Corrective Action Plans

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FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Pia O’Connor, County Auditor Contact Phone Number and Email Address: 812-379-1510; pia.oconnor@bartholomew.in.gov Views of Respons...
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Pia O’Connor, County Auditor Contact Phone Number and Email Address: 812-379-1510; pia.oconnor@bartholomew.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will continue to work with the Commissioner’s Office and other county departments to improve upon the process of administering the COVID-19 Coronavirus State and Local Fiscal Recovery Fund. The County implemented a Procurement, Suspension and Debarment Policy; however it did not specifically reference federal funds. The County will amend the current policy to include the necessary verbiage and information related to the federal funds. By establishing this system of Internal Controls and developing the proper policies and procedures, this should help ensure contractors and sub recipients, as appropriate are not suspended, debarred or otherwise excluded prior to entering any contacts or sub awards. Anticipated Completion Date: December 31, 2025
Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Carpenter Apartments agrees with the audi...
Finding #2024-002 Prior Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Carpenter Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Carpenter Apartments agrees with the au...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Carpenter Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Hawley-Winton Apartments agrees with th...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Hawley-Winton Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
Create and enforce a policy requiring all reclassification or non-standard journal entries to be approved by a supervisor and documented prior to posting. Journal entries will be posted by a staff member separate from the approver. Documentation will include explanation, grant impact, and approval s...
Create and enforce a policy requiring all reclassification or non-standard journal entries to be approved by a supervisor and documented prior to posting. Journal entries will be posted by a staff member separate from the approver. Documentation will include explanation, grant impact, and approval signature.
Conduct an internal review to ensure proper segregation of duties across grant-related financial processes, including journal entries and drawdowns.
Conduct an internal review to ensure proper segregation of duties across grant-related financial processes, including journal entries and drawdowns.
Create a centralized tracking system to document expenditures, deadlines, allowable costs, and drawdowns.
Create a centralized tracking system to document expenditures, deadlines, allowable costs, and drawdowns.
Require and document monthly reconciliations between the general ledger and individual grant reports.
Require and document monthly reconciliations between the general ledger and individual grant reports.
Review and document quarterly compliance and performance reports to ensure proper spend-down, journal entries, and use of funds.
Review and document quarterly compliance and performance reports to ensure proper spend-down, journal entries, and use of funds.
Conduct annual training for grant managers, administrators, and business office staff on federal compliance, financial policies, and internal controls.
Conduct annual training for grant managers, administrators, and business office staff on federal compliance, financial policies, and internal controls.
Update and distribute grants and finance-related policies annually. Maintain acknowledgement forms from relevant staff.
Update and distribute grants and finance-related policies annually. Maintain acknowledgement forms from relevant staff.
Conduct a self-assessment or internal audit of grant compliance and internal controls. Make adjustments based on findings.
Conduct a self-assessment or internal audit of grant compliance and internal controls. Make adjustments based on findings.
Management’s Response/Corrective Action Plan (Unaudited): Future subrecipient contracts will include provisions requiring the submission of financial documentation in accordance with the requirements set forth in 2 CFR Part 200, Subpart F – Audit Requirements. Specifically, all subrecipients will be...
Management’s Response/Corrective Action Plan (Unaudited): Future subrecipient contracts will include provisions requiring the submission of financial documentation in accordance with the requirements set forth in 2 CFR Part 200, Subpart F – Audit Requirements. Specifically, all subrecipients will be required to submit either a fiscal year Profit and Loss Statement or, if applicable, a Single Audit report in accordance with the federal award expenditure thresholds established under 2 CFR § 200.501. These provisions ensure compliance with federal monitoring and oversight responsibilities and will be tailored to the subrecipient’s level of federal funding. Policies and procedures, including the Procurement Regulations manual are being updated to reflect these modifications. Planned Completion Date: These modifications are being implemented immediately and the documentation to update the policies and procedures will be updated by August 31, 2025. Contact Person Responsible for Correction Action: Leigha Boling, Division Director of Procurement & GrantsManagement or Designee
Finding 573174 (2024-003)
Significant Deficiency 2024
Views of Responsible Officials: Despite difficulty preparing the report within the timeframe requested, the grant was administered in accordance with Uniform Guidance and no questioned costs were identified. To assist with more efficient and accurate reports, AcademyHealth will begin implementing a ...
Views of Responsible Officials: Despite difficulty preparing the report within the timeframe requested, the grant was administered in accordance with Uniform Guidance and no questioned costs were identified. To assist with more efficient and accurate reports, AcademyHealth will begin implementing a new accounting system (Sage Intaact) in August 2025 which includes an integrated SEFA module to ensure complete and accurate reporting in future years.
Finding 573173 (2024-002)
Significant Deficiency 2024
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation wa...
Views of Responsible Officials: One out of the two drawdowns for the major program during 2024 was not supported with a P&L to substantiate the costs were expended against the program. This drawdown was initiated and executed by the previous CFO, Deborah Edwards, and the appropriate documentation was not available. In 2025, AcademyHealth initiated a new control under the direction of the Director of Grants and Contracts, Tamika King. On a monthly schedule, the Grants and Contracts Associate will prepare each payment request by reviewing timecard reports and reconciling costs to the Job Cost Transactions report. The Director of Grants and Contracts will subsequently review and log the prepared request. The log will be reviewed with the CFO and Senior Accounting Manager during the weekly cash flow meetings.
Finding 573172 (2024-001)
Significant Deficiency 2024
Views of Responsible Officials: A new indirect cost rate proposal to obtain final rates for 2019 through 2022 and requesting provisional rates for 2023 through 2025 was prepared by the previous CFO, Deborah Edwards and submitted by the current CFO, Holly Hueston on July 25, 2024. It was subsequently...
Views of Responsible Officials: A new indirect cost rate proposal to obtain final rates for 2019 through 2022 and requesting provisional rates for 2023 through 2025 was prepared by the previous CFO, Deborah Edwards and submitted by the current CFO, Holly Hueston on July 25, 2024. It was subsequently negotiated and approved in March 2025. AcademyHealth is currently working with an outsourced auditor to prepare a proposal to obtain final rates through 2024. In the future, the Chief Financial Officer will submit the indirect cost rate proposal to obtain final rates for the fiscal year just completed, and requests for provisional rates for upcoming years will be submitted within the required timeframe.
2024-003 – Reporting – Significant Deficiency Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization identified during the pre...
2024-003 – Reporting – Significant Deficiency Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization identified during the preparation of its second quarter 2024 expenditure report approximately $25,000 in costs incurred during November 2022 that had not previously been included in a submitted expenditure report to PCCD and which were included in the second quarter 2024 expenditure report. While such costs were incurred during the overall program performance period and were allowable and attributable to the program, such costs were not timely identified and reported on the correct expenditure report. Corrective Action Plan: To strengthen our internal controls and ensure full compliance with grantor reporting requirements, we are implementing the following corrective measures: 1. Review and Update of Reporting Procedures: o We will review and revise our existing grant expenditure reporting procedures to ensure that all expenditures are properly captured, reviewed, and reconciled before submission to the grantor. o Revised procedures will clearly define roles and responsibilities for program staff, grants management, and accounting. 2. Monthly Reconciliation Process: o A monthly reconciliation process will be implemented to match recorded expenditures in the general ledger with grant budgets and program activity. o Variances will be reviewed and resolved in advance of quarterly reporting deadlines to prevent errors in submitted reports. 3. Dual Review and Approval: o All quarterly expenditure reports will be subject to dual review by the grant’s accountant and the accounting operations manager prior to submission. o This control will ensure that reports are complete, accurate, and supported by accounting records. 4. Training and Communication: o Finance and program staff involved in grant administration and reporting will receive training on updated procedures and internal control expectations. o Ongoing communication between departments will be encouraged to ensure awareness of allowable costs, budget constraints, and reporting timelines. 5. System Enhancements: o We are evaluating our current financial system and looking for a system that will allow better tracking of grant-specific expenditures, including improved reporting functionality and coding accuracy.
2024-002 - Subrecipient Monitoring - Material Weakness/Noncompliance Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization do...
2024-002 - Subrecipient Monitoring - Material Weakness/Noncompliance Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: The Organization 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/Organization audit reports. Corrective Action Plan: CCAP will be implementing the following corrective actions: 1. Formalization of Subaward Documentation: o We will revise our subaward agreement templates to ensure that all required elements (as outlined in 2 CFR §200.331(a)) are explicitly included. o All subawards will clearly identify the agreement as a “subaward” and specify required data elements such as the Federal Award Identification Number (FAIN), CFDA/Assistance Listing number, period of performance, and applicable federal terms and conditions. 2. Subrecipient Risk Assessment Framework: o A standardized risk assessment tool is being developed and will be implemented for all subrecipients prior to executing a subaward. o This tool will evaluate prior audit history, organizational capacity, experience with federal funds, and other risk indicators as required by §200.331(b). 3. Monitoring and Oversight Procedures: o We are enhancing our subrecipient monitoring policy to include a tiered approach based on the results of the risk assessment. o Monitoring activities will include regular desk reviews, periodic programmatic and financial reporting, and site visits for high-risk subrecipients as per §200.331(d)-(e). 4. Audit Verification: o Our grants team will verify annually that each subrecipient subject to audit under Subpart F has completed the required Single Audit. o We will obtain and review audit reports and maintain documentation of our review in accordance with §200.331(f). 5. Results Review and Adjustments: o Any issues identified through audits, site visits, or other monitoring will be evaluated to determine if they necessitate changes in our records, subaward terms, or overall monitoring strategy (§200.331(g)). 6. Enforcement Procedures: o We are formalizing a process for escalating issues of noncompliance, including written warnings, corrective action plans, suspension of funds, or termination of subawards, as appropriate and consistent with §200.338.
2024-001 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: While the Organi...
2024-001 - (Noncompliance) Uniform Guidance Written Policies/Procedures Federal Program: Assistance Listing #16.812 Second Change Act Reentry Initiative, Passed Through Pennsylvania Commission on Crime and Delinquency, Pass-Through Entity Identifying Number: 36758 Condition/Context: While the Organization 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, procurement, travel, conflict of interest or subrecipient monitoring as required under the Uniform Guidance. Corrective Action Plan: To address this finding and strengthen our internal controls and compliance framework, CCAP will be implementing the following corrective actions: 1. Policy Development and Documentation: o We will be initiating a project to develop and formalize comprehensive written policies and procedures in the following required areas:  Allowability of Costs (2 CFR §200.403–§200.405)  Cash Management (2 CFR §200.305)  Procurement Standards (2 CFR §200.317–§200.326)  Travel Costs (2 CFR §200.474)  Conflict of Interest (2 CFR §200.112)  Subrecipient Monitoring (2 CFR §200.331–§200.333) o These policies will reference relevant Uniform Guidance sections and incorporate internal controls, approval processes, and documentation standards. 2. Internal Review and Approval: o Draft policies will be reviewed by senior leadership, legal counsel (if necessary), and the finance and grants teams to ensure alignment with regulatory requirements and operational realities. 3. Training and Dissemination: o Once finalized, all relevant staff (including program managers, finance personnel, and procurement staff) will receive training on the new policies. o Policies will be made available on CCAP’s intranet. 4. Ongoing Maintenance and Review: o A process will be established for annual review and update of these policies to incorporate regulatory changes and feedback from internal audits or grantor reviews.
The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management wh...
The Corporation identified a subrecipient’s misuse of grant funds during a regular audit of draws and a scheduled monitoring review/technical assistance consultation for the agency. Ethic complaints were received by the Corporation during the same timeframe regarding the subrecipient’s management which expanded the scope of the financial review. As a result of these monitoring efforts, the Corporation identified ineligible and questioned costs, and efforts are underway to recapture ineligible and unsupported costs. The Corporation has put the following policies and procedures in place to mitigate future risk: 1. Biennial Risk Assessment with Annual Updates 2. Annual Project Compliance Report (APCR) required by subrecipient agencies (with the exception of subrecipients receiving only Department of Energy and LIHEAP grants for the Weatherization Assistance Program, which are governed by separate monitoring procedures). 3. Enhanced Draw Monitoring and draw documentation requirements 4. Expansion of the Corporation’s Compliance and Training Team Given the policies, procedures, and changes outlined above, the Corporation feels confident it will be able to comply with its Compliance Monitoring Plan going forward and identify any concerns with subrecipient compliance in a timely manner. Curtis Stauffer, Managing Director, Housing Contract Administration, and applicable compliance staff will implement by October 1, 2024.
View Audit 363980 Questioned Costs: $1
The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing th...
The Financial Aid Office has added system controls that will assure that disbursements that are recorded on PeopleSoft is recorded on COD to assure that the Pell reporting requirements are executed in compliance with Federal statutes. The process consisted of creating automation that and reducing the manual intervention so that the issues preventing the Pell disbursement from being recorded on COD is reduced. We are adding automation for processing: FABATCH, ATB automation, and Citizenship automation.
The Society of American Foresters has implemented a process during the vendor selection process to check for vendor suspension and debarment when utilizing federal grant funds, ensuring that no federal grant funds go to excluded vendors. For all new contracts to which the compliance requirement appl...
The Society of American Foresters has implemented a process during the vendor selection process to check for vendor suspension and debarment when utilizing federal grant funds, ensuring that no federal grant funds go to excluded vendors. For all new contracts to which the compliance requirement applies, the Society will require the vendor to sign a standardized form acknowledging they are not suspended or debarred to ensure compliance requirements are met when entering a contract using federal dollars.
The Organization acknowledges the delay in the submission of the Single Audit reporting package and has taken steps to prevent future occurrences. Specifically: • The Organization has implemented a revised audit timeline that includes earlier kickoff dates, stricter internal deadlines for submission...
The Organization acknowledges the delay in the submission of the Single Audit reporting package and has taken steps to prevent future occurrences. Specifically: • The Organization has implemented a revised audit timeline that includes earlier kickoff dates, stricter internal deadlines for submission of audit schedules, and enhanced monitoring of milestone progress. • Cross-entity coordination procedures have been formalized to improve efficiency when consolidating information involving related parties. • Additional training has been provided to the finance team on audit readiness and Single Audit compliance requirements.
Middleborugh Housing Authority will make sure our Fee Accounatnt has access to the FASSPH system next year so that submission are timely.
Middleborugh Housing Authority will make sure our Fee Accounatnt has access to the FASSPH system next year so that submission are timely.
Finding 573123 (2024-002)
Significant Deficiency 2024
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The City should update all contracts to include a suspension and debarment paragraph to verify status with every renewal, request certification from the proposed entity, or verify vendor thro...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The City should update all contracts to include a suspension and debarment paragraph to verify status with every renewal, request certification from the proposed entity, or verify vendor through SAM.gov prior to utilizing vendor services. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: The finance director and the public works director have already implemented a process to verify the SAM status of all contractors on all projects regardless of funding. Name of the Contact Person Responsible for Corrective Action: Leann Perino, Finance Director Planned Completion Date for Corrective Action Plan: Implemented April 2025
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