Corrective Action Plans

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Audit Finding: 2023-002 Eligibility Corrective Action Plan: Policy & Procedure modified to align more with IHS requirements and to make access for minors less burdensome. Persons Responsible: Tara Nolen, Director of Population Health Estimated Completion Date: August 31,2024
Audit Finding: 2023-002 Eligibility Corrective Action Plan: Policy & Procedure modified to align more with IHS requirements and to make access for minors less burdensome. Persons Responsible: Tara Nolen, Director of Population Health Estimated Completion Date: August 31,2024
Finding 403480 (2023-012)
Significant Deficiency 2023
EARMARKING – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County implements a policy requiring a review of the administrative expenditures as reported on the quarterly DWP reports. Explanation of disagreement with audit finding: There is no disagreement with ...
EARMARKING – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County implements a policy requiring a review of the administrative expenditures as reported on the quarterly DWP reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement a review policy to ensure they are following compliance requirements for administrative expenditure reporting. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2024
Finding 403476 (2023-009)
Significant Deficiency 2023
EARMARKING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County reviews their policies and federal requirements to ensure all costs are reported under the correct category. Explanation of disagreement with audit finding: There is no disagreem...
EARMARKING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County reviews their policies and federal requirements to ensure all costs are reported under the correct category. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will review their policies and federal requirements related to earmarking to ensure compliance requirements are met. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024
Finding 403475 (2023-008)
Significant Deficiency 2023
REPORTING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County review their policies and federal requirements to ensure all costs incurred are reported timely. Explanation of disagreement with audit finding: The finding was due to reporting s...
REPORTING – COVID-19 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS Recommendation: It is recommended that the County review their policies and federal requirements to ensure all costs incurred are reported timely. Explanation of disagreement with audit finding: The finding was due to reporting system issues which caused the County’s inability to report this project expenditure in the 4th quarter of 2023. Action taken in response to finding: The County will implement policies to ensure that all costs incurred are reported timely. Name of the contact person responsible for corrective action plan: Nancy Malecha, Finance Director Planned completion date for corrective action plan: December 31, 2024
Finding 403469 (2023-011)
Significant Deficiency 2023
SPECIAL PROVISIONS – STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: It is recommended that income documentation be reviewed for each eligible case file to ensure the information matches MAXIS. Explanation of disagreement with audit f...
SPECIAL PROVISIONS – STATE ADMINISTRATIVE MATCHING GRANTS FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP CLUSTER) Recommendation: It is recommended that income documentation be reviewed for each eligible case file to ensure the information matches MAXIS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will continue to work on training new staff on requirements. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2024
Findings and Questioned Costs Relating to Federal Awards: Late Single Audit Submission, Reporting Management submitted Single Audit reports up to fiscal year 2023. To address the root cause for this finding, management performed the following actions: • Management audit contracts are followed up dir...
Findings and Questioned Costs Relating to Federal Awards: Late Single Audit Submission, Reporting Management submitted Single Audit reports up to fiscal year 2023. To address the root cause for this finding, management performed the following actions: • Management audit contracts are followed up directly by CFO to ensure timely execution to ensure audits are timely completed and planned. • Management enhancements to the finance function, such as accounting closing checklists, accounting closing meetings and reconciliation processes, among other actions, should improve the timing of audit results. Additional resources (consultants) were hired to assist in the audit process to ensure external auditors have information on a timely basis. In order to ascertain that basic and recurrent information requested by auditors is ready, management prepared an updated list of information normally requested and prepared a OneDrive (cloud backup storage) where all information will be archived and ready to be delivered to the auditors as requested. This should provide the efficiency and agility to response to auditors in a timely manner. Management successfully completed late Single Audit submissions with this 2023 Single Audit Report. With this filing, DDEC is up to date in its regulatory reports. Furthermore, with the process enhancements and improved controls implemented, DDEC expects to continue filing on or before filing due dates.
Federal Agency Review *Significant Deficiency in Internal Controls over Compliance; Noncompliance Federal Program - CFDA 10.555 – National School Lunch Program ASDOE School Lunch Program (SLP) continues to work with the representative who oversees civil rights for the USDA Western region. SLP co...
Federal Agency Review *Significant Deficiency in Internal Controls over Compliance; Noncompliance Federal Program - CFDA 10.555 – National School Lunch Program ASDOE School Lunch Program (SLP) continues to work with the representative who oversees civil rights for the USDA Western region. SLP continues to have training to correct the issues in their USDA FNS report. POC  SLP Assistant Director Christina Fualaau
Special Tests and Provisions * Significant Deficiencies in Internal Controls over Compliance; Non-Compliance Federal Program - CFDA 20.205 - Highway Planning & Construction The Department of Public Works (DPW) awaits approval of its Implementation and Stewardship agreement from Federal Highway. ...
Special Tests and Provisions * Significant Deficiencies in Internal Controls over Compliance; Non-Compliance Federal Program - CFDA 20.205 - Highway Planning & Construction The Department of Public Works (DPW) awaits approval of its Implementation and Stewardship agreement from Federal Highway. The finding will remain open until the agreement is approved. POC  DPW Deputy Director Laupule Tilei  Civil Engineer Uaealesi Doris Faumuina-Sipelii
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified that the method used for reporting lost revenue was inaccurate. Method 2 wa...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing # FCDA 93.498 Finding Summary: Eide Bailly LLP identified that the method used for reporting lost revenue was inaccurate. Method 2 was reported, when it should’ve been method 3. Responsible Individuals: Dara Bartels, CEO Corrective Action Plan: Mile Bluff Medical Center has not had a lot of experience with a single audit prior to COVID grant funds. This year we experienced turnover in our CFO role, leaving the process to be re-created. We pulled together most of the information that was required but needed assistance/guidance from our auditors on how to pull the information together and report them on the required forms. We will continue to learn the layout and review the Schedule of Expenditures of Federal Awards prior to sending or addressing this with the Auditors. Anticipated Completion Date: Ongoing
FINDING NO. 2023-001: NON-COMPLIANCE WITH SPECIAL TESTS AND PROVISIONS RELATED TO TRI-PARTITE BOARD COMPLIANCE AND SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER NONCOMPLIANCE WITH THE RELEVANT SPCIAL TESTS AND PROVISIONS Planned Corrective Action Plan: Key members of the Organization’s management ...
FINDING NO. 2023-001: NON-COMPLIANCE WITH SPECIAL TESTS AND PROVISIONS RELATED TO TRI-PARTITE BOARD COMPLIANCE AND SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER NONCOMPLIANCE WITH THE RELEVANT SPCIAL TESTS AND PROVISIONS Planned Corrective Action Plan: Key members of the Organization’s management will work with the Board of Directors to develop a plan for board recruitment, developing, and training to fill the vacant public sector seat and strengthen monitoring of compliance with the CSBG Act, Texas Administrative Code, and corporate bylaws. The results of the monitoring efforts will be reported to the Governance & Operations Committee and/or the Board of Directors at least on an annual basis. Anticipated Implementation Date: December 31, 2024 Contact Person Responsible for Corrective Action: Dr. Jonita Reynolds, Chief Executive Officer
Finding 403169 (2023-002)
Significant Deficiency 2023
Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audi...
Timestudy Testing Medical Assistance Program – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2024
The Authority will implement and execute strengthened controls over tenant file documentation maintenance processes and procedures. Erial Branch, Executive Director, has assumed the responsibility of executing strengthened controls over tenant file documentation maintenance as of September 1, 2024.
The Authority will implement and execute strengthened controls over tenant file documentation maintenance processes and procedures. Erial Branch, Executive Director, has assumed the responsibility of executing strengthened controls over tenant file documentation maintenance as of September 1, 2024.
Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Contact Person: Christina Ogle, Federal & State Programs Director Anticipated Completion Date: May 30, 2025 Planned Corrective Action: A Use of Funds by Category reporting documen...
Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Number: 84.425D, 84.425U Contact Person: Christina Ogle, Federal & State Programs Director Anticipated Completion Date: May 30, 2025 Planned Corrective Action: A Use of Funds by Category reporting document has been developed to support Part 1 of the LEA Uses of ESSER funds reporting requirements. Additionally, maintaining an ESSER Reporting documentation spreadsheet. The ESSER reporting spreadsheet includes PO#’s and JE’s with expenditures that are in alignment with the ESSER Use of Funds reporting. These documents and spreadsheets are compiled by utilizing: - Transaction Detail Reports – Visions - Purchase Order Pay History Report – Visions - Payroll Distribution Reports – Visions - ESSER Budget – Grants Management Enterprise These documents/spreadsheets are also shared with the Federal & State Programs Coordinator and will be uploaded into GME related documents for continuity regardless of staffing changes.
Management acknowledges the recommendations associated with this finding and will ensure that—going forward—all reconciliations will be completed timely.
Management acknowledges the recommendations associated with this finding and will ensure that—going forward—all reconciliations will be completed timely.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Our plan to correct issues associated with GLBA compliance by sections are stated as below: For 16 CFR § 314.4(c)(l-8) (partially implemented) We plan to implement and correct all deficiencies related to the multi-factor authentic...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Our plan to correct issues associated with GLBA compliance by sections are stated as below: For 16 CFR § 314.4(c)(l-8) (partially implemented) We plan to implement and correct all deficiencies related to the multi-factor authentication on our VPN, by implementing a new software and hardware solution that will sufficiently address the lack of MFA on that side. One of our other software products used for Financial Aid administration will require either a replacement, or compensating control/exception placed into our policies and risk management policies. Modify our asset risk assessment policy to include steps to annually review access to all financial applications to determine whether the user is still required to access the systems. For 16 CFR § 314.4(f)(3) (partially implemented) We plan to change our risk management policy to do regular (at least annually) checks on all of our vendors supplying information on whether they comply with GLBA in their security, disaster recovery and incident response controls to keep our data confidential, keep its integrity and require its availability. For 16 CFR § 314.4(i) (not implemented) Adjust our information security policy to include reporting to our board of directors annually with a written report about the Program and its compliance with GLBA. Person Responsible for Corrective Action Plan: Matthew Hager, Director of IT. Anticipated Date of Completion: 7/31/2024
Mid-East Regional Housing Authority Corrective Action Plan for the year ended September 30, 2023 Section II - Financial Statement Findings - None Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Lynn Alligood Executive Director Corrective Action: ...
Mid-East Regional Housing Authority Corrective Action Plan for the year ended September 30, 2023 Section II - Financial Statement Findings - None Section III - Federal Award Findings and Questioned Costs Finding 2023-001 Name of Contact Person: Lynn Alligood Executive Director Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately
Finding 2023-002 – Significant Deficiency in Internal Controls over Reports Submitted to Grantors – Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on grant reporting ensuring that proper...
Finding 2023-002 – Significant Deficiency in Internal Controls over Reports Submitted to Grantors – Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on grant reporting ensuring that proper evidence is maintained of the control over compliance with financial reporting requirements. Corrective Action: Management will ensure that reviews of documents submitted to grantors will be reviewed and documented such that evidence of such reviews will be retained. Person Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date for Corrective Action: The Corrective Action will be immediately implemented in response to the auditor’s recommendation. If there are questions regarding this corrective action plan, please call Marcy Towns, Chief Financial Officer, at (615) 259-9622.
Finding 2023-001 – Significant Deficiency in Internal Controls over Allowable Costs (Payroll) – COVID-19 ARPA Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on employee time sheets and p...
Finding 2023-001 – Significant Deficiency in Internal Controls over Allowable Costs (Payroll) – COVID-19 ARPA Child Care and Development Block Grant – 93.575 Recommendation: YMCA management should strengthen its controls related to the review and approval of information on employee time sheets and pay rates including proper evidence is maintained of the control over compliance with allowable cost requirements, related to payroll. Corrective Action: The referenced significant deficiency was due to several factors including, but not limited to system migration from one third party payroll provider to another. For any future system migrations, the evidence of the review and approval of employee time sheets and pay rates will be retained. Person Responsible for Corrective Action: Chief Financial Officer Anticipated Completion Date for Corrective Action: The third party payroll provider has transitioned to one more well suited to the needs of the YMCA and management has begun efforts to ensure that the approval of payroll, as captured within the system at the time of processing payroll, will also be retained for future reference, should it be needed. The remaining aspects of the Corrective Action will be immediately implemented in response to the auditor's recommendation.
Corrective Action Plan and Views of Responsible Officials The Corporation will ensure that all monthly deposits to the replacement reserve are made in a timely manner.
Corrective Action Plan and Views of Responsible Officials The Corporation will ensure that all monthly deposits to the replacement reserve are made in a timely manner.
Finding 2023-001 - Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance andSignificant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fisca l year-...
Finding 2023-001 - Housing Choice Voucher Tenant Files - Eligibility - Internal Control over Tenant Files - Noncompliance andSignificant Deficiency Corrective Action Plan: The Housing Authority of the City of Greenville (HACG) has implemented and/or will implement the following by our fisca l year-end September 30, 2024: a. Hous ing Choice Voucher tenant files will be reviewed and quality controlled each mo nth prior to initiali za tio n (25t 11- 30 111 of each month) by the Deputy Executive Director/COO. b. An action pla n has been develo ped for the Housing Choice Voucher department to ensure that all Housing Choice Voucher files are HUD and GHA compliant starting with October 1, 2023 files through the cun-e nt. c. Hous ing Choice Voucher calendar-year 2024 (October 2023-September 2024) re-exams are substantially complete, as they become effective. All tenant files will be reviewedand HUD-co mpliant by FYE2024. d. During FYE2024, the Deputy Executive Director/COO will perform 40% quality controls of the monthly re-exams processed by the Housing Specialists. e. File checklist sheets will be placed in each file upon quality control review to be signed off by the Deputy Executive Director/COO. f. Additional training has been and will be made available as necessary. g. Other interna l control measures will be implemented as deemed necessary by the Deputy Executive Director/COO, to eliminate future audit findings. Person Responsible: Shanetta Moye, Deputy Executive Director/COO Anticipated Completion Date: September 30, 2024
Finding 2023-022 Pandemic EBT Food Benefits, ALN 10.542 - Lack of Documentation for School Modality Data Reviews Management Views MDHHS disagrees that not formally documenting the review details on the log rises to the level of a material weakness and material noncompliance. MDHHS selects a sampl...
Finding 2023-022 Pandemic EBT Food Benefits, ALN 10.542 - Lack of Documentation for School Modality Data Reviews Management Views MDHHS disagrees that not formally documenting the review details on the log rises to the level of a material weakness and material noncompliance. MDHHS selects a sample of schools that submitted data and verifies the accuracy of Pandemic EBT (P-EBT) school modality data reported, documenting the schools reviewed within a log. Following the written business process, P-EBT staff first identify public information available to verify the school’s modality data such as the school’s calendar or news articles, and then reach out to school administration if public information is not available. If additional steps are required to reconcile the data, P-EBT staff document the support and results, sign off on the reconciliation, and forward to a supervisor for review. For this review period, no discrepancies were identified between what the school reported, and school websites. Since no discrepancies were noted, staff verbally communicated the review results to the manager and the log of sample items reviewed were kept within a shared drive. Planned Corrective Action MDHHS has no corrective action planned at this time as P-EBT benefit issuance ended as of May 11, 2023. No additional benefits will be issued in fiscal year 2024. Anticipated Completion Date Not applicable Responsible Individual(s) Kathy Cornell, MDHHS
Finding 2023-021 SNAP Cluster, ALN 10.551 and 10.561 - EBT Reconciliations Management Views MDHHS disagrees that a material weakness and material noncompliance exist. MDHHS federal reporting conducts a daily reconciliation of federal draws and authorizations to retailers based on vendor EBT reports...
Finding 2023-021 SNAP Cluster, ALN 10.551 and 10.561 - EBT Reconciliations Management Views MDHHS disagrees that a material weakness and material noncompliance exist. MDHHS federal reporting conducts a daily reconciliation of federal draws and authorizations to retailers based on vendor EBT reports. In addition, MDHHS conducts a monthly reconciliation between Bridges, Bridges data warehouse, and vendor EBT reports using daily data to ensure the client information in Bridges and Bridges data warehouse is accurate. The monthly reconciliation process does not impact the federal draw because the daily reconciliation of the vendor EBT report is used for this purpose. MDHHS provided detailed and accurate descriptions of MDHHS daily and monthly EBT reconciliations to the designated federal awarding agency contacts at the United States Department of Agriculture Food and Nutrition Service Agency that are familiar with MDHHS processes and received confirmation that the current reconciliation processes in place are sufficient to comply with federal regulations. Planned Corrective Action MDHHS disagrees with the finding and does not intend to take further action. Anticipated Completion Date Not applicable Responsible Individual(s) Sara Gross, MDHHS
Corrective Action Plan: The Executive Director will advise the CPA of all purchases that exceed the capitalization threshold when they occur. Copies of the check(s) and invoice(s) will be scanned into the month they are paid (into the Laserfiche electronic storage system). The CPA will review the pa...
Corrective Action Plan: The Executive Director will advise the CPA of all purchases that exceed the capitalization threshold when they occur. Copies of the check(s) and invoice(s) will be scanned into the month they are paid (into the Laserfiche electronic storage system). The CPA will review the payments scanned monthly and also scan the disbursements for any that could have been missed. At the end of the fiscal year, the disbursements that meet the capitalization requirements of HAHC and RTS will be entered into the depreciation schedule. Person(s) responsible: Executive Director- Connie Stewart CPA- Barfield and Kinkead LLC Completion Date: Fiscal year ending September 30, 2024
Management Corrective Action Plan For the Year Ended December 31, 2023 Community Roots Housing US Department of Homeland Security auditee identification number: PMDC-PJ-10-WA-2018-010 Audit Firm: Clark Nuber PS Audit Period: Year ended December 31, 2023 Finding 2023-001 – Significant deficiency in i...
Management Corrective Action Plan For the Year Ended December 31, 2023 Community Roots Housing US Department of Homeland Security auditee identification number: PMDC-PJ-10-WA-2018-010 Audit Firm: Clark Nuber PS Audit Period: Year ended December 31, 2023 Finding 2023-001 – Significant deficiency in internal controls over compliance related to special tests and provisions. Requirement: Per the requirements contained in 24 CFR Part 982, property owners must perform housing quality inspections at the time of initial occupancy and at least annually thereafter to ensure that the units are decent, safe, and sanitary. Finding: Out of 12 units selected for testing, 2 units did not have documentation supporting that a housing quality standards inspection was completed during 2023. Recommendation: CRH should implement the necessary internal controls to ensure annual inspections are performed and documented. Comments Community Roots Housing agrees with this finding and recommendation. Corrective Action Plan Community Roots Housing maintains detailed listings of annual inspection work orders, including unit numbers and when they were finished. This listing is prepared by the maintenance department. An additional control will be added to include secondary review and oversight by the Director of Property Management. This review will occur quarterly, starting in the with the second quarter of 2024, to ensure that all inspections are completed before the end of 2024, and annually thereafter. The Director of Maintenance and the Director of Property Management will be responsible for ensuring these tasks are carried out. Corrective Action Plan prepared by: Leslie Woodworth, Chief Financial Officer, 206-895-2030
2023-003 Finding - Federal Award - Significant Deficiency - Reporting US Department ofCommerceAL#11.611 Context and Cause - The Organization was not made aware by grants, CMTC or prior auditors that the final upload package of the federal reports and requests for reimbursement should have internal c...
2023-003 Finding - Federal Award - Significant Deficiency - Reporting US Department ofCommerceAL#11.611 Context and Cause - The Organization was not made aware by grants, CMTC or prior auditors that the final upload package of the federal reports and requests for reimbursement should have internal control oversight procedures and did not exercise such oversight. Only one individual was responsible for preparing and filing these final documents after such details were reviewed individually throughout the month by other individuals responsible for that review. The payroll time sheet review process was consistently followed, however, and there is not a process for the final processed payroll rep01ts to be reviewed by a second individual.Recommendation: We recommend management implement procedures to ensure the Uniform Grant Guidance and the Compliance Supplement requirements for controls over Reporting, Allowable Costs, and Cash Management are designed and performed. The month­ end checklist currently being used is a good start, and this could be enhanced by adding sections for the above items, and having specific individuals' initial and date on the checklist when the procedures are completed. A fiscal policy and procedure manual would also be a good tool. Action Taken: Manex will update fiscal Policy to include oversight on reporting to funders
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