Corrective Action Plans

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The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director
The Division will contact each unit distributing TEFAP assistance and communicate the requirement to retain documentation regarding the determination of client eligibility. Anticipated Completion Date: June 2024. Responsible Contact Person: Julie Luft, Northwest Division Social Services Director
Finding 403960 (2022-005)
Significant Deficiency 2022
Finding 2022-005 – Significant Deficiency, Procurement and Suspension, and Debarment - Internal Control over Verification Against the System for Award Management (“SAM”) Condition: During our audit, we noted that the City did not have documentation to support that it verified vendors selected for te...
Finding 2022-005 – Significant Deficiency, Procurement and Suspension, and Debarment - Internal Control over Verification Against the System for Award Management (“SAM”) Condition: During our audit, we noted that the City did not have documentation to support that it verified vendors selected for testing against the SAM to ensure that they were not suspended or debarred from federally funded purchases. Cause: While the City has a formal policy requiring the purchasing department to perform verification of suspension or debarment over vendors that the City enters into contracts with for federally funded projects, it does not maintain formal documentation that this procedure occurred. Response: We agree with the finding. We are adding this step to our checklist and have assigned the task to our Grants Compliance Coordinator.
Finding 403959 (2022-004)
Significant Deficiency 2022
Finding 2022-004: Significant Deficiency and Noncompliance Finding, Reporting- Special Reporting Assistance Listing Program Title and Number: Coronavirus State and Local Fiscal Recovery Funds Federal Agency: Department of Treasury Pass-through Entity: N/A Award year: 2022 Criteria or specific requir...
Finding 2022-004: Significant Deficiency and Noncompliance Finding, Reporting- Special Reporting Assistance Listing Program Title and Number: Coronavirus State and Local Fiscal Recovery Funds Federal Agency: Department of Treasury Pass-through Entity: N/A Award year: 2022 Criteria or specific requirement: Cities were required to submit a one-time interim report with expenditures by Expenditure Category covering the period from March 3 to July 31, 2021, by August 31, 2021. The initial quarterly Project and Expenditure Report covered three calendar quarters from March 3, 2021 to December 31, 2021, and was required to be submitted to Treasury by January 31, 2022. The subsequent quarterly reports will cover one calendar quarter and must be submitted to Treasury by the last day of the month following the end of the period covered. Condition: The interim report and 2 Project and Expenditure Reports were not submitted as required. Cause: Grant management and reporting is not fully centralized within the City and there was turnover in the grant administrator position. The City did not have sufficient internal controls in place to ensure the reports were filed. Effect: The progress reports should be submitted by the deadline. This results in non-compliance with the Reporting requirements of the program. This can result in the Federal government cancelling funding of the program or denying eligible expenditures. Prevalence: There was 1 interim report and 3 project and expenditure reports required to be submitted during the audit period. Only one project and expenditure reports was submitted. Questioned Cost: None Repeating Finding: No. Recommendation We recommend that the City implement controls to ensure all compliance requirements are complied with as well as contact the grantor about whether or not the delinquent reports should still be filed. Views of Responsible Officials: Management agrees with the finding.
Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed
Corrective Action Plan: After monthly reconciliations, financial statements will be delivered to AJAC Directors monthly. AJAC Accounting Department will hold monthly close calls to collaborate with AJAC Directors to ensure accuracy of financials. Anticipated Completion Date: Completed
Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26...
Corrective Action Plan: The deficiencies related to internal control policies and procedures were initially identified in a Federal Desk Monitoring Review conducted in November 2022. Internal control policies and procedures were updated in response to these findings and approved by DOL on October 26, 2023. All financial reporting policies and procedures will be reviewed and updated on an annual basis by AJAC Directors and Supervisors. Anticipated Completion Date: Completed
This payment was a one-time payment for a single project completed by the City of Meridian. Moving forward, Lauderdale County will document the completion of the project.
This payment was a one-time payment for a single project completed by the City of Meridian. Moving forward, Lauderdale County will document the completion of the project.
Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have institute...
Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers and a purchasing manager to help ensure policies and procedures are being followed. In response to this finding, the CFO and Director of Grants Management have instituted multiple internal processes to confirm administrative fees do not exceed 10% of grant award. The grant biller will prepare a monthly reimbursement schedule in Excel which shows the budgeted amount for each category. The Director of Grants Management reviews and approves this schedule to ensure it meets the grant requirements. Each individual monthly reimbursement form is approved and signed by the Director of Grants Management to confirm accuracy. Then the reimbursement form submitted is entered in a master spreadsheet "Projects by Line Item" which shows original budget, monthly amounts billed for each budget line item, and remaining balance for each item. This is reviewed each month to ensure no amounts, including the administrative costs exceed approved amounts. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO
View Audit 310763 Questioned Costs: $1
The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followe...
The CFO has instituted multiple approvals for each reimbursement or purchase request. Since completion of the fiscal year ended 9/30/2022, the Organization has added a Director of Grants Management, two grant billers, and a purchasing manager to help ensure policies and procedures are being followed. For reimbursements, employees will complete an Employee Reimbursement Form which is signed by the employee and employee's direct supervisor. For purchase requests, employees will complete a Purchase Order form which is signed by the employee and the employee's supervisor. The signed form is sent to the finance department where it is entered in Bill.com for payment by accounts payable personnel. The Director of Finance approves the reimbursement or purchase on Bill.com, then the CFO approves and releases for payment. The approved Reimbursement Form or Purchase Order is sent to the Director of Grants Management, and if eligible, attached to the monthly billing to grantor for reimbursement. Anticipated Completion Date: 9/30/2023 Responsible Contact Person: Chris White, CFO
Finding Reference Number: 2022-001 Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit Report to the federal clearinghouse in May 2024, eight months after it was due. Statement of Concurrence or Nonconcurrence: The Organization concurs with this findi...
Finding Reference Number: 2022-001 Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit Report to the federal clearinghouse in May 2024, eight months after it was due. Statement of Concurrence or Nonconcurrence: The Organization concurs with this finding. The delinquency was caused by staff turnover in key positions responsible for the preparation of the Audited Statements and Schedule of Expenditures of Federal Awards. Corrective Action: The Organization has since hired a Chief Operating Officer (COO) who has direct responsibility for the audit process. In addition, the Center created the position of Senior Accountant who will support the COO to ensure the timeliness of the accounting close and submission of the audit. Name of Contact Person: David Heitstuman, Executive Director. Phone 916 442-0185. Email: david.heitstuman@saccenter.org Projected Completion Date: August 2024
Public Health’s Center for Preparedness and Response (CPR) agrees that it did not establish a formal risk assessment process over its subrecipients of ELC COVID-19 awards. CPR will establish and document formal procedures for conducting risk assessments of ELC subrecipients. Public Health will also...
Public Health’s Center for Preparedness and Response (CPR) agrees that it did not establish a formal risk assessment process over its subrecipients of ELC COVID-19 awards. CPR will establish and document formal procedures for conducting risk assessments of ELC subrecipients. Public Health will also develop and implement specific subrecipient monitoring procedures. CPR also agrees that it did not obtain single audit reports from ELC subrecipients. CPR will develop and implement procedures outlining the process for obtaining single audit reports from subrecipients, which will include a monitoring mechanism to track compliance with the single audit mandate. Estimated Implementation Date: December 2024 Contact: Melissa Relles, Assistant Deputy Director Division of Operations Center for Preparedness and Response California Department of Public Health
The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of He...
The Local Governmental Financing Division, in collaboration with the Audits and Investigations Division, agrees that policies and procedures will be developed to take additional action for significantly late-cost reports and non-compliant counties. As of July 1, 2023, the California Department of Health Care Services transitioned counties away from cost reconciliation financing, and for any state fiscal year after July 1, 2023, counties will no longer be required to submit cost reports. Estimated Implementation Date: July 2023 Contact: Wendy Griffe, Chief Internal Audits California Department of Health Care Services
If the Organization is subject to a Single Audit in the future, additional procedures will be implemented to track and monitor disbursements and allowable costs. Management does not anticipate having a Single Audit in the future.
If the Organization is subject to a Single Audit in the future, additional procedures will be implemented to track and monitor disbursements and allowable costs. Management does not anticipate having a Single Audit in the future.
Finding 402404 (2022-002)
Significant Deficiency 2022
Finding ref number: 2022-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal subrecipient monitoring requirements. Name, address, and telephone of City contact person: Mike Riley, Director of Financial Services 345 6th Street, Suite 100 Bremer...
Finding ref number: 2022-002 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal subrecipient monitoring requirements. Name, address, and telephone of City contact person: Mike Riley, Director of Financial Services 345 6th Street, Suite 100 Bremerton, WA 98337 (360) 473-5303 Corrective action the auditee plans to take in response to the finding: The City will ensure every subaward agreement clearly identifies that it is a federal award and includes the applicable federal requirements for programs funded with Coronavirus State and Local Fiscal Recovery Funds and other federal funding. Anticipated date to complete the corrective action: Immediately
The Organization will implement control procedures that maintain proper segregation of duties. Federal program reporting shall be prepared by the Staff Accountant or program manager and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The p...
The Organization will implement control procedures that maintain proper segregation of duties. Federal program reporting shall be prepared by the Staff Accountant or program manager and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access. Name(s) of Contact Person(s) Responsible for Corrective Action: Nhia Xiong, Staff Accountant, Andrea Vasquez, Chief Operating Officer, Alex Sukalski, New Controller, start date June 3, 2024. Anticipated Completion Date: May 2023
The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being re...
The Organization will implement control procedures that maintain proper segregation of duties. Expenditure amounts that are to be applied to federal awards shall be prepared the Staff Accountant and will require the formal approval from an individual in leadership (COO, Controller) prior to being recorded. The prepared file and documentation of the review and approval will be retained in a share drive for future access.
2022-009 Special Tests and Provisions – The Gramm-Leach-Bliley Act (GLBA) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leac...
2022-009 Special Tests and Provisions – The Gramm-Leach-Bliley Act (GLBA) Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the University engage a third party or perform the risk assessment for the two areas required by the Gramm-Leach-Bliley Act that have not been completed and documented and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University began engagement with AIS, an IT Managed Service Provider in May 2022 and hired a Director of IT in November 2023. The University is working with AIS and Cowbell to develop and implement a Cybersecurity policy, as well as to provide training for all employees, the Board of Governors, and students. The University has also deployed Cloud Storage backup solutions for all data. Name(s) of the contact person(s) responsible for corrective action: Scharvin Wilson, Director of IT, AIS, IT Managed Services Provider, E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration Planned completion date for corrective action plan: June 30, 2024
Finding 401561 (2022-006)
Significant Deficiency 2022
2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the docu...
2022-006 Special Tests and Provisions – Return of Title IV Funding Student Financial Aid Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the institution maintain proper documentation in accordance with federal grantor requirements and ensure that the documents are readily available for review upon request, including monitoring of students with triggering events that require a return to Title IV calculation to be completed, reviewed, and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has implemented policy and procedures that require a review of all official and unofficial withdrawals to have R2T4 calculations on a real time basis to ensure compliance with the Department of Education guidelines on a consistent and regular basis. Internal audits of the process will also be implemented for continuous improvement. Names of the contact persons responsible for corrective action: E. ZeNai Savage, CPA, CFO and Executive VP of Finance and Administration, and Qiana Hall, Associate VP of Enrollment Services Planned completion date for corrective action plan: June 30, 2024
Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic ...
Management’s Response – To ensure that K'ima:w Medical Center has all supporting documentation to confirm Native American eligibility, we will update our PRC policies to reflect a more standardized and robust procedure for collecting and storing patient eligibility documentation, including periodic review of our patient records in compliance with IHS standards and requirements. Additionally, we have some understanding in our Medical Records Department, which we plan to fill by next fiscal year.
Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’...
Federal Program: Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s required report for the quarter ended December 31, 2022 was due to be filed by January 31, 2023. The County filed its report on March 23, 2023, 48 days after the required due date. Recommendation: We recommend that the County revisit its policies and procedures related to reporting to ensure future reports are completed and submitted within the appropriate time period. Planned Corrective Actions: The County is current on all reporting. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk
Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...
Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County does not have a formal risk assessment or oversight program in place to monitor its subrecipients as required under the Uniform Guidance, including ensuring that financial information reconciles between the underlying expenditure reports and the subrecipient/County audit reports. Recommendation: We recommend that the County revisit its policies and procedures related to subrecipient monitoring and ensure that there are formal subaward agreements with all subrecipients, prepare a formal, initial, risk assessment of each potential subrecipient and document its monitoring activities of each subrecipient. Planned Corrective Action: Management understands that the organization receiving these funds receives a single audit also. We will continue to work with this agency ensuring that policies and procedures are understood and will follow the requirements. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk
Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...
Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: The County’s December 31, 2022 Single Audit was not completed and submitted within the required time period. Recommendation: We recommend that as the County gets up and running on the new accounting system, the audit be prioritized in future periods. Planned Corrective Action: Management understands that the organization receiving these funds receives a single audit also. We will continue to work with this agency ensuring that policies and procedures are understood and will follow the requirements. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk Anticipated Completion Date: For the 2023 audit.
Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Ag...
Federal Program: Assistance Listing #14.228 Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii, U.S. Department of Housing and Urban Development, Passed Through Pennsylvania Department of Community and Economic Development and Pennsylvania Emergency Management Agency, Pass-Through Entity Identifying Numbers: C000071546, C000073444, C000075689, C000075284, C000080637, and PEMA-2022-007 Assistance Listing #21.027, COVID-19 - Coronavirus State and Local Fiscal Recovery Funds, U.S. Department of Treasury, Passed Through Pennsylvania Department of Community and Economic Development, Pass-Through Entity Identifying Number: not available Assistance Listing #21.023, COVID-19 Emergency Rental Assistance Program, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Assistance Listing #93.658, Foster Care - Title IV-E, U.S. Department of Treasury, Passed Through Pennsylvania Department of Human Services, Pass-Through Entity Identifying Number: not available Condition/Context: While the County has informal policies and procedures surrounding the administration of its federal programs, these policies and procedures have not been formally documented to ensure compliance with the areas of allowability of costs, cash management or subrecipient monitoring as required under the Uniform Guidance. Recommendation: We recommend that County management prepare the required written policies/procedures related to allowability of costs, cash management and subrecipient monitoring outlined with the Uniform Guidance. Corrective Action Planned: The County is working to write and adopt procedures that are needed to meet compliance. Name(s) of Contact Person(s) Responsible for Corrective Action: David Witchey, Chief Clerk Anticipated Completion Date: For the 2023 audit
Finding 401269 (2022-003)
Significant Deficiency 2022
Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: ...
Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: Social Services Block Grant Assistance Listing #: 93.667 Questioned Costs: None Corrective Action: We agree with the auditor’s comments and actions stated in the recommendation. The Organization is rewriting its accounting policies and procedures to ensure adherence to the proper procedures for vouchering, which will be completed in fiscal year 2024. In August 2022, the building at 4730 N. Sheridan was sold. During the move some documents were misfiled or otherwise missed place. This made it difficult to find vouchers for the audit. The new accounting system allows Alternatives to save a copy of the vouchers and necessary support within the software. The electronic filing of the backup documentation will prevent misplacement of vouchers in the future. Contact Person: Sonya Cook, Finance Director Anticipated Completion Date: December 15, 2023
Noted, the County will work with the departments responsible for administering federal funds to create procedures requiring the review of the System Of Award Management (SAM) for suspended or debarred parties in accordance with Federal Regulation. We agree with the auditor's comments and the county ...
Noted, the County will work with the departments responsible for administering federal funds to create procedures requiring the review of the System Of Award Management (SAM) for suspended or debarred parties in accordance with Federal Regulation. We agree with the auditor's comments and the county recognizes the challenges with staffing, training, onboarding, and managing unforeseen large amounts of federal funds coming into the county during COVID response. The county will be utilizing a contractor to assist in establishing policies, procedures, training, and strategic improvements to allow quick onboarding of staff in policies, procedures and regulations outlined by CRF 200 for future emergency federal funding and routine federal funding. Walla Walla County is committed to the importance of managing federal funding.
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expe...
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expected quantity for adequate monitoring. As a management team, we assessed risk and determined the level of appropriate monitoring to consist of: 1) financial monitoring through review of reimbursement requests, which contained eligibility information necessary for oversight; 2) execution of regularly scheduled status and reporting meetings wherein we obtained ongoing programmatic data; and 3) review of audit reports, where applicable. We note neither our award agreement nor applicable federal regulations require a specific quantity of files to be reviewed as part of subrecipient monitoring. Accordingly, we do not concur with the presence of a finding. In addition, no instances of ineligible beneficiaries were identified by the auditor such that a material weakness classification does not appear reasonable or appropriate. That being said, we will assess our procedures and add greater clarity to help better tell this story going forward. We will also consider whether testing a specific number of beneficiaries is necessary and may be conducted efficiently.
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