within nine months of the Organization’s fiscal year end. Condition and Context – As a result of a conversion to a new accounting system, the impact of COVID-19, and reconciliation differences, the data collection form was not timely submitted for the year ended December 31, 2021. Questioned Costs – None. Effect – The Organization was not in compliance with the Uniform Guidance reporting requirements. Cause – With the conversion to a new accounting system, combined with the COVID-19, new accounting staff and reconciliation differences, the data collection form could not be timely completed and submitted. Recommendation – The financial records of the Organization should be reconciled and closed shortly after year-end, which will permit the timely submission of the data collection form. Views of Responsible Officials and Planned Corrective Actions Management agrees with this finding. We will anticipate being able to comply with this requirement effective with the FY2023 audit. Anticipated Completion Date: The financial records for the year ended December 31, 2022, will be reconciled and closed, permitting the audited financial statements, financial reporting package and data collection form to be filed timely by January 31, 2025. The financial records for the year ended December 31, 2023, will be reconciled and closed, permitting the audited financial statements, financial reporting package and data collection form to be filed timely by September 30, 2024. Contact Person: Natalia Arno, President, 916-849-3057
Reference Number: 2021-003 Name of Contact Person: Carlene Moore, CEO Corrective Action: The 22nd DAA has procured new accounting (Activity HD) and human resources (BambooHR) software for proper electronic data retention and safekeeping. Electronic records are now backed up daily by the IT staff....
Reference Number: 2021-003 Name of Contact Person: Carlene Moore, CEO Corrective Action: The 22nd DAA has procured new accounting (Activity HD) and human resources (BambooHR) software for proper electronic data retention and safekeeping. Electronic records are now backed up daily by the IT staff. Proposed Completion Date: December 31, 2022
View Audit 337708 Questioned Costs: $1
Reference Number: 2021-002 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired adequate and knowledgeable staff to review documents and since has regularly retained proper consultant for advice. Proposed Completion Date: ...
Reference Number: 2021-002 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired adequate and knowledgeable staff to review documents and since has regularly retained proper consultant for advice. Proposed Completion Date: December 31, 2022
Reference Number: 2021-001 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired and trained a combined 5 full-time employees to fill the needs in human resources and accounting departments. In the future, the 22nd DAA will ...
Reference Number: 2021-001 Name of Contact Person: Carlene Moore, CEO Corrective Action: As the 22nd DAA returned to financial stability, management hired and trained a combined 5 full-time employees to fill the needs in human resources and accounting departments. In the future, the 22nd DAA will engage subject matter experts when pursuing and obtaining any federal grant programs. Proposed Completion Date: December 31, 2022
Audit Recommendation: The Organization should submit the audit reporting package and data collection form as soon as the audit is available. Planned Corrective Actions: The Organization will submit the current year and subsequent year audit reporting packages and data collection forms as soon as the...
Audit Recommendation: The Organization should submit the audit reporting package and data collection form as soon as the audit is available. Planned Corrective Actions: The Organization will submit the current year and subsequent year audit reporting packages and data collection forms as soon as the audits are complete and available. The Organization is reviewing its procedures to file and submit audits timely beginning in the fiscal year ending June 30, 2024. The Organization accepts the recommendation. Anticipated Completion Date: March 31, 2025 Contact Person: Helen Gates, Accounting
Confluence Health has made significant changes to its internal controls to ensure federal funds are accounted for properly in the Schedule of Expenditures of Federal Awards. Confluence Health developed a Grants Committee that approves all Federal and State Grants. This Committee reviews all grant ap...
Confluence Health has made significant changes to its internal controls to ensure federal funds are accounted for properly in the Schedule of Expenditures of Federal Awards. Confluence Health developed a Grants Committee that approves all Federal and State Grants. This Committee reviews all grant applications and after approval, contacts finance and executive leaders of the approved grants by the committee. In addition to the control implemented above, Confluence Health meets internally monthly with all parts of the organization that receive cash payments from grant programs and incur federal expenditures to confirm if federal grant funds have or have not been received and spent. Our Revenue Cycle department that received the funds related to this program has provided education to their team, and leadership is aware of the risk and importance of reporting federal funding of grants and monitoring compliance. The COVID-19 HRSA Uninsured Program has been reported appropriately on Confluence Health’s restated 2021 Schedule of Expenditures of Federal Awards. This process has been put in place and continues monthly during our month-end close meetings to ensure federal grant funds are being reported correctly. The Vice President of Finance, Eric Caldwell, will be the individual responsible for the corrective action plan.
FINDING 2021-007 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Other Matters The County did not have an effective internal control system to ensure compliance with the Reporting compliance requirement. Recipients were...
FINDING 2021-007 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Summary of Finding: Material Weakness, Other Matters The County did not have an effective internal control system to ensure compliance with the Reporting compliance requirement. Recipients were required to submit a one-time Interim report to the U.S. Department of the Treasury (Treasury). The County submitted the required interim report during the audit period. The County's process for the completion and submission of the Interim Report was that the County Auditor prepared the Interim Report based on the County's records, without a proper oversight or review process in place prior to submission. The Interim Report was determined to be materially misstated. The County understated the December 31, 2019, Base Year Revenues by $660,302. Contact Person Responsible for Corrective Action: Timothy Stabosz Contact Phone Number and Email Address: 219-326-6808 x2226 tstabosz@laporteco.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: To correct this finding, we will require one person to complete the report and another to review the report prior to submission. The preparer and reviewer will sign/initial to document the review process. Anticipated Completion Date: We will begin requirement a review prior to submission as of November 21, 2024.
Recommendation: We recommend the organization work closely with the audit firm to ensure that the single audit reporting package is issued by the deadline or within a federally approved extended date along with submitting the required data collection form with the Federal Audit Clearinghouse. Respo...
Recommendation: We recommend the organization work closely with the audit firm to ensure that the single audit reporting package is issued by the deadline or within a federally approved extended date along with submitting the required data collection form with the Federal Audit Clearinghouse. Response: The delinquent single audit reporting package and data collection form will be filed in December 2024. Going forward, we will work with the external audit firm to ensure that their required grant testing is completed, and the single audit reports included with the single audit reporting package, as well as the required data collection form is submitted to the Federal Audit Clearinghouse within the required or extended due date each year.
Recommendation: We recommend that the organization provide proper training in compiling and preparing the Schedule of Expenditures of Federal Awards which includes identifying the correct ALN’s and pass-through contract numbers, and identifying those contracts that are state funded. Response: SAS ...
Recommendation: We recommend that the organization provide proper training in compiling and preparing the Schedule of Expenditures of Federal Awards which includes identifying the correct ALN’s and pass-through contract numbers, and identifying those contracts that are state funded. Response: SAS AR specialists will be properly trained in compiling and preparing the SEFA, including the correct identification of all signed contracts.
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