Corrective Action Plans

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National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, r...
National Park Service Conservation, Protection, outreach, and Education – Assistance Listing No. 15.954 Recommendation: We recommend management review its current processes and procedures to ensure reports are submitted timely, reviewed, and ensure evidence is retained to support the compilation, review, and submission of the reports and ensure compliance with UG. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As of the fall of fiscal year 2023, all Federal Reporting has been brought up to date. TAS now tracks all reporting due dates and requirements in a spreadsheet that is managed by our Program point person in conjunction with the finance staff to ensure both Project Performance Reports and Financial Reports are submitted by the federal due dates. Name(s) of the contact person(s) responsible for corrective action: Kim Lopez, Director of Finance & Operations, Erin Zylstra, Quantitative Ecologist Planned completion date for corrective action plan: COMPLETED
Finding # 2021-005 Report Submission Corrective Action Plan: The new director and staff know that SEMAP reports are due annually. They also know that the report is the responsibility of the director to complete the SEMAP filing. The director who was in place during the 2019-2020-2021 should have fi...
Finding # 2021-005 Report Submission Corrective Action Plan: The new director and staff know that SEMAP reports are due annually. They also know that the report is the responsibility of the director to complete the SEMAP filing. The director who was in place during the 2019-2020-2021 should have filed the SEMAP report.
Corrective Action The University Financial Aid Office will implement processes to review Pell response files more closely to identify rejects more timely and increasing the frequency of Pell reconciliations. Anticipated Completion Date: October 31, 2021 (once this came to our attention) Contact P...
Corrective Action The University Financial Aid Office will implement processes to review Pell response files more closely to identify rejects more timely and increasing the frequency of Pell reconciliations. Anticipated Completion Date: October 31, 2021 (once this came to our attention) Contact Person: Tony Lubbers, Financial Aid Director
Finding 2021-003 Cash Management Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We ag...
Finding 2021-003 Cash Management Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We agree with the auditor's comments and actions stated in the recommendation. CMSDC will update its policies and procedures to include procedures for reconciling expenditures to cash drawdowns monthly. Contact Person: Jose Robles Michelena, Executive Vice President Anticipated Completion Date: In efforts to improve and prevent the above finding CMSDC engaged a new accounting firm as of September of 2021 and they also brought in new leadership in April of 2022.
Finding 2021-002, 2020-01 Noncompliance with Uniform Guidance's Report Submission Requirements - Repeating Finding Federal Agency: U.S. Department of Commerce Pr...
Finding 2021-002, 2020-01 Noncompliance with Uniform Guidance's Report Submission Requirements - Repeating Finding Federal Agency: U.S. Department of Commerce Program Name: MBDA Business Center Assistance Listing #: 11.805 Questioned Costs: None Corrective Action: We agree with the auditor's comments and actions stated in the recommendation. Management will complete the financial close and reporting process three months after the end of the fiscal year. Contact Person: Jose Robles Michelena, Executive Vice President Anticipated Completion Date: In effort to improve and prevent the above finding CMSDC engaged a new accounting firm as of September of 2021 and they also brought in new leadership in April of 2022.
Management agrees with the finding that federal funds related to program 93.354 of $2.3 million were incorrectly excluded from the FY 2021 SEFA and believes this omission is immaterial (less than 1% of the total FY 2021 SEFA) and therefore does not significantly impact our FY 2021 financial statemen...
Management agrees with the finding that federal funds related to program 93.354 of $2.3 million were incorrectly excluded from the FY 2021 SEFA and believes this omission is immaterial (less than 1% of the total FY 2021 SEFA) and therefore does not significantly impact our FY 2021 financial statements or funding activity. As CHOP is committed to full compliance with reporting requirements for all external agencies, our organization determined that even though not material to the federal funding received during FY2021, correcting, and refiling the FY 2021 SEFA is the appropriate action to take. We acknowledge that this contract was unique and executed during an unsettled time due to the Coronavirus pandemic. CHOP has since enhanced internal controls with respect to our award intake, review and set up processes to ensure full and complete external reporting including but not limited to the SEFA. Enhancements to the process, include detailed intake checklists, increased staff training and awareness regarding review of all contracts to evaluate full and complete data elements are provided. In addition, CHOP performs routine data audits on the set ups of awards and will ensure a more detailed review of guidance for reporting requirements occurs in the future, and inquiries sent when the guidance is unclear. James Avington, AVP – Finance at CHOP, will have responsibility for this corrective action plan.
Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensiv...
Federal Award Finding: 2021-008 Material Weakness in Internal Control over Compliance and Nompliance - Reporting Requirements. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with exte...
Federal Award Finding: 2021-007 Material Weakness in Internal Control over Compliance and Noncompliance - Eligibility Requirement. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm {Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP {Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's...
Financial Statement and Federal Award Finding: 2021-005 Material Weakness in Internal Control over Financial Reporting and Compliance and Noncompliance -Allowable Costs/Cost Principles. Name and Contact Person: Pete Kelly, Chief Executive Officer. Corrective Action: The Fairbanks Rescue Mission's Board of Directors created a Finance Committee with extensive banking and accounting experience to create a higher level of scrutiny and oversite of the Missions finances. We contracted a professional accounting/bookkeeping firm (Midnight Sun Bookkeeping Services) and empowered them to establish procedures and practices consistent with GAAP (Generally Accepted Accounting Principles) as well as track and participate in day to day activities of Accounting; thereby, assuring accuracy of financial data and assuring compliance. We have formalized check writing, money handling, and credit card control procedures. Switched to an online time tracking system for employees and digitized all employee documents. Created an online filing system for all grant expenses Proposed Completion Date: January 01, 2024
View Audit 302911 Questioned Costs: $1
Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that ...
Significant Deficiency in Internal Control over Compliance, Noncompliance – Reporting Name of Contact Person: Anita Andrews, Tribal Administrator Corrective Action Plan: As we continue to recover from the many set-backs over the past few years related to COVID-19 we will strive to ensure that our future audits are completed in time to file the form SF-SAC within the required nine months of our fiscal year end (9/30). Our corrective action plan includes: - Closing the fiscal year books within 90 days after our fiscal year end (excluding any required adjusting journal entries that may be necessary). - Scheduling our audit to occur within 100 days after our fiscal year end. - Obtaining a final audit report prior to the end of June following our fiscal year end. Proposed Completion Date: We are anticipating that the completion date of the above corrective action plan will be for Fiscal Year 2023.
Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. ...
Contact Person: Timothy Evans Managements Response: The issue involved not keeping manual purchase order requests that contained original approvals for a period of greater than two years. At the time of the audit the original manual purchase requisition requests had not been saved or scanned. When we recognized this deficiency, we immediately changed our processes so that all original requests for purchase orders that have the authorizing signatures are saved for a period of 5 years. Completion Date: January 2024.
Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed o...
Contact Person: Timothy Evans Managements Response: Management had claimed pharmacy costs for drugs that were reimbursed by insurance plans. We incorrectly made an assumption that all drug related expenditures for treating the coronavirus virus were allowable expenditures. We have changed our processes for inclusion of only expenditures that have not been reimbursed. Similarly we included costs of COVID testing expenditures however, some of those costs were either billed to patients or reimbursed from other sources. We have corrected that process also. Completion Date: January 2024.
View Audit 302889 Questioned Costs: $1
Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...
Finding 2021-004- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the CRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024
View Audit 302859 Questioned Costs: $1
Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligibl...
Finding 2021-003- Material Weakness and Material Noncompliance over Allowable Cost and Reporting Contact Person: Andrew Wenning Managements Response: During a review of expenses related to the COVID pandemic, the audit identified payroll and non-payroll expenses that management first thought eligible but on further review, (and subsequent to the submission to the portal) determined were unallowable per the Provider Relief Fund grant and Coronavirus Relief Fund grant terms and conditions. Management has put into place a policy for an individual in the accounting department to review all COVID expenses on a monthly basis going forward. In addition, management will further investigate the total likely questioned cost in order to determine the complete known questioned cost in the period 1 payroll and non-payroll expenditure population by June 30, 2024. For payroll expenses, the policy includes that a review and approval of the expenditures will be performed by an individual in accounting to ensure that the hours and wages calculated meet the terms and conditions of the PRF. If any non-eligible payroll expenses are identified during the review process, they will be removed. For all other expenses, we will obtain and retain approved copies of all invoices or other documentation to support expenses and review for eligibility. If any non-eligible expenses are identified during the review process, they will be removed. Completion Date: April 5, 2024
View Audit 302859 Questioned Costs: $1
Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlyi...
Finding 2021-002- Material Weakness and Material Noncompliance over Reporting Contact Person: Andrew Wenning Managements Response: We have determined that certain expenses reported through the Department of Health and Human Services PRF reporting portal for period 1 did not reconcile to the underlying expense details by nature and/or function, and therefore did not comply with PRF reporting requirements. We have implemented a monitoring control over PRF reporting to ensure that expenses submitted through the PRF portal are properly classified by nature and/or function, and that such amounts reconcile to the underlying details and accounting records. Completion Date: April 5, 2024
Finding 392368 (2021-003)
Significant Deficiency 2021
The Hospital selected option ii for reporting budgeted versus actual revenue for the computation of lost revenues for 2020 and the first two quarters in 2021. The Hospital’s budget through June 2020 was approved by March 27, 2020 but the budget for July 2020 to June 2021 was approved subsequent to ...
The Hospital selected option ii for reporting budgeted versus actual revenue for the computation of lost revenues for 2020 and the first two quarters in 2021. The Hospital’s budget through June 2020 was approved by March 27, 2020 but the budget for July 2020 to June 2021 was approved subsequent to March 27, 2020. Accordingly, the Hospital should have selected option iii, a reasonable alternative methodology, when reporting lost revenue. Management will review procedures to ensure that lost revenues are reported under method iii on future PRF report submissions.
Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare p...
Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The Hospital did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The Hospital will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources.
View Audit 302715 Questioned Costs: $1
Finding 392366 (2021-001)
Significant Deficiency 2021
The Hospital’s calculation of lost revenues for the Period 1 submission did not exclude the actual patient care revenues associated with a new non-COVID related service. The new non-COVID related service was not included in the baseline period and therefore the revenue associated with the new non-C...
The Hospital’s calculation of lost revenues for the Period 1 submission did not exclude the actual patient care revenues associated with a new non-COVID related service. The new non-COVID related service was not included in the baseline period and therefore the revenue associated with the new non-COVID related service should have been excluded from the comparison period. The Hospital will correct the lost revenue calculations to exclude new non-COVID related patient care revenues in both the baseline and comparison periods in all subsequent PRF reporting.
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 20...
2021–006 Allowable Costs Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00233 – 20 Award Period: January 1, 2021 through December 31, 2021 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: Documentation supporting allowable costs was not maintained by the Family Practice. Questioned costs: Unknown Context: During our testing of expenditures we noted two instances where payroll expenditures charged to the grant were not supported the by the employee’s approved wage rate. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to support wage calculations are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of the Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type...
2021–005 Period of Performance Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H8ECS37958 Award Period: May 1, 2020 through May 31, 2021 Type of Finding: • Material Weakness in Internal Control over Compliance • Other Matters (Modified Opinion) Criteria or specific requirement: According to § 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity’s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to § 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: CLA was unable to verify if the Family Practice is in compliance with period of performance. Questioned costs: Unknown Context: During our review expenditures for period of performance we noted expenditures were not supported by adequate records and documentation to facilitate testing. Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records required to identify expenses and the date incurred are properly maintained in the files of the Family Practice. Cause: Management oversight. The Family Practice lacked established internal controls and procedures over financial grant management to ensure supporting records and documentation are properly maintained in the files of the Family Practice. Effect: Inability to support compliance with the grant and a potential loss of federal funding. Recommendation: We recommend the Family Practice design controls and procedures to ensure documentation is properly maintained in the files of Family Practice. Views of responsible officials: There is no disagreement with the audit finding.
2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is ...
2021-004 Significant Deficiency - Cash Management Activities Recommendation: We recommend the Family Practice design controls and procedures to ensure the documentation and records are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure documentation and records are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls.. Furthermore, a controller has been hired to prepare the reports and oversee cash management activities. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: March 11, 2024
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Pract...
2021-003 Material Weakness - Allowable and Unallowable Activities and Allowable Costs Recommendation: We recommend the Family Practice design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Family Practice designed controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of the Family Practice. The CEO and CFO roles have been separated into two distinct positions. Separating the roles has significantly strengthened internal controls. Furthermore, a controller has been hired to prepare the reports and maintain appropriate and complete supporting documentation, which will then be reviewed by the CFO and CEO before submission. Name(s) of the contact person(s) responsible for corrective action: Amanda Blodgett, CEO Planned completion date for corrective action plan: December 31, 2024
Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.
Management will continue to allow the audit firm to create the draft financial statements and related footnote disclosures, and will review and approve these prior to the issuance of the annual financial statements.
We contacted our auditors upon receipt of the notice of rejection. The audit engagement was then revised to include the additional components needed under the Uniform Guidance for nonfederal entities, and the audit results will be reported as required to the Federal Audit Clearinghouse. No further a...
We contacted our auditors upon receipt of the notice of rejection. The audit engagement was then revised to include the additional components needed under the Uniform Guidance for nonfederal entities, and the audit results will be reported as required to the Federal Audit Clearinghouse. No further action should be needed.
CSG will ensure appropriate staff have adequate time to prepare for the audit and work with the audit firm to make sure the reporting package is submitted by the due dates on a go-forward basis.
CSG will ensure appropriate staff have adequate time to prepare for the audit and work with the audit firm to make sure the reporting package is submitted by the due dates on a go-forward basis.
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