Corrective Action Plans

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Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establ...
Finding Number: 2023-003 Condition: Related to the WaterSMART grant (ALN 15.507), controls in place were not adequate to ensure expenses were reported in the proper categories on the performance reports. Planned Corrective Action: The City hired a full-time Grants Manager in February 2024 to establish procedures to track grants that are awarded and expended by the City. New procedures will be developed to ensure that financial and performance reports for grants will be reviewed by the Grants Manager prior to submission of the reports to the awarding entities. Documentation of this review will be retained with the grant documents. Contact person responsible for corrective action: Stacey Swanson, Grant & Special Revenue Manager Anticipated Completion Date: December 31, 2024
Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Divi...
Corrective Action Plan: • Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements. Responsible Division/Office and Individual: • NWYS Housing leadership staff – Luis Reyna, Andy Johnson, Rebecca Pendergraft, Addison Ausley • Finance leadership staff – Stephanie Wagner, Dianne Ersser Estimated Completion Date: 9/30/2024
View Audit 323157 Questioned Costs: $1
Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s rec...
Material Weakness, Internal Control Over Compliance and Compliance, Allowable Costs and Activities, Reporting Personnel Responsible for Corrective Action: Samantha Martin, County Administrator Anticipated Completion Date: 12/31/2024 Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant allowable costs and activities determinations and reporting requirements and will implement a process that ensures federal expenditure accounting and reports are prepared and then reviewed and approved by a separate employee prior to submission.
2023-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corpor...
2023-001 Program Income The Corporation is increasing its efforts to ensure that its policies and procedures surrounding documentation of patient income, identification, and registration is followed, and specifically that this documentation is archived correctly within every patient file. The Corporation has conducted several staff trainings and has revised its review procedures for checking compliance to improve monitoring of the process by the Corporation. Completion Date: Estimated December 2024. Contact Person: Rajuan Sherman - Chief Financial Officer - 2731 M.L. King, Jr. Blvd, Tuscaloosa, AL 35403 - (205) 614-6070 - rsherman@whatleyhealth.org.
FINDINGS - FINANCIAL STATEMENT AUDIT None FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 R...
FINDINGS - FINANCIAL STATEMENT AUDIT None FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2023-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all current and new staff are trained on tenants’ 90-day EIV reports and ensuring they are generated within the required time period to verify tenant information promptly and help reduce errors in subsidy payments. ACTION TAKEN The Project will be monitoring use of the EIV system for move ins and recertifications.
We continue to update our compliance processes, following implementation of the Fulton County Subrecipient Monitoring Policy and our compliance review project, initiated in 2022. Based on project and staffing that are in place, we can ensure that subrecipients are monitored during the contract perio...
We continue to update our compliance processes, following implementation of the Fulton County Subrecipient Monitoring Policy and our compliance review project, initiated in 2022. Based on project and staffing that are in place, we can ensure that subrecipients are monitored during the contract period noted in the contractual agreements. We have identified and updated the annual monitoring plan to ensure that all subrecipient are monitored and in compliance with the 2 CFR 200.331 federal standards.
The Fulton County Department of Senior Services concurs with the finding. Although the Department follows the monitoring standards established by the pass-through entity, the recent period subrecipient monitoring is in process and the current year monitoring will be completed within the grant period...
The Fulton County Department of Senior Services concurs with the finding. Although the Department follows the monitoring standards established by the pass-through entity, the recent period subrecipient monitoring is in process and the current year monitoring will be completed within the grant period. Risk assessments were done and have been formally documented and provided to the auditor. The Department will maintain an annual monitoring plan to ensure that all subrecipients are monitored in compliance with 2 CFR200 requirements.
The Fulton County District Attorney’s Office (FCDAO) was made aware during the recent Department of Justice (DOJ) audit in July 2024 of the need to strengthen compliance in this process. Effective August 2024, processes were revised to meet the 2 CFR 200 compliance requirement. Currently, FCDAO is c...
The Fulton County District Attorney’s Office (FCDAO) was made aware during the recent Department of Justice (DOJ) audit in July 2024 of the need to strengthen compliance in this process. Effective August 2024, processes were revised to meet the 2 CFR 200 compliance requirement. Currently, FCDAO is conducting the required monitoring to meet the response timeline given by the DOJ. The revised subrecipient monitoring process has been documented into a department procedure and is now included in the FCDAO’s standard operating procedure.
Finding 2023-001 Material Weakness, Internal Control Over Compliance and Compliance, Reporting Personnel Responsible for Corrective Action: Adam Rogers Anticipated Completion Date: Already completed Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal c...
Finding 2023-001 Material Weakness, Internal Control Over Compliance and Compliance, Reporting Personnel Responsible for Corrective Action: Adam Rogers Anticipated Completion Date: Already completed Corrective Action Plan: The County agrees with the auditor’s recommendation to improve its internal controls related to federal grant reporting requirements and has implemented a process that ensures federal expenditure accounting and reports are prepared by the Grants Analyst and then reviewed and approved by the Deputy Director of Finance or Director of Finance to provide oversight and detect and correct errors before reports are submitted.
The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when retur...
The System returned the remainder of funds required. Firelands Regional Medical Center School of Nursing has implemented the following control to prevent this error in the future. The Financial Coordinator will submit a copy of the Return of Title IV funds report to the business office when returning funds. The business office will use this report to make sure the appropriate amount is posted to the student's account.
View Audit 323097 Questioned Costs: $1
Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in respon...
Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will undertake a thorough review and subsequent update of our documented policies and procedures related to federal awards. This review aims to ascertain whether any adjustments are necessary to guarantee that subawarded federal funds are utilized exclusively for their designated purposes. We are dedicated to enhancing our internal controls to adhere to federal regulations concerning the monitoring of our subrecipients. We plan to engage a consultant to help us develop policies and procedures for subrecipient monitoring, as well as to propose an organizational framework for fiscal monitoring that will strengthen our internal controls. We anticipate having the finalized policies, procedures, and training implemented by 12/31/2024. We will develop and implement a risk assessment program for subrecipients, enabling management to monitor the outcomes and demonstrate compliance with federal requirements. Records will be maintained to show that risk assessments were performed. We are dedicated to offering annual training sessions aimed at reinforcing the single audit requirements to our subrecipients. We will establish a subrecipient monitoring/compliance workgroup to define roles and responsibilities for assessing and updating policies and procedures related to subrecipient monitoring and to strengthen internal controls. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO), Sharon Brown (CEO). Planned completion date for corrective action plan: 12/31/2024
Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with au...
Recommendation: We recommend that the Organization implement policies and procedures to ensure subrecipients are paid within 30 days of when the billing is received. If the request is believed to be improper, support for the delay in payment should be maintained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will review and update our policies and procedures for managing accounts payable. Furthermore, we will provide additional orientation and training sessions focused on disbursements for subrecipients involved in federal grant programs. We will improve the enforcement of policies and procedures by setting up a system to track the receipt and payment of bills. Additionally, we will implement a weekly review by the compliance team to ensure that payments are made on time and that accurate documentation is retained to support any delays in payment requests that are found to be inappropriate. Name(s) of the contact person(s) responsible for corrective action: Jan Warren/Amber Henderson (Compliance), Haydee Hill (CFO) Planned completion date for corrective action plan: 12/30/2024
All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years...
All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years, allowing clients to be seen by a medical provider quickly. This practice ended in 2023. 30-day eligibility is no longer allowed.
Finding 2023-004: Reporting The auditors noted the following areas for improvement: ● The SDA could not provide evidence of an internal review and approval on submitted performance metric report. ● The SDA was unable to provide proof of submission for one NT-106 performance metric report and three N...
Finding 2023-004: Reporting The auditors noted the following areas for improvement: ● The SDA could not provide evidence of an internal review and approval on submitted performance metric report. ● The SDA was unable to provide proof of submission for one NT-106 performance metric report and three NT-110 performance metric reports. ● The SDA submitted 2 reports late, one for NT-108 and one for NT-110. The auditors recommend the following: 1. Management implements procedures to ensure all required reports are prepared, reviewed, and submitted on time, with supporting documentation maintained in compliance with grant agreements. SDA Response ● Cook County has acknowledged receipt of all of the SDA performance grant reporting in a timely manner, however was unable to produce the specific submission information due to a change in the County system to GovGrants to the level requested by the SDA auditor. ● The delay in submission for the NT-108 report was due to the Cook County system change to GovGrants. The delay in submission to NT-110 is acknowledged, with the note that the due date for NT-110 metrics was shortened compared to the prior year. SDA Corrective Actions Management has fully transitioned to GovGrants for all metric and financial reporting, which will permit self-access to the data for all submitted reports in 2024. For NT-110, the SDA continues to document submission via email in addition to keeping track of all reports in Sharepoint. These actions aim to resolve this finding in all future audits. The full implementation of our checklist tool and quarterly review will further enhance our compliance.
Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent ve...
Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.
View Audit 323067 Questioned Costs: $1
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.
Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive app...
Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive approval for the period beginning September 1, 2023. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will submit the management certification to HUD for approval retroactively.
View Audit 323052 Questioned Costs: $1
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accountin...
View of Responsible Official: We agree with the auditors' comments, and the following action has been taken to improve the situation. We have adjusted the agency’s Accounting Policies & Procedure Manual to include a detailed review of the General Ledger detail supporting each draw request. Accounting personnel will ensure the agency’s General Ledger specifically details the month of rent and utility allowance being provided so eligible costs are clearly delineated. Someone other than the preparer will perform a review of each drawdown request to ensure that costs are not being drawn down prior to the operating start date of each individual grant. This issue was discussed with HUD in March 2024 at which time procedural changes were implemented. Additionally, as noted above, our agency was able to repay and redraw the funds drawn outside of the aforementioned period of performance without further penalty. Corrective Action: Effective March 2024 the preparer is required to include the month of rent and utility allowance being provided in the General Ledger detail. A review of the General Ledger detail supporting each draw request will be performed by someone other than the preparer to ensure that costs are not being drawn down prior to the operating start date of each individual grant.
Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward o...
Management is committed to enhancing our federal grant policy by incorporating a requirement for an annual review and recalculation of the indirect cost recovery rate. The Controller will take responsibility for recalculating the indirect rate each year, making necessary adjustments—whether upward or downward—to ensure it accurately reflects our current cost structure. To maintain compliance and integrity in our financial processes, the Technical and Internal Controls Accountant will oversee the review of costs included in the indirect cost pool to ensure they meet the criteria for allowability. Additionally, this role will involve verifying that invoices utilize the most current indirect cost recovery rate. Furthermore, management will prepare and submit the required indirect cost proposal to the appropriate cognizant agency to finalize our provisional billing rates used in fiscal year 2023, that aligns with our operational needs and complies with federal guidelines. This proactive approach will strengthen our financial management practices and support our ongoing commitment to transparency and accountability in the administration of federal grants.
View Audit 323015 Questioned Costs: $1
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallo...
US Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07CH011832-04-00 11/1/2023 – 10/31/2024, 07CH011832-03-00 11/1/2022 – 10/31/2023, 07CH011832-02-00 11/1/2021 – 10/31/2022 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Material Weakness in Internal Control Over Compliance Material Noncompliance Criteria: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Condition: The Organization requested drawdowns of grant funds in excess of amounts awarded for the grant years ended 10/31/2023 and 10/31/2022 that were denied by the passthrough agency, Omaha Public Schools, resulting in an overstatement in grant revenue and receivables, and federal awards expended included in the schedule of expenditures of federal awards. Corrective Action Plan: Management is in the process of reviewing its accounting policies and procedures over grant monitoring to ensure amounts are tracked appropriately. Management has hired a new fiscal services director to oversee this process. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2024
View Audit 322999 Questioned Costs: $1
Finding 2023-002 Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Subrecipient Monitoring Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting The Foundation developed a matrix for subrecipient monitoring an...
Finding 2023-002 Program: AL No. 10.523 Centers of Excellence at 1890 Institutions Significant Deficiency and Noncompliance over Subrecipient Monitoring Corrective Action Plan for Significant Deficiency and Noncompliance over Reporting The Foundation developed a matrix for subrecipient monitoring and Single Audit reports/findings is a key attribute in our assessment of risk. Our subrecipient monitoring policy and procedure was completed on November 30, 2023. Additionally, we hired a Program Coordinator in June 2023. The Program Coordinator focuses on the interface work required by our organization to support our grants administration role including subrecipient monitoring The Foundation requires quarterly progress and financial reports from our subrecipients, and our current process is to increase scrutiny of reports and supporting documents, when risk is medium or high. The Foundation performed reviews of subrecipients in 2023, however, the time stamp was not effectively documented. The Foundation has implemented procedures to effectively time stamp the verification process using Sam.gov going forward. Contact Person: Calece Hilliard, CFAO 1890 Universities Foundation Completion Date: September 30, 2024
Finding 500133 (2023-005)
Significant Deficiency 2023
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.
Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training t...
Turnover and vacancies in positions resulting in applications and petitions not being completed within 20 days of receipt. The Domestic Relations Department filled vacant positions through 2023. In response to the prior year finding, the Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.
This finding occurred as a result of a data entry error in the file. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in No...
This finding occurred as a result of a data entry error in the file. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/petitions to case files and file documentation beginning in November 2023.
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Hu...
The County Human Services department noted that the service providers were paid at their negotiated rates agreed upon by contract terms, however no reconciliation was completed for the remainder eligible cost adjustments to the service providers for the fiscal year ended June 30, 2023. The County Human Services department will complete the reconciliation of the service providers costs reports for the fiscal year ended June 30, 2024 before March 2025.
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