Corrective Action Plans

Finding 480518 (2021-002)

Material Weakness 2021

Virginia Commonwealth University Health System

VA

Internal Control / Segregation of Duties Procurement, Suspension & Debarment Cash Management

Corrective action plan over control environment over completeness and accuracy of expenditures COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019) Recommendation: The Authority’s develop and implement effective internal controls to ensure that expenditures are reviewed for completenes...

Corrective action plan over control environment over completeness and accuracy of expenditures COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019) Recommendation: The Authority’s develop and implement effective internal controls to ensure that expenditures are reviewed for completeness and accuracy to ensure that the terms and conditions are met. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: This program has ended. Management will enhance its procedures around the completeness and accuracy of expenditure schedules for similar future grant expenditures. Evidence of review and approval of supporting documentation of the expenditures related to report submissions will be 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 316713

Finding 480517 (2021-001)

Material Weakness 2021

Virginia Commonwealth University Health System

VA

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking

Timely Preparation of Schedule of Expenditures of Federal Awards (SEFA) COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019); COVID – 19 – Provider Relief Fund (Assistance Listing #93.498) Recommendation: The Authority’s policy and procedure should be designed to ensure timely reportin...

Timely Preparation of Schedule of Expenditures of Federal Awards (SEFA) COVID – 19 – Coronavirus Relief Fund (Assistance Listing # 21.019); COVID – 19 – Provider Relief Fund (Assistance Listing #93.498) Recommendation: The Authority’s policy and procedure should be designed to ensure timely reporting as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will enhance its procedures around the preparation of the SEFA to include a timely year-end reconciliation between the general ledger and all source documentation to ensure that all Federal expenditures are complete and accurately reported in the SEFA in fiscal 2024. 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: For the creation of the Schedule for FY2023.

View Audit 316713

Finding 479746 (2021-004)

Material Weakness 2021

Cambria Heights School District

PA

School Nutrition Programs Internal Control / Segregation of Duties Reporting

CONDITION: The District did not maintain a general ledger system of accounting for its Cafeteria Fund which reports the financial activity of the federal National School Lunch and School Breakfast Programs. The financial activity occurring in this Fund is maintained in checkbook fashion during the f...

CONDITION: The District did not maintain a general ledger system of accounting for its Cafeteria Fund which reports the financial activity of the federal National School Lunch and School Breakfast Programs. The financial activity occurring in this Fund is maintained in checkbook fashion during the fiscal year. This is a repeat finding (2020-004) from the previous fiscal year. CRITERIA: Prudent internal control over accounting for federal program funds requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the receipt and use of federal funds as stated in Section 2 CFR Part 200 of the Uniform Guidance. Best practices suggest that the use of a general ledger system of accounting would enable the District to aggregate financial information involving federal funds during the fiscal year in such a manner to properly manage, monitor, and report the financial activity in compliance with federal program guidelines. RECOMMENDATION: During the 2018-2019 fiscal year, the District implemented new accounting software that can readily account for the financial activity of all Funds in a manner like the District’s General Fund. I am recommending that the management of the School District utilize the new accounting software to enter the financial activity (Receipts and Disbursements) of the Cafeteria Fund in a manner like the General Fund. This procedure will significantly enhance the District-wide internal controls over financial reporting for the Cafeteria Fund, as well as provide management the ability to produce meaningful financial reports reflecting the activity in the Cafeteria Fund for prudent oversight by the Board of Education. In addition, this procedure will enable the District to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200 of the Uniform Guidance. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is reviewing its current system of processing the transactions for the Cafeteria Fund to determine the most efficient and effective manner for implementation of a general ledger system of accounting for this Fund as opposed to its current manual process. It is anticipated that the conversion of this Fund into the District’s accounting software can be completed during the 2024-2025 fiscal year to enable the District to comply with the recordkeeping requirements for federal funds as specified in 2 CFR Part 200 of the Uniform Guidance.

View Audit 316302

Finding 479728 (2021-005)

Material Weakness 2021

Cambria Heights School District

PA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.302

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office o...

CONDITION: The District did not properly record its federal program expenditures for the GEER, ESSER, and ARP ESSER federal grant programs using the various federal funding source expenditure codes as prescribed by the Chart of Accounts for PA Local Educational Agencies maintained by the PA Office of the Budget, Office of Comptroller Operations. CRITERIA: The Pennsylvania Department of Education (PDE), through the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts requires School Districts to utilize specific funding source codes for federal program expenditures. In addition, Section 2 CFR 200.302(a) and 302(b) of the Uniform Guidance requires non-federal organizations such as the School District to maintain financial records which account for federal funds in such a manner as to be able to properly track the identification and use of federal funds. RECOMMENDATION: I am recommending that the School District properly follow the guidance contained within the PA Office of the Budget, Office of Comptroller Operations Chart of Accounts for recording all expenditures of the School District, most specifically, federal program grant expenditures to 1) enhance internal controls for tracking and monitoring federal program expenditures and 2) comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations. MANAGEMENT’S CORRECTIVE ACTION PLAN: District management is in the process of revising its chart of accounts in the general ledger to properly reflect the funding source codes for federal program expenditures, and other available funding source codes (state and local) as applicable to the District. It is anticipated that the updated chart of accounts will be utilized by the District starting with the 2024-2025 fiscal year to enable the District to enhance its internal controls for tracking and monitoring federal program expenditures and to comply with the recordkeeping requirements for federal funds as specified in Section 2 CFR Part 200.302(a) and 302(b) of the Uniform Guidance and PDE regulations.

View Audit 316302

Finding 479702 (2021-002)

Material Weakness 2021

City of Pekin

IL

Reporting Cash Management

The Director of Finance, along with staff will prepare and review grant policy and procedures. The Finance Department will review all grant agreements on a timely basis and perform monthly reconciliations of grant revenues and expenses. The Finance Department will further utilize features and functi...

The Director of Finance, along with staff will prepare and review grant policy and procedures. The Finance Department will review all grant agreements on a timely basis and perform monthly reconciliations of grant revenues and expenses. The Finance Department will further utilize features and functions available within its accounting system that allows tracking of expenditures and revenues by projects by utilizing task codes in our Project Management module. The Finance Department will collaborate with Departments by utilizing grant report forms to be completed periodically.

View Audit 316258

Finding 479433 (2021-002)

Material Weakness 2021

Unity Medical Center INC

TN

Reporting Allowable Costs / Cost Principles Material Weakness § 200.303 § 200.507

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal awar...

2 CFR Part 200.303(a) states that the auditee must establish and maintain effective internal control over the federal award that provides reasonable assurance that the auditee is managing the federal award in compliance with federal statutes, regulations, and terms and conditions of the federal award. Section 200.507 of the Uniform Guidance states that the program-specific audit shall be completed, and reporting required submitted within the earlier of 30 calendar days after receipt of the auditors’ report, or nine months after the end of the audit, unless a longer period is specified in a program-specific audit guide. During 2023, we have strengthened internal controls related to review of the quarterly lost revenue calculations and reporting in the PRF reporting portal. Going forward, we will complete our audits and submit the required reports by the deadlines. We have taken appropriate steps to identify all other assistance received by quarter during the period of availability on the PRF report going forward.

View Audit 315964

Finding 479201 (2021-005)

Significant Deficiency 2021

Mental Health Association of Columbia-Greene Counties Inc.

NY

Reporting

All SEFA grants will be tracked thoroughly in FundEZ and annotated with their own cost center code to allow tracking them to be easier. The Director of Finance, Ethan Terrio, will reconcile these awards and expenses once a month to ensure that the numbers tie out in the general ledger. Should there ...

All SEFA grants will be tracked thoroughly in FundEZ and annotated with their own cost center code to allow tracking them to be easier. The Director of Finance, Ethan Terrio, will reconcile these awards and expenses once a month to ensure that the numbers tie out in the general ledger. Should there be any issues, he will contact the respective Division Director, either Susan Cody or Roxane Carpenter, to determine the cause of the variance, and how to correct the entry to be accurate.

View Audit 315733

Finding 478559 (2021-007)

Material Weakness 2021

City of Adelanto

CA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking

Corrective action has been immediately implemented in response to the auditors' recommendation. As financial reporting is still in process of getting to current, the City anticipates findings to be reduced in future fiscal years.

View Audit 315185

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

1. Review and Revise Budget Development and Fiscal Monitoring Policies and Procedures August 2024 Fiscal Staff/Management Team Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and U...

1. Review and Revise Budget Development and Fiscal Monitoring Policies and Procedures August 2024 Fiscal Staff/Management Team Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

2. Board of Director and Policy Council approval of revised Policies and Procedures September 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Gu...

2. Board of Director and Policy Council approval of revised Policies and Procedures September 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

3. Training Staff on Revised Policies and Procedures September 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2)...

3. Training Staff on Revised Policies and Procedures September 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

4. Implement revise Policies and Procedures October 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial ...

4. Implement revise Policies and Procedures October 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

5. Monitor Implementation of the policies and procedures November 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures and MIP Financial Reports Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guid...

5. Monitor Implementation of the policies and procedures November 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures and MIP Financial Reports Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

6. Provide copies of the reports to the Executive Director, Board and Policy council November 2024 Executive Director Monitoring summary report and MIP Financial Reports Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 7...

6. Provide copies of the reports to the Executive Director, Board and Policy council November 2024 Executive Director Monitoring summary report and MIP Financial Reports Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

7. If necessary, conduct additional revision to the policies and procedures. November 2024 Executive Director & Management Team Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and ...

7. If necessary, conduct additional revision to the policies and procedures. November 2024 Executive Director & Management Team Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

8. Conduct follow-up monitoring to ensure fully implementation. December 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75...

8. Conduct follow-up monitoring to ensure fully implementation. December 2024 Executive Director Revise Budget Development and Fiscal Monitoring Policies and Procedures Head Start Performance Standards 45 CFR Part 1302.101 (a)(3) Management system (Implementation) and Uniform Guidance 45 CFR Part 75.302(b)(2) Financial Report and 75.341 Reporting Requirements

View Audit 315155

Finding 478527 (2021-005)

Material Weakness 2021

Child Development Council of Franklin County

OH

Reporting

9. Complete Summary Schedule January 2025 Executive Director Summary Schedule Uniform Guidance 45 CFR Part 75.511 Audit findings follow-up

View Audit 315155

Finding 478310 (2021-007)

Significant Deficiency 2021

City of Compton

CA

Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller drafted a grants policy which is currently under review by the City Manager, that includes succession planning in case of staff turnover and parameter...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller drafted a grants policy which is currently under review by the City Manager, that includes succession planning in case of staff turnover and parameters for grant reporting compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Grants Manager

View Audit 314981

Finding 478306 (2021-002)

Material Weakness 2021

City of Compton

CA

HUD Housing Programs Material Weakness Reporting

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in pl...

Management Response and Corrective Action Plan City's Response: The City concurs with the recommendation. Corrective Action Plan: The City Controller's Office drafted a grants policy that is currently under review by City Management. Community development staff will ensure a succession plan is in place for any staff turnover and for report preparation compliance. Planned Implementation Date: December 31, 2024 Responsible Person(s): City Manager, Community Development Director, and City Controller

View Audit 314981

Finding 478182 (2021-001)

Material Weakness 2021

La'i'opua 2020

HI

Reporting Internal Control / Segregation of Duties

In response to the negative finding of the 2019, 2020 and 2021 audits, immediate actions have been taken by L2020 to address the issues and prevent reoccurrence in the future. The individuals who were previously responsible for financial reporting and cash management during the audit are no longer e...

In response to the negative finding of the 2019, 2020 and 2021 audits, immediate actions have been taken by L2020 to address the issues and prevent reoccurrence in the future. The individuals who were previously responsible for financial reporting and cash management during the audit are no longer employed at L2020. Going forward, Rebecca “Kawehi” Inaba, appointed as the Executive Director in late 2021, will take charge of ensuring that L2020 remains compliant with all financial requirements, including conducting audits in a timely manner. The organization expresses confidence in her ability to keep L2020 up to date with all financial obligations. In an effort to enhance control and oversight, L2020 will be instituting a quality control review process for all forthcoming report submissions. This measure aims to identify any discrepancies or delays in submissions, enabling corrective actions to be taken promptly. L2020 remains dedicated to upholding transparency and accountability in their financial practices. These proactive steps are crucial in enhancing processes and performance. The organization appreciates understanding and support as they strive for improved financial management practices at L2020.

View Audit 314855

Finding 406473 (2021-002)

Significant Deficiency 2021

Leech Lake Tribal College

AZ

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.328

The College will ensure that all grant reports are reviewed in detail and information reported will be traced to the source reports by the reviewer. The College also implemented policies and procedures to ensure all grant reports are submitted prior to the due date.

View Audit 311635

Finding 406469 (2021-001)

Material Weakness 2021

Leech Lake Tribal College

AZ

Material Weakness Reporting Internal Control / Segregation of Duties § 200.512

Management has implemented policies and procedures to ensure the timely submission of single audit reporting package.

View Audit 311635

Finding 406447 (2021-006)

Significant Deficiency 2021

City of Jersey City

NJ

Internal Control / Segregation of Duties Cash Management HUD Housing Programs

Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely wi...

Corrective Action: The Chief Financial Officer will oversee efforts to close out the old accounts in a timely manner and make sure all systems are reconciled. Internal controls have been set into place to ensure future compliance. The Municipal Comptroller will train and continue to work closely with personnel in charge of reporting and processing IDIS and vouchers drawdowns. The Division of Accounts & Control will continue to maintain a sub-ledger to ensure IDIS and the City’s financial system tie out prior to the processing of any payments, and each payment request will require an IDIS activity reference number in order to be processed. Monthly reconciliation of funds has been implemented and copies are sent to US HUD on a monthly basis. In addition, the City has hired a 3rd party grant consultant to help navigate and strengthen our overall processes. Implementation Date: Ongoing

View Audit 311633

Finding 406040 (2021-003)

Significant Deficiency 2021

Hospital Damas INC

PR

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.512

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial sta...

Finding No. 2021-003 – Reporting - Late filing of data collection form and reporting package Corrective Action Plan Commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be the designated officer in charge of concluding all necessary procedures, including the audit of financial statements and single audit, for the Hospital to file its reporting package within it´s due date, as required by the CFR. Also, Mr. Julio Colón, Chief Financial Officer, will be the designated officer in charge of supervising and monitoring compliance with timely submittance each year. Name (s) of the Contact Person (s) Responsible for Corrective Action Mr. Julio Colón, Chief Financial Officer Anticipated Completion Date December 2024

View Audit 311582

Finding 406039 (2021-002)

Significant Deficiency 2021

Hospital Damas INC

PR

Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief ...

Finding No. 2021-002 - Reporting Corrective Action Plan On July 29, 2022, all pending reports were submitted to AAFAF. Also, commencing immediately, Mr. José R. Rodríguez, Accounting Manager, will be de designated officer in charge of submitting the report by its due date and Mr. Julio Colón, Chief Financial Officer, will be de designated officer in charge of supervising and monitoring compliance with timely submittance each month. Name (s) of the Contact Person (s) Responsible for Corrective Action Julio Colón, Chief Financial Officer Anticipated Completion Date Completed on July 29, 2022

View Audit 311582

Corrective Action Plans

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