Corrective Action Plans

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U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to sup...
U.S. Department of Health and Human Services 2021-003 Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend that the Organization design, implement and monitor internal controls over reporting as well as maintain source documentation to support amounts reported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will maintain evidence of timely submission of reports, review of reports and documentation to support amounts reported. Additionally, management will implement a formal documentation retention policy. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 3/1/2024
We agree that we have not been reporting on a timely basis current findings and results. We have established a calendar to ensure that the submission of all required annual reporting, be strictly followed by our newly created job position (Federal Funding Accounting Coordinator). The plan will be ap...
We agree that we have not been reporting on a timely basis current findings and results. We have established a calendar to ensure that the submission of all required annual reporting, be strictly followed by our newly created job position (Federal Funding Accounting Coordinator). The plan will be approved by the Board and implemented no later than April 26th, 2024.
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.
View Audit 304032 Questioned Costs: $1
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund dis...
Given the complexity of the reporting requirements, including changing FAQ's, reporting deadline extensions, and the inability to update reporting to reflect expenses incurred within the guidelines such as lost revenue the Authority will apply such expenses as offsets to its provider relief fund distributions. The Authority will continue to monitor the Health and Human Resources Provider Relief Fund General and Targeted Distribution Post-Payment Notice of Reporting Requirements and the most recently distributed Provide Relief Fund frequently asked questions which provide details on requirements related to the program.
View Audit 304032 Questioned Costs: $1
U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority was not able to provide signed and dated copies of HUD-52663 and HUD-52681 reports submitte...
U.S. Department of Housing and Urban Development – CFDA #14.182/14.856 Section 8 Project-based Cluster– 2021 Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: The Authority was not able to provide signed and dated copies of HUD-52663 and HUD-52681 reports submitted in 2021. In addition, the Authority did not submit timely revised reports after they had received notification from certain landlords who were opting out of the Mod Rehab program in 2021. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: Due to staff turnover at the Executive level and in the Accounting Department, these forms were misplaced and we were not able to reproduce them. We have established procedures to ensure that all forms filed with HUD will be filed timely and saved electronically so that this should not happen again. Anticipated Completion Date: January 2023
Management Response: This finding has been corrected, management concur that in the past, we have been late in filing both our form 990 with the IRS and our Audit report with the Federal Audit Clearinghouse (FAC). For filing our 990 taxes return our tax year ends September 30, and with the submissio...
Management Response: This finding has been corrected, management concur that in the past, we have been late in filing both our form 990 with the IRS and our Audit report with the Federal Audit Clearinghouse (FAC). For filing our 990 taxes return our tax year ends September 30, and with the submission of this Audit we are current. Management has put in place procedures and processes to ensure that the return is filed in a timely manner. Gateway’s Board is regularly updated regarding the Audits and the 990 this is an effective business practice monthly documented meeting with the Board of Directors. Gateway Board of Directors are involved with the engagement of all Auditors, this has always been an active procedure and remains ongoing.
The required financial reports and forms for Fred Bell Way were not submitted to the RD due to numerous changes in personnel in the Finance Department and issues related to the accounting system conversion in March 2021. We anticipate that the FY21, FY22 and FY23 audits will all be completed in May...
The required financial reports and forms for Fred Bell Way were not submitted to the RD due to numerous changes in personnel in the Finance Department and issues related to the accounting system conversion in March 2021. We anticipate that the FY21, FY22 and FY23 audits will all be completed in May 2024 putting us in the position to provide the RD with all delinquent reports. Anticipated Completion Date October 15, 2024.Responsible Contact Person-Kathleen Boyce, CFAO
In collaboration with the audit team, we will correct the procedures used to develop the Schedule of Expenditures of Federal Awards to ensure that it is completed correctly and accurately .Anticipated Completion Date April 30,2024.Responsible Contact Person-Kathleen Boyce, CFAO
In collaboration with the audit team, we will correct the procedures used to develop the Schedule of Expenditures of Federal Awards to ensure that it is completed correctly and accurately .Anticipated Completion Date April 30,2024.Responsible Contact Person-Kathleen Boyce, CFAO
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
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