Corrective Action Plans

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To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minn...
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minneapolis, MN 55415 African American Child Wellness Institute submits the following corrective action plan for the year ended December 31, 2023. Please contact Akinyele Akinsanya at 763-522-0100. Finding 2023-001 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Expenses charged to the federal grant cannot be traced into the Organization’s general ledger. Invoices submitted to the pass-through agency for reimbursement also cannot be traced into the general ledger. Actions Planned in Response to the Finding: It is clear to management that the Organization needs to boost its accounting team to fulfil effective reporting that could easily be traced into the organization’s general ledger. As a result, the organization will recruit and hire a full-time accountant to work with the current team. Further steps may be required including replacing the organization’s current accounting software that will identify and record expenditure specific to each cost centers for each federal grant. The in-house accountant will also be required to obtain additional training in Uniform Guidance and federal grant management and create a system of financial reporting to record expenditure directly to each federal grant award. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: March 15, 2025
View Audit 344524 Questioned Costs: $1
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee R...
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Errors in recording and reporting of revenues and expenditures of federal awards may not be detected and/or corrected. Because the Auditee’s SEFA that was presented for audit was completed incorrectly, and not reconciled to the general ledger, the SEFA was materially misstated, prior to auditors’ correction recommendations. Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • Inadequate reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: November 1, 2024 Responsible Person: District Business Manager
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.
Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management ...
Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management company is aware of the prevailing wage and certified payroll requirement and will make sure any future projects adhere to these requirements.
Finding 524581 (2023-001)
Significant Deficiency 2023
Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 3...
Management’s Corrective Action Plan: Due to changes in departmental management and responsibilities submission was not timely. We have now implemented policies and procedures to ensure grant activity is reported in accordance with the grant requirements. This matter was resolved subsequent to June 30, 2023.
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to as...
Condition: Controls did not identify that expenses submitted to the State were outside of the period of performance. Planned Corrective Action: Background: Sinai began the process of risk assessment in the government grants area at the end of 2022. At that time, Sinai engaged outside counsel to assist in this process. In December of 2023, Sinai created the Office of Government Grant Administration (OGGA) and developed a comprehensive grant compliance policy and procedure. The Audit and Compliance Committee of the Board was updated on this initiative. In 2024, the OGGA created a Grant Compliance Manual which sets forth processes and procedures in grant management to ensure compliance with government regulations. Unfortunately, these controls were not implemented until after the relevant time period at issue in this audit. In 2025, Sinai is continuing to improve its compliance procedures with respect to government grants, and has developed the following plan: 1. Working Group: Sinai will implement a process of convening a Working Group for each government grant, which will consist of a representative from Finance, the OGGA, and the stakeholder involved (i.e., nursing, medicine, etc.) The Working group will be responsible for, among other things, ensuring that that the reported qualifying expenditures are incurred during the period of performance of the grant. In other words, allowable costs will be discussed early in the process, so that there is fulsome understanding among the key individuals involved. 2. Record-Keeping: The OGGA will also establish shared folders to house all of the pertinent documentation relative to the grant. 3. Invoice/Supporting Documentation Review. The Grant Accounting Manager will review all invoices and other supportive documentation to ensure that allowable costs are submitted for reimbursement. This compliance check will be completed prior to submission of the documentation for reimbursement. Monthly reviews of these activities will be performed by the Grant Accountant, the Compliance Grant Manager, and other OGGA staff as needed. Proactive review to prevent or resolve issues in the upcoming month’s billings should be pursued. 4. Annual Assessment. The Chief Compliance Officer, with the assistance of the General Counsel, will meet with the OGGA team annually to assess procedures and risk controls; a report of this assessment will be made to the Audit and Compliance Committee of the Board of Directors Contact person responsible for corrective action: Dimas Ortega - Vice President of Finance, Deputy Chief Financial Officer Anticipated Completion Date: 06/30/2025
View Audit 343640 Questioned Costs: $1
Name of Federal Agency: U.S. Department of the Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program year 2023. Name of Pass-through Entity (if applic...
Name of Federal Agency: U.S. Department of the Treasury Federal Program Name: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Identification number unavailable. Program year 2023. Name of Pass-through Entity (if applicable): The Community Economic Development Assistance Corporation. Recommendation: It is recommended that the Agency establish written procurement policies and procedures to ensure that the Agency is in compliance with the Uniform Guidance and that all staff are trained on this policy to ensure compliance and related internal controls over compliance are operating effectively. Action Taken: Management is in the process of revising internal controls to address procurement, suspension, and debarment requirements. Additionally, management has retroactively performed this requirement to the applicable transactions during the audit period, noting no vendors were suspended or debarred. As the agency has experienced significant growth and increasingly complex reporting requirements, the investment was made early in FY24 to have a department dedicated to agency compliance. FBMS is committed to ensuring compliance with all funder requirements. Anticipated Completion Date: Management estimates that additional processes will be in place by June 30, 2025.
All future federal expenditures will be reconciled to the disbursement ledger.
All future federal expenditures will be reconciled to the disbursement ledger.
To resolve this issue and prevent recurrence, we are taking the following corrective actions: To ensure that all reports are submitted within the required time frame, we will implement a tracking system using calendar reminders that will provide alerts for upcoming deadlines, ensuring no reports are...
To resolve this issue and prevent recurrence, we are taking the following corrective actions: To ensure that all reports are submitted within the required time frame, we will implement a tracking system using calendar reminders that will provide alerts for upcoming deadlines, ensuring no reports are late. We will streamline our internal processes to ensure there is a clear and defined workflow for report preparation and submission. This will include setting internal submission deadlines well in advance of the official due dates to allow for any necessary review or corrections.
Finding 524097 (2023-004)
Material Weakness 2023
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be moni...
Action taken in response to finding: Trilogy will thoroughly review the grant agreements to understand specific start and end dates as well as any allowable cost guidelines. Training will be provided to staff on identifying cut off periods and the reviewing of invoices for expenditures will be monitored closely when entered into the system to ensure it is entered into the system in the correct period in which the expense is incurred. Documentation will be reviewed by the Controller before posting to the general ledger to ensure expenses are charged to the correct grant period. During the grant invoice preparation there will be an additional review of the expenses in the general ledger to ensure the cut-off for grant expenditures are included in the correct period for the monthly grant vouchers. Trilogy will also implement a quarterly review of expenses charged to grants in preparation of the quarterly reports to ensure proper allocation to grants and cut off grant expenditures during the first and last month of the grant budget period. Name(s) of the contact person(s) responsible for corrective action: Richard Powell, Shunita Rhodes, Hagar Buster, Han Qi Planned completion date for corrective action plan: October 31, 2024, and ongoing as needed.
View Audit 343276 Questioned Costs: $1
We understand the importance of proper monitoring of providers and are taking steps to improve our system.
We understand the importance of proper monitoring of providers and are taking steps to improve our system.
Finding 523656 (2023-231)
Significant Deficiency 2023
Finding 23-1: The School’s net cash resources exceeded 3 months average expenditures at the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue,...
Finding 23-1: The School’s net cash resources exceeded 3 months average expenditures at the end of the year. Recommendation: To keep monitoring the net cash resources throughout the year to ensure it doesn’t exceed three months average expenditures. Action Taken: Since being made aware of the issue, the School’s administrator has begun to routinely monitor the net cash resources to ensure it does not exceed three months of average expenditures. As such, the required correction actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of March 13, 2024. Person Responsible for Implementation: Yonoson Sanders, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: (732)901-3913.
We created a file for new vendors and/or transactions greater than $25K done outside of the consortium with saved W9s and subsequent business search for debarment.
We created a file for new vendors and/or transactions greater than $25K done outside of the consortium with saved W9s and subsequent business search for debarment.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
We have reviewed the qualifications for allowable expenses classified as supplies versus capital expenditures that of a 600 code with ODE CCIP representatives for project relate cash requests as well as getting pre-approval if varying from the budget details request.
View Audit 342736 Questioned Costs: $1
Finding 523384 (2023-034)
Significant Deficiency 2023
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Stan...
Finding No.: 2023-034 Refunding of Overpayments Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and has developed a corrective action plan that includes a new Standard Operating Procedure (SOP), 2024-005, for the Intake and Processing of Overpayment Checks. This new SOP addresses a gap in our process for tracking overpayment checks and refunding the Federal Share of Medicaid Overpayments to Providers. Furthermore, we are also in the process of updating SOP 2023-03, which focuses on Public Health Professional (PHPro) Entry for Provider Overpayment Checks and Recoupments, to improve our tracking and monitoring of overpayment checks and recoupment reconciliations. Currently, we are still addressing updates to this SOP and require additional time to work with BHCFA staff(s) to gather more information in finalizing the SOP. We intend to complete this SOP no later than February 28, 2025.
View Audit 342645 Questioned Costs: $1
Finding 523383 (2023-033)
Significant Deficiency 2023
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with t...
Finding No.: 2023-033 Reporting Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency acknowledges this finding and recognizes it as an ongoing issue related to the alignment of our reporting with the Department of Administration (DOA) financial system. One of the primary challenges arises from transactions that are not processed within the designated reporting period, which impacts on our initial submissions to CMS. Any adjustments or transactions made after the quarter's close, which were not captured in our previous reports, contribute to this issue. We understand that addressing this finding is a critical part of our corrective action measures. We are currently working on updating the existing Standard Operating Procedure (SOP) 2023-01, which governs interactions between the Department of Public Health and Social Services (DPHSS) and DOA/Division of Accounts. Since November 2024, we have been collaborating with DOA to revise this SOP with the goal of reconciling Medicaid and CHIP expenditures, as well as aligning reports from CMS-64 with the new Guam Financial Management Information System (GFMIS). Currently, PMS staff is in the process in finalizing the DRAFT SOP. We intend to have the DRAFT SOP completed and forwarded to DOA by Friday, January 31, 2025. If there are no changes to the SOP, we will work to have the SOP signed by all parties no later than February 14, 2025.
Finding 523380 (2023-032)
Significant Deficiency 2023
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau wil...
Finding No.: 2023-032 Health and Safety Requirements Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency has issued notices of noncompliance to those unresponsive. Moving forward, the bureau will hold providers accountable by issuing a Letter of Warning (LOW) and a Correction Action Plan (CAP) from the Social Service Licensing Officer or Child Care Compliance Officer to ensure compliance with the standards. The Agency disagrees with Condition 1. License-exempt childcare providers will not have an annual DEH inspection since they are not required to obtain a sanitary permit.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds...
Finding No.: 2023-031 Subrecipient Monitoring Responding Agency: Department of Public Health and Social Services Responsible Personnel: Theresa Arriola, Director (DPHSS) The Agency disagrees with these findings. As per the Information Memorandum ARP Act Child Care Stabilization Funds under the Qualified and Eligible Child Care Providers, Provider Reporting and Monitoring, the ARP Act does not include specific reporting requirements for childcare providers receiving subgrants and any subgrant reporting requirements are at the discretion of the lead agency, page 21. Additionally, Lead Agencies that use other governmental or non-governmental subrecipients to administer the program must have written agreements in place outlining roles and responsibilities for meeting CCDF requirements. The contents of the written agreement may vary based on the role the subrecipient is asked to assume or the type of product undertaken, but must include, at a minimum, tasks to be performed, a schedule for completing tasks, a budget which itemizes categorical expenditures, and indicators or measures to assess performance. The Lead Agency has fulfilled this requirement in accordance with 45 CFR section 98.1.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due ...
Finding No.: 2023-030 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process. For condition 2, the Agency will report first-tier subawards to the FSRS system. However, it is noteworthy to mention that the system will be expiring as of March 2025.
Finding 523371 (2023-029)
Significant Deficiency 2023
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
Finding No.: 2023-029 Period of Performance Responding Agency: Department of Public Health and Social Services (DPHSS) Responsible Personnel: Theresa Arriola, Director (DPHSS) The agency agrees with the finding and will apply the recommendations moving forward.
View Audit 342645 Questioned Costs: $1
Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any ...
Finding No.: 2023-025 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any subrecipient account a copy of the FATA report be attached, as well as, creating a check list of subrecipient monitoring requirements prior to any payments being made.
Finding No.: 2023-020 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the cr...
Finding No.: 2023-020 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The agency followed the criteria stated in the finding. Improvements to monitoring controls have been implemented. Prior to the creating of any subrecipient account a copy of the FFATA report be attached, as well as, creating a check list of subrecipient monitoring requirements prior to any payments being made.
Finding No.: 2023-019 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) An awardee could not report the required information in FSRS unless the federal awarding agency has registered the award. The US Treasury has no...
Finding No.: 2023-019 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) An awardee could not report the required information in FSRS unless the federal awarding agency has registered the award. The US Treasury has not advised the Government that they have registered the Capital Projects Fund award.
Finding 523360 (2023-018)
Significant Deficiency 2023
Finding No.: 2023-018 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Government continues to disagree with the auditor. The language of CFR 200.331(c) is clear that it is the judgement of the pas...
Finding No.: 2023-018 Subrecipient Monitoring Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Government continues to disagree with the auditor. The language of CFR 200.331(c) is clear that it is the judgement of the pass-through entity that is important. The auditor does not explain the reasoning for reaching a different opinion. Many jurisdictions have engaged third-party administrators for programs without concluding that they become sub-recipients.
Finding 523358 (2023-016)
Significant Deficiency 2023
Finding No.: 2023-016 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Du...
Finding No.: 2023-016 Reporting Responding Agency: Department of Administration (DOA) Responsible Personnel: Edward M. Birn, Director (DOA) The Agency disagrees with the finding of non-compliance as we have complied to submit the reporting in a timely manner to the federal agency. Due to the timing of required reporting, it may not align with reported AS400 expenditures after reporting has been posted. There is no provision in the reporting for adjustments of previously reported values. Moving forward all reporting will be reviewed and approved by the Federal and Compliance Section. Implementation of the Federal Module anticipated to be fully functional by end of FY2025 will automate and improve this process.
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