Corrective Action Plans

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Procedures have been established to run program financial statements to monitor spending monthly. Form 1037 is being added to the comprehensive year-end checklist to ensure that the reports are completed in time.
Procedures have been established to run program financial statements to monitor spending monthly. Form 1037 is being added to the comprehensive year-end checklist to ensure that the reports are completed in time.
Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring appro...
Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.
Sandra Dalida, CFO September 30, 2024 AL# 2 1.027 - Coronavirus State and Local Recovery Funds; 2023 Pursuant to CFR Section 200.332(b), pass-through ent1t1es must evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the tenns and conditions of the subaward for ...
Sandra Dalida, CFO September 30, 2024 AL# 2 1.027 - Coronavirus State and Local Recovery Funds; 2023 Pursuant to CFR Section 200.332(b), pass-through ent1t1es must evaluate each subrecipient's risk of noncompliance with Federal statutes, regulations, and the tenns and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring. The Unity Council did not perform a risk assessment of subrecipients. Management is in agreement with the finding and is in the process of developing and documenting a risk assessment process. Chief Financial Officer, Sandra Dalida Chief Operating Officer Chief Program Officer September 30, 2024
To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 202...
To Health Resources and Services Administration Care Alliance Health Center, Inc. respectfully submits the following corrective action plan for the year ended October 31, 2023. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: October 31, 2023 The findings from the October 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Federal Award Findings: Finding 2023.001 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken We will invest the time and resources into improving all areas related to the Sliding Fee Scale. We will implement the following steps to our process to ensure all federal guidelines and requirements are met. 1. Documented Process: Design and implement an internal control process to ensure sliding fee discounts are accurately calculated based on family size and income. 2. Documented Procedures: Establish clear procedures and guidelines for front desk staff to follow when determining discounts, including appropriate documentation requirements, eligibility criteria, and fee structure. These procedures will be aligned with our written policy to ensure consistency and accuracy in discount calculations. 3. Training and Education: Provide training to front desk staff members responsible for determining eligibility and applying sliding fee discounts to ensure they understand the process. 4. Regular Reviews: Implement regular reviews and monthly audits to verify that all discounts are properly supported and documented. Quarterly reviews will be conducted to verify compliance, identify areas for improvement, and evaluate the effectiveness of the sliding scale fee program to ensure it meets our patients' needs and complies with all federal guidelines. Responsible Parties: 1. The Controller and revenue cycle staff will develop the written procedure. 2. The Clinical Support Supervisor and revenue cycle staff will overseE3 the training. 3. The Revenue Cycle Manager_will monitor adherence to the procedure, conduct regular monthly audits, and report results to the Controller. 4. The Controller will conduct quarterly documentation reviews of the internal audit results. Timeline: 1. Procedure draft completion: Completed 2. Review and approval by senior management: July 24, 2024 3. Initial staff training session: July 25, 2024 4. Follow-up training sessions: As needed 5. Monthly compliance audits: Starting September 1, 2024
Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1,...
Dayton’s Bluff Neighborhood Housing Service and Subsidiary submits the following corrective action plan for the year ended December 31, 2023. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: January 1, 2023 – December 31, 2023 The findings from the December 31, 2023 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2023-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Jim Erchul, Executive Director, 651-774-6995 Anticipated Completion Date: Ongoing
Views of Responsible Officials and Planned Corrective Actions: AL has a long-standing preassessment Questionnaire (sample attached) that we require each potential subgrantee to complete before they can receive any financial remuneration from us. In response to this finding, we will require all subgr...
Views of Responsible Officials and Planned Corrective Actions: AL has a long-standing preassessment Questionnaire (sample attached) that we require each potential subgrantee to complete before they can receive any financial remuneration from us. In response to this finding, we will require all subgrantees to complete this questionnaire on an annual basis. In addition we have included the following questions to the questionnaire:  Does the organization perform an annual audit of financial statements?  Annual amount of US Government Funds received?  Is the organization subject to a US compliance audit under 2 CFR 200 Subpart F?  If the organization is subject to a compliance audit under 2 CFR 200 Subpart F, please provide a copy of your most recent 2 CFR 200 Subpart F audit report. Anticipated Completion Date: We will submit the questionnaire to all subgrantees during the month of June 2024 and then perform it annually. Responsible Officials: Chief Innovation and Operations Officer and Finance Manager.
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.
View Audit 316070 Questioned Costs: $1
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign...
During the period being audited internal controls for program participants documents were not reviewed by the former Executive Director. The new Executive Director has implemented a check and balance procedure that requires the Case Manager, Program Manager, and Executive Director to review and sign off on participant application forms and to be documented on the participants application before the participant can move forward in the program.
The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to creat...
The Organization had a significant turnover in both Fiscal Manager Consultant and Executive Director during the year being audited. The Fiscal Manager Consultant was replaced by the Director of Finance in the later part of the fiscal year 2022-2023. This required the new Director of Finance to create and implement as many internal controls that were needed, that were not implemented, and/or recommended by our current CPA firm who had been previously auditing prior years. Additionally, our Director of Finance has engaged the Board of Directors in taking a more active role in the financial statement overview that was not previously recommended to them by our CPA firm.
Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify...
Name of Contact Person: Ben Godwin, Director. Recommendation: We recommendthe Center verify a vendor's status by checking the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Corrective Action: We will verify all vendors' status using the System for Award Management (SAM) maintained by the General Services Administration before making purchases expected to exceed $25,000. Proposed Completion Date: Immediately.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee ra...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges the error identified in the sliding fee discount. To address this issue and prevent future occurrences, the following corrective actions will be implemented: • Internal Audit Procedure o An internal audit procedure will be established to review 10% of the applications processed by each eligibility worker. This review will include verification of application accuracy, calculation correctness, and appropriate selection of sliding fee scales. • Identification of Errors o During the internal audit, if any errors are found, immediate action will be taken to rectify the identified mistakes. • Retraining and Testing o In cases where errors are detected, affected staff will undergo retraining. This retraining will cover all relevant processes and guidelines to ensure a thorough understanding. o Post-retraining, the staff will be subjected to a period of testing to confirm their competence in handling the sliding fee discount applications accurately. These steps will help ensure the integrity and accuracy of the Sliding Fee Discount program moving forward. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Dan Becker, CEO, at 970-423-8833.
Spectrum Health and Human Services received federal funding in 2023 as a prime recipient of a grant under CFDA #93.243. The grant is subject to the Federal Funding Accountability and Transparency Act (FFATA). Under FFATA, prime recipients are required to report certain information related to subawar...
Spectrum Health and Human Services received federal funding in 2023 as a prime recipient of a grant under CFDA #93.243. The grant is subject to the Federal Funding Accountability and Transparency Act (FFATA). Under FFATA, prime recipients are required to report certain information related to subawards to the federal government using the FFATA Subaward Reporting System (FSRS). Because we did not have a procedure in place to identify federal grants that are subject to FFATA, we did not perform the required reporting under FSRS. To ensure compliance with this requirement, Spectrum Health and Human Services has identified an individual, our Contracts/Grants Manager, who will be responsible for ensuring this reporting is done going forward. Our Contracts/Grants Manager will review all grants for FFATA reporting requirements upon receipt of a federal award and track all deadlines for any reporting required. Additionally, the Contracts/Grants Manager has already reviewed our existing federal awards for any FFATA reporting requirements, and has updated the FSRS system for the required reporting of our subaward under CFDA #93.243.
Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reportin...
Corrective Action Plan for Finding FA-2023-001: Lack of Timely Reporting, Reporting, Education Stabilization Funds (ESF) #84.425C, 84.425D, and 84.425U (Material Weakness and Nonmaterial Compliance) A master calendar is now being kept of required reports and their due date to ensure timely reporting. Responsible Official: Dr. Rhonda Hall, Accomack County Public Schools Superintendent, rhonda.hall@ accomack.k12.va.us (757-787-5759); Estimated completion date is not later than the June 30, 2024.
Finding 479434 (2023-002)
Significant Deficiency 2023
Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.
Management has taken sufficient corrective action to resolve and does not believe this will be an issue in the future.
COVID - 19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Condition: During our testing of nine covered transactions (three vendors and six subawards), we noted all three vendors did not have proper supporting documentation for suspension and debarment procedures for vendors. Recommendati...
COVID - 19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Condition: During our testing of nine covered transactions (three vendors and six subawards), we noted all three vendors did not have proper supporting documentation for suspension and debarment procedures for vendors. Recommendation: We recommend the County obtain certifications from vendors stating their organization is not suspended, debarred, or otherwise excluded from participation in federal assistance programs or document the procedures performed to verify the vendor is not identified as suspended or debarred on SAM, even if no formal agreement exists with a vendor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Program will on a quarterly basis review all vendor expense and pull the suspension and debarment when the vendor is close to reaching $20,000 in expenses. Name of the contact person responsible for corrective action: Laura Garcia Planned completion date for corrective action plan: December 31, 2024
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate suppo...
Finding, Reference Number: 2023-001 Federal Agency: Department of Agriculture (USDA) Description of Finding: Criteria: 7 CFR Section 250.1 9(a) identifies requirements related to record keeping for this major program. It is important to note the Food Bank appeared to maintain the appropriate supporting documents and required components, this finding relates to one component regarding the lack of a signoff not lack of documentation. Condition: During audit testing, we noted the following; the invoices created as a result of USDA orders being made were not consistently signed off on by the recipient agency representative upon pick up or delivery of the commodities. Statement of Concurrence or Nonconcurrence: The Food Bank agrees with this finding. Corrective Action: The Food Bank places a strong emphasis on ensuring accountability in the pickup process for agencies by requiring them to sign invoices upon receiving their orders. This practice is crucial for maintaining accurate records and verifying the receipt of products and other items. To strengthen this procedure, we will be reinforcing with our staff the absolute requirement for agencies to sign for their orders at the time of pickup. As of July 8, 2024 we will implement a new procedure mandating dual sign-offs on all orders by both the agency representative and a Food Bank staff member. Our Programs team will also conduct educational marketing raising awareness among the agencies about the importance of signing their invoices. These steps will not only enhance our operational efficiency but also uphold our commitment to transparency and accountability in distributing food resources to those in need. Name of Contact Person: Nicholas Pisani, Chief Operating Officer; phone number 518-786-3691 ext. 241; email NickP@Regionalfoodbank.net Projected completion date: July 8, 2024
Finding 2023-003 Epidemiology and Laboratory Capacity for Infectious Diseases Reporting Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. Also, for that particular report there was a confusion on the date as to when was need it to be submitted by the federal governm...
Finding 2023-003 Epidemiology and Laboratory Capacity for Infectious Diseases Reporting Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. Also, for that particular report there was a confusion on the date as to when was need it to be submitted by the federal government. However, we have established procedures to meet the reporting requirements to all federal programs be submitted on time. Responsible Officials Mrs. Sylvianette Luna Anavitate Program Director 787-765-2929 ext. 3121 Mr. Bryan Santos Martínez Financial and Accountant Analyst 787-765-2929 ext. 3361 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.
Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemente...
Finding 2023-001 Financial Administration- Standards for Financial Management System Financial Internal Control Weakness and Noncompliance The PRDOH agrees with the finding. However, PRDOH has implemented various corrective actions. Regarding Project Costing Module, the PRDOH already has implemented the Travel and Expenses Module, Payment Management System, which integrates with the Account Receivable to streamline revenue records and Payroll Solutions. The effectiveness of these will be observed during the fiscal year 2024-2025. Also, the PRDOH and Central Government are currently working on ERP implementation in all Government Agencies. This new ERP will be in place in the fiscal year 2024-2025. Furthermore, the PRDOH has established control in order for all program to ensure the timely performed reconciliations between the finance office, the federal affair office, this procedure has started since august 2022. In the other hand the State Department of Treasury has begun a series of training with regard the new ERP that will, be in place by October 2024. This new system in order to close the monthly period all programs will need to reconcile first before closing of the period. Responsible Official Mrs. Velmary Martinez Yace Finance Director Tel. 787-765-2929 ext. 3291 Mrs. Mayra Reyes Accounting Office Supervisor Tel. 787-765-2929 ext. 3294 Estimated Completion Date Implementation is expected to be completed on or before the end of October 2024.
2023-001: Reporting (Significant Deficiency) and Compliance During our audit of the reporting requirements for the Organization’s subawards, we noted the Organization did not complete the necessary reporting to be in compliance with FFATA. Under the requirements of the Federal Funding Accountability...
2023-001: Reporting (Significant Deficiency) and Compliance During our audit of the reporting requirements for the Organization’s subawards, we noted the Organization did not complete the necessary reporting to be in compliance with FFATA. Under the requirements of the Federal Funding Accountability and Transparency Act (“FFATA”) (Pub. L. No. 109-282), as amended by Section 6202 of Pub. L. No. 110-252, hereafter referred as the “Transparency Act” that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The finding appears to be the result of an oversight and lack of understanding of FFATA reporting requirements. Recommendation: We recommend the Organization implement policies and procedures to ensure its compliance with the reporting requirements of FFATA. View of Responsible Officials: OPCS agrees with the finding and are in the process of up-dating our procedures to mitigate issues in the future. See our Corrective Action Plan for the fiscal year ended December 31, 2023 for additional detail. Corrective Action Plan: The finding relates to a sub-recipient in excess of $30,000 which has attached FFATA reporting requirements. Our plan to mitigate the irsk of a repeat finding Old Pueblo will implement a control where all sub-recipients more than $30,000 will undergo an additional layer of review specifically for FFATA requirements. If the associated direct award agreemenet is not clear on the requirement’s applicability management will reach out to the awarding federal agency. Sub-recipients in excess of $30,000 will have documentation that the above review was taken place by Ellyn, Langer, CFO. The new control will be in place by August 2024.
To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed document...
To ensure compliance with grant regulations the school district will implement the following: ● Conduct a comprehensive assessment of existing procedures to identify gaps that led to non-compliance with grant regulations. ● Ensure timely submission of grant applications. ● Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. ● Ensure all documentation is easily accessible and systematically organized for audit purposes. ● Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and ONLY with written approval from the Federal awarding agency (as per 2 CFR 200.458). ● Establish a process for obtaining and documenting written approval for pre-award costs. ● Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. ● Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. ● Assign accountability for monitoring and reporting compliance to specific roles within the organization. This implementation of this plan shall be the responsibility of the Russ Kaubris, Business Manager. Starting with the Fiscal Year 2025 grant cycle, procedures to comply will be implemented.
Moving forward, a supervisory review of the move in files will be performed by a different staff member for the Authority than the staff member who initially determined eligibility. This will ensure that the Authority continues compliance with eligibility requirements.
Moving forward, a supervisory review of the move in files will be performed by a different staff member for the Authority than the staff member who initially determined eligibility. This will ensure that the Authority continues compliance with eligibility requirements.
It was discovered that our financial institution was pledging securities based on book value and not on market value which led to the deposits not being fully collateralized according to HUD requirements and State Statutes. The Authority will review the collateral reports at least quarterly to dete...
It was discovered that our financial institution was pledging securities based on book value and not on market value which led to the deposits not being fully collateralized according to HUD requirements and State Statutes. The Authority will review the collateral reports at least quarterly to determine that pledging requirements are adequate to ensure compliance in the future.
Finding 479161 (2023-002)
Significant Deficiency 2023
Finding 2023‐002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal cont...
Finding 2023‐002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID‐19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: 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. Per 31 CFR 19.300, prior to enter in subawards and contracts with award funds, recipients must verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded pursuant to 31 CFR § 19.300. The County did not review two counselors to determine that they were not suspended, debarred, or otherwise excluded prior to entering into a transaction with them. Responsible Individuals: Kent Reeves, County Auditor Corrective Action Plan: The County will start reviewing all vendors paid with federal funds against the sam.gov suspension and debarment review tool, and will document the periodic review of suspended and debarred vendors. Anticipated Completion Date: Fiscal year 2024
Treston Hall, County Administrator, will seek out training opportunities before December 31, 2024 related to the ever changing reporting requirements associated with CLFRF to ensure future reporting periods are properly presented.
Treston Hall, County Administrator, will seek out training opportunities before December 31, 2024 related to the ever changing reporting requirements associated with CLFRF to ensure future reporting periods are properly presented.
Finding 479130 (2023-002)
Significant Deficiency 2023
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties...
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties or add mitigating controls to prevent material misstatement of the financial statements.
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