Corrective Action Plans

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1. In process of getting caught up on prior year audits will result in timely submission of data collection form going forward.
1. In process of getting caught up on prior year audits will result in timely submission of data collection form going forward.
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
1. Processes related to the program stating roles of each individual involved in the process were documented and implemented in September 2022. 2. Regular risk assessment and monitoring functions are performed by management and grant awarders.
2021-002 Summary of Finding (optional) Late submission of required financial, programmatic, and performance reports: All of the grants under these programs require that financial, programmatic, and performance reports be submitted on a monthly, quarterly basis and/or annual basis. Monthly and quarte...
2021-002 Summary of Finding (optional) Late submission of required financial, programmatic, and performance reports: All of the grants under these programs require that financial, programmatic, and performance reports be submitted on a monthly, quarterly basis and/or annual basis. Monthly and quarterly financial and performance reports are due within thirty calendar days from the end of each quarter. Annual financial and performance reports are due within 90 calendar days from the end of each grant year. During our testing, we noted nine reports that were submitted after the deadline. We consider this to be an instance of noncompliance and a material weakness in internal control over compliance for the reporting requirement. Statement of Concurrence or Nonconcurrence The Maryland Network Against Domestic Violence concurs with this finding. Corrective Action MNADV continued to experience significant transitions during FY21. FY21 was the first full fiscal year for the new Executive Director and a new finance manager was hired at the beginning of FY21. These senior leadership transitions were marked by a learning curve for both the Executive Director and Finance Manager who had to learn the reporting processes and online systems for each of the different grants which included federal, state and private reporting systems. Also of note was a lack of completed audits for FY19 and FY20, which meant that substantial work had to be completed to ensure that what was reported for each grant was indeed accurate. All of these factors contributed to reports being late and none of these factors are still at play. The current Executive Director and Finance Manager are now familiar with all reporting systems. All login and secondary authentication methods have been properly set up and are functioning as desired. Internal processes for collecting grant data and reporting out this data have been established.
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not hav...
Tracking of Eligible Expenditures and Lost Revenues Finding 2021‐006 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: The Authority did not have internal controls established over the federal award to ensure the federal award has been managed in compliance with federal states, regulations and conditions of the federal award. Corrective Action Plan: The Authority’s management company is reviewing compliance with all laws and regulations and ensuring conditions are met. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: August 2022
Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐005 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: Eide Bailly LLP pre...
Preparation of Schedule of Expenditures of Federal Awards Finding 2021‐005 Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.498 Program Name: COVDI‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Finding Summary: Eide Bailly LLP prepared the schedule of expenditures of federal awards (schedule) and accompanying notes to the schedule. Corrective Action Plan: Due to cost considerations, we will continue to have our auditor prepare our schedule and accompanying notes to the schedule. Responsible Individual: Priacilla Leatherman, VP of Finance Anticipated Completion Date: Ongoing.
Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thorough...
Condition: HealthSource's controls in place for reporting submissions did not identify that guidelines were not followed related to expense reporting and the lost revenue calculations. Planned Corrective Action: All future submissions will be reviewed with CEO and President for accuracy and thoroughness prior to submission upload. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place ov...
Condition: HealthSource does not have a review process in place related to the Covid expense spreadsheet used to input expenses into the required reporting submissions to the U.S. Department of Health and Human Services for the Provider Relief Fund program and not having a review process in place over the forementioned required submissions. Planned Corrective Action: A review of all updates to Covid revenue and expenses will be performed with the CEO and President as indicated by new activity, and before any submissions are uploaded. Contact person responsible for corrective action: Sonja Martinez, Chief Financial Officer Anticipated Completion Date: 12/31/2024
2021-005 – Reporting Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will immediately complete the annual narrative reports for all fiscal years through September 30, 2023. • CBNHC will immediately complete the SF-425 financial reports for all fiscal years through ...
2021-005 – Reporting Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will immediately complete the annual narrative reports for all fiscal years through September 30, 2023. • CBNHC will immediately complete the SF-425 financial reports for all fiscal years through September 30, 2023, and thereafter, every quarter through the current fiscal year. • CBNHC will actively communicate its status with the IHS Area Office regarding its progress towards the required deliverables. • CBNHC will implement an executive leadership team who are collectively responsible for assuring regulatory compliance for the entity, which will be achieved through the timely sharing of important information. • CBNHC’s Board of Directors will serve as governance over these requirements. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring that the annual narrative reports are submitted to IHS according to the AFA. In addition, the CEO will initiate monthly progress meetings with IHS. • Interim Finance Director (Volelle Zamora) – Is responsible for ensuring that the SF-425 financial reports are submitted to IHS according to the AFA. • Chief Executive Officer (Derrick Watchman), Chief Medical Officer (Sheryl O’Shea MD), Chief Operations Officer (Volelle Zamora), Executive Administrative Assistant (Ophelia Mace), and Human Resource Director (Christina Chavez) – Will serve as the CBNHC executive leadership team and are collectively responsible for assuring that the required reporting and other compliance are achieved. • Board of Directors (Kimberly Bruce, Harrison Platero, Lester Secatero) – Are responsible for CBNHC’s governance and will monitor required completion of reporting. Completion Date: The annual narrative reports for fiscal years 2021, 2022, and 2023 were completed as of December 31, 2023. The SF-425 reports will be completed and submitted to IHS by March 31, 2024. CBNHC is conducting monthly progress meetings with IHS regarding its requirements for financial reporting. CBNHC has implemented an executive leadership team, and they meet regularly, to share information and establish timelines for the completion and submission of its required reporting.
2021-004 – Late Audit Report Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will continue in its recruiting and will hire the various accounting positions as defined in the corrective action plan for finding 2021-001. • CBNHC will implement the corrective actions...
2021-004 – Late Audit Report Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will continue in its recruiting and will hire the various accounting positions as defined in the corrective action plan for finding 2021-001. • CBNHC will implement the corrective actions described in the corrective action plan for finding 2021-001 to assure compliance with its regulatory requirement for completing its timely audits. • In the event that the CBNHC experiences changes in its staffing levels again, it will actively seek interim support through an accounting consultant in order to maintain its accounting records. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring the scope of work as defined in CBNHC’s Annual Funding Agreement (AFA) with the Indian Health Service (IHS) is administered accordingly. • Human Resource Director (Christina Chavez) – Will participate by actively recruiting for CBNHC’s vacant positions within the hiring requirements defined by the Navajo Nation. • Interim Finance Director (Volelle Zamora) – Is responsible for ensuring the timely completion of the CBNHC’s annual financial audits in accordance with the requirements defined by the Single Audit Act (2 CFR Part 200.512). Completion Date: June 30, 2024. CBNHC will be back on track with additional accounting support and expects to have its audit reports completed on time for fiscal year 2023.
Management Response and Corrective Action Plan City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: Current City Finance staff in conjunction with Police Department staff are monitoring ESAC ...
Management Response and Corrective Action Plan City’s Response: The City concurs with the finding. Staff responsible for this control during FY 2021 are no longer employed by the City. Corrective Action Plan: Current City Finance staff in conjunction with Police Department staff are monitoring ESAC reporting processes. Planned Implementation Date: started in Q4 FY 2023 and has continued into FY 2024 Responsible Person: Finance Department staff
Finding 384265 (2021-006)
Significant Deficiency 2021
Finding Reference Number: SA 2021-006 Timely Reporting and Return of Unspent Grant Advance AL Number: 21.019 Assistance Listing Title: COVID-19 – Coronavirus Relief Fund Federal Agency: Department of Treasury Pass Through Entity: Yolo County, California Department of Finance Federal Award Ide...
Finding Reference Number: SA 2021-006 Timely Reporting and Return of Unspent Grant Advance AL Number: 21.019 Assistance Listing Title: COVID-19 – Coronavirus Relief Fund Federal Agency: Department of Treasury Pass Through Entity: Yolo County, California Department of Finance Federal Award Identification Number: Unavailable (Yolo County) and 607 (California Department of Finance) • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Kelly Stachowicz, Assistant City Manager • Corrective Action Plan: City notified Yolo County of unspent funds in January 2021. City returned unspent funds to Yolo County in January ($222) and March ($27,617) of 2021, with reporting submitted to County in March of 2021. For future short-notice and unexpected grants provided to the City, the City will designate a lead staff person with bandwidth to manage said grant and clarify timelines with the granting agency. • Anticipated Completion Date: Completed in March 2021.
Finding 384254 (2021-004)
Material Weakness 2021
Finding Reference Number: SA 2021-004 Federal Funding Accountability and Transparency Act (FFATA) Reporting AL Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Federal Agency: Department of Housing and Urban Development Federal Aw...
Finding Reference Number: SA 2021-004 Federal Funding Accountability and Transparency Act (FFATA) Reporting AL Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: The City has an existing FFATA Procedure. All relevant staff (those working with federal funds) will receive training on the procedure to ensure familiarity with it and understanding of the requirements to complete FFATA reporting. The City filed the missing report in March 2024. • Anticipated Completion Date: March 10, 2024
Finding 384252 (2021-002)
Material Weakness 2021
Finding reference number: SA 2021-002 Accurate Financial Reporting in the Annual PR26 Report Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Name of Federal Agency: Department of Housing and Urban Development Federa...
Finding reference number: SA 2021-002 Accurate Financial Reporting in the Annual PR26 Report Assistance Listing Number: 14.218 Assistance Listing Title: COVID-19 - Community Development Block Grants/Entitlement Grants (CDBG) Name of Federal Agency: Department of Housing and Urban Development Federal Award Identification Number: B-14-MC-06-0037, B-18-MC-06-0037, B-19-MC-06-0037, B-20-MC-06-0037, B-20-MW-06-0037 • Fiscal Year of Initial Finding: 2021 • Name(s) of the contact person: Jennifer Block, Management Analyst • Corrective Action Plan: Since FY 2021, the City has reviewed its organizational structure and processes for management of the CDBG grant program. At the end of FY 2023, the City brought the program back in-house to the newly-created Department of Social Services and Housing (SSH). In FY 2024, staff developed a process to ensure timely and consistent draws, with reconciliation to the general ledger at the point of each draw. SSH staff have developed a timeline of required actions for the program to ensure compliance with deadlines. • Anticipated Completion Date: June 30, 2024
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported ...
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Under a revised calculation, utilizing detailed listings of expenses and updated lost revenue calculations, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
Management continues to evaluate the current controls related to reporting to ensure amounts are appropriately stated. Though the decrease was significant, we have adequate expenses and lost revenues to support funding reported for Periods 1 and 2.
2021-008 – Submission to Federal Audit Clearinghouse; Beginning March 2024, the Agency will establish and implement internal controls over financial reporting sufficient to ensure Single Audits are completed and submitted in a timely manner. The Board of Directors will request a review of Financial ...
2021-008 – Submission to Federal Audit Clearinghouse; Beginning March 2024, the Agency will establish and implement internal controls over financial reporting sufficient to ensure Single Audits are completed and submitted in a timely manner. The Board of Directors will request a review of Financial Audits annually. This will ensure Single Audits are completed and submitted in a timely manner. The Chief Executive Officer [CEO, Executive Director], Marianne Gribbon will meet with the Controller (Jarri Melton) weekly to ensure timely financial reporting. Reports will be provided to the board of Directors monthly. The Agency plans to adhere to the following timeline: •June 2024: completion of 21-22 (2022) audit •December 2024: completion of 22-23 (2023) audit •March 2025: completion of 23-24 (2024) audit •December 2025: completion of 24-25 (2025) audit Additionally, the Board of Directors will meet with the auditors during the December Board of Directors meeting to review the findings of the previous year’s audit (i.e., in December 2025, the auditors will review the 2024-2025 audit.) This will be a standing meeting between the Board of Directors and the auditors. Considering the significant delay in reporting, the Board of Directors will review the audit within one month of finalizing the audit. The timeline for outstanding audits is as follows: •21-22 (2022) audit will be reviewed no later than July 2024 •22-23 (2023) audit will be reviewed no later than January 2025 •23-24 (2024) audit will be reviewed no later than April 2025 •24-25 (2025) audit will be reviewed no later than January 2026 The Board is aware of the significant reporting delay. The CAP, presented here, will be shared with the Board during March 2024 to ensure compliance and timely reporting.
2021-007 Financial and Performance Reporting; Beginning March 2024, the Agency will conduct a review of timely submission of reporting is performed as part of the audit procedures. The Agency will implement a procedure that includes establishing reoccurring due dates on the Agency’s Microsoft 365 Ou...
2021-007 Financial and Performance Reporting; Beginning March 2024, the Agency will conduct a review of timely submission of reporting is performed as part of the audit procedures. The Agency will implement a procedure that includes establishing reoccurring due dates on the Agency’s Microsoft 365 Outlook Calendar with the following positions included on the calendar invite: •Chief Program Officer – Mackenzie Anson, •Program Director – Catherine Cruz, •Controller – Jarri Melton, and Chief Executive Officer – Marianne Gribbon. This will ensure the required reports are completed and submitted by the required due dates. The Controller (Jarri Melton) will develop monthly and quarterly closing procedures to aid in the timely closing and filing of reports required by CFDA No. 93.676. Furthermore, the Board of Directors Executive Committee will be notified of all upcoming audits at the beginning of each fiscal year. The Board will be kept informed of the audit process and the CEO, Marianne Gribbon, will provide monthly updates during Executive Committee meetings.
Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate sche...
Finding 2021-009 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards being audited. Responsible Individuals: Scott Callender Corrective Action Plan : Due to the small accounting staff there was little internal review of the schedule of federal expenditures resulting in errors. The Hospital will adopt a policy where the schedule of expenditures will be reviewed by a qualified individual. Anticipated Completion Date: Ongoing
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with under...
Finding 2021-008 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy to ensure reported amounts agreed with underlying supporting documentation. In addition the underlying supporting documentation contained errors. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to a ensure the report agrees with the under lying supporting documentation. Anticipated Completion Date: Ongoing
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Authority develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. Explanation of disagreement with audit finding: There is no disag...
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Authority develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Financial Reporting (Material Weakness) Recommendation: The Authority must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Authority. This information must...
Financial Reporting (Material Weakness) Recommendation: The Authority must implement processes and controls to ensure accurate interim and year-end financial statements. Adequate and accurate financial information is vital to make management decisions that impact the Authority. This information must be shared timely and discussed to make the necessary changes that are needed and to prepare the proper cash flow projections. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines; Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Commission develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. EQ\JALHOUSIIIG OPPORTUNITY Explanation of disagreement ...
Data Collection Form and Financial Data Schedule (Non Compliance) Recommendation: We recommended that the Commission develop procedures to ensure that future reporting packages and FDS reports are submitted by the respective deadlines. EQ\JALHOUSIIIG OPPORTUNITY Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will review and enhance our policies and procedures over year end close, to ensure all adjustments are made timely to allow for timely audit facilitation to ensure we are meeting the DCF and FDS deadlines. Name(s) of the contact person(s) responsible for corrective action: Don Bibb, Executive Director Planned completion date for corrective action plan: December 31, 2023
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