Corrective Action Plans

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Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were bei...
Finding 2021-007 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an adequate internal control policy in place to ensure expenses claimed were being reduced by Medicare's reimbursement or claimed on other grants. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process to ensure amounts claimed for this program are reduced by amounts reimbursed or obligated by another source and include a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission Anticipated Completion Date: Ongoing
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were...
Finding 2021-006 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA# 93.498 Finding Summary: The Hospital did not have an adequate internal control process in place to ensure expenditures claimed were being in the proper period. The Hospital also did not have a control to ensure the reporting was reviewed and approved by someone other than the preparer. Responsible Individuals: Scott Callender Corrective Action Plan: The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues ...
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution CFDA # 93.498 Finding Summary: The Hospital did not have an internal control process in place to ensure the calculation of lost revenues was reviewed and approved. Accordingly, the errors in the lost revenue calculation spreadsheet were not identified by management. In addition, the Hospital did not have an internal control process in place to ensure a review and approval of the Period 1 Report was performed by someone other than the preparer of the report. Responsible Individuals: Scott Callender Corrective Action Plan : The Hospital will implement a control process which includes a documented secondary review and approval of required reports to be submitted to the federal agency prior to submission. Anticipated Completion Date: Ongoing
Finding 375511 (2021-002)
Significant Deficiency 2021
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been impl...
Church at the Park has created formal, written policies relating to the approval of expenditures. This includes a more formal process for the approval of expenditures, as well as a requirement of the documentation of said approval after the disbursement of funds. Additionally, a policy has been implemented in which the bank and credit card statements are reconciled to C@P’s General Ledger. These procedures were evaluated to effectiveness as part of the 2022 Single Audit. Andrew Squires, Finance Director, is responsible for the implementation of these procedures. The procedures were implemented in February of 2022 and have been followed since then. If the Department of the Treasury has questions regarding this plan, please contact Andrew at Andy.Squires@church-at-the-park.org.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
View Audit 294536 Questioned Costs: $1
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement a system of internal controls to ensure compliance with all applicable grant requirements.
Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.
Management will work together to design and implement procedures to address county wide controls over federal programs and to ensure compliance with grant agreements.
Management will work together to design and implement a system of internal controls to ensure an accurate reporting of revenues and expenditures on the SEFA, that the notes to the SEFA are prepared, and compliance with all applicable federal requirements.
Management will work together to design and implement a system of internal controls to ensure an accurate reporting of revenues and expenditures on the SEFA, that the notes to the SEFA are prepared, and compliance with all applicable federal requirements.
Finding 2021‐013 Gift Cards – Activities Allowed or Unallowed; Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Controls over Compliance Corrective Action Plan Management will review current policies and will ensure that policies and procedures are adhered to ensure ...
Finding 2021‐013 Gift Cards – Activities Allowed or Unallowed; Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Controls over Compliance Corrective Action Plan Management will review current policies and will ensure that policies and procedures are adhered to ensure that proper reconciliations are done. Expected Completion Date Fiscal Year 2025.
Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expecte...
Finding 2021‐012 Expenditure Approval – Activities Allowed and Unallowed, Allowable Costs – Material Weakness in Internal Control over Compliance Corrective Action Plan Management will implement policies and procedures to ensure expenditures are reviewed timely and approved prior to posting. Expected Completion Date Fiscal Year 2025.
Finding 2021‐007 Late Reporting – Significant Deficiency in Internal Control over Compliance Corrective Action Plan Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Expected Completion Date Fiscal Year 2025.
Finding 2021‐007 Late Reporting – Significant Deficiency in Internal Control over Compliance Corrective Action Plan Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Expected Completion Date Fiscal Year 2025.
Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rate...
Finding 2021‐006 Payroll Documentation – Activities Allowed and Unallowed, Allowable Costs/Cost Principles – Noncompliance and Material Weakness in Internal Control over Compliance Corrective Action Plan Management will review current employee pay rates within the payroll module and ensure that rates agree to the most current pay rate as is specified in the employee’s current personnel action form. Expected Completion Date Fiscal Year 2025.
The County also produced reimbursement requests well in excess of not only the subject amount referenced above, but also well over the state allocated CARES Act funds the County was eligible to receive in reimbursement. Regardless, the County will increase efforts to provide internal review of these...
The County also produced reimbursement requests well in excess of not only the subject amount referenced above, but also well over the state allocated CARES Act funds the County was eligible to receive in reimbursement. Regardless, the County will increase efforts to provide internal review of these type items to ensure clarity of reimbursement s and/or costs moving forward on state and federally funded projects.
View Audit 292133 Questioned Costs: $1
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Poli...
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head.
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the ...
The Treasurer, Town Manager and Select Board will take the following actions to address finding 2021-003 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager that has implemented training for the Treasurer and the Select Board. She has implemented a process of having the Treasurer complete a warrant each week. The Select Board meets bi-monthly and the Town Manager has the Select Board review and approve all warrants as a regular action item in their meeting. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head.
The Board of County Commissioners will work with all Count Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all Count Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization retain clear documentation of meal count sheets, including labeling of the particular month they relate to. We also recommend the Organization reconcile the meal count sheets with the...
Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization retain clear documentation of meal count sheets, including labeling of the particular month they relate to. We also recommend the Organization reconcile the meal count sheets with the clicker reports, and retain specific documentation as to the variances. Explanation of disagreement with audit finding The Child and Adult Care Food Program was created as an emergency response during the COVID-19 pandemic. In such an emergent situation, management believes the federal government acted in good faith to meet the needs of the country by contracting with regional sponsoring organizations. New Vision Foundation was selected by the sponsoring organization to be a community-based food provider to culturally-specific populations. All activities related to the program were expressly approved by the sponsoring organization. The finding of material noncompliance is overstated. Management followed all guidelines and fulfilled all obligations outlined by Feeding Our Future. Documentation of meal count sheets and clicker reports were accepted and approved by the sponsoring organization. Additional documentation was not requested nor were any changes to management’s practices. Action taken in response to finding The program noted was discontinued at the end of 2021. If the Organization enters into any other federal funding, we will consult with experts on compliance requirements from the start of the grant. Name of the contact person responsible for corrective action Hussein Farah, Executive Director Planned completion date for corrective action plan N/A
Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization attend training, review federal requirements, and fully understand the documentation and meal requirements of the program if they apply for funding with this program again. Explanatio...
Child and Adult Care Food Program - Assistance Listing No. 10.558 Recommendation Auditor recommends the Organization attend training, review federal requirements, and fully understand the documentation and meal requirements of the program if they apply for funding with this program again. Explanation of disagreement with audit finding The Child and Adult Care Food Program was created as an emergency response during the COVID-19 pandemic. In such an emergent situation, management believes the federal government acted in good faith to meet the needs of the country by contracting with regional sponsoring organizations. New Vision Foundation was selected by the sponsoring organization to be a community-based food provider to culturally-specific populations. All activities related to the program were expressly approved by the sponsoring organization. The auditor was provided meal logs, invoices and documents signed by program participants as evidence of meals delivered. However, this documentation was not accepted by the auditor even though it had been approved by the sponsor organization. The auditor requested delivery driver schedules and/or volunteer assignments for specific deliveries which were not available since the sponsor organization never requested such documents be kept. The finding of material noncompliance is overstated. Management followed all guidelines and fulfilled all obligations outlined by Feeding Our Future. Action taken in response to finding The program noted was discontinued at the end of 2021. If the Organization enters into any other federal funding, we will consult with experts on compliance requirements from the start of the grant. Name of the contact person responsible for corrective action Hussein Farah, Executive Director Planned completion date for corrective action plan N/A
View Audit 291230 Questioned Costs: $1
Finding Summary: During our testing, there was no documentation for a portion of the sample selected. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: Management will enhance internal control policies to ensure all expenditures are supported...
Finding Summary: During our testing, there was no documentation for a portion of the sample selected. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: Management will enhance internal control policies to ensure all expenditures are supported to ensure that all payments are necessary, correct, and meet the requirements of the federal program. The unsupported invoices were damaged in a flood. The support was available at the time the expenditures were being recognized. The organization has gone to an electronic accounts payable system in 2021 so invoices are being stored electronically and that will assist in making sure that all expenditures are supported. Anticipated Completion Date: Ongoing
Finding Summary: The Organization selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to the approved budget. The Organization did not have a budget for the entire reporting period that was approved prior to March 27, 2020. ...
Finding Summary: The Organization selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to the approved budget. The Organization did not have a budget for the entire reporting period that was approved prior to March 27, 2020. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: The organization thought it was calculating lost revenue appropriately and later realized the budget needed to be approved prior March 27, 2020. The lost revenue calculation was revised to Option i in Period 4 reporting. Anticipated Completion Date: March 2023
Finding Summary: The Organization’s final expenditure listing and lost revenue identified as eligible and claimed under the Provider Relief Fund program did not have documented review and approval by a separate individual outside of the preparer. In addition, the Organization’s special reports submi...
Finding Summary: The Organization’s final expenditure listing and lost revenue identified as eligible and claimed under the Provider Relief Fund program did not have documented review and approval by a separate individual outside of the preparer. In addition, the Organization’s special reports submitted to the Department of Health and Human Services (HHS) for Period 1 and Period 2 were not reviewed and approved by a separate individual outside of the preparer. Responsible Individuals: Stephanie Schmidt, Director, Financial Planning & Analysis Corrective Action Plan: When summarizing eligible costs and lost revenue for submission, a secondary review of the summary spreadsheet prepared from the underlying supporting expense records will be documented. Before reports are submitted to the federal agency, documented approval of this submission will be acquired. Anticipated Completion Date: 2/1/2024
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
Corrective Action: Coastal Harvest will implement formal internal control procedures, including independent reviews or other checks and balances, for all significant compliance requirements for its federal programs. Anticipated Completion Date: June 30, 2024
Finding 11002 (2021-001)
Material Weakness 2021
The Manor agrees with the finding. The Manor reported expenses in its period 1 submission of $798,256 which included all skilled nursing supplies expenses and an allocation of dining supplies which all of which were not necessarily used to prevent, prepare for, and respond to coronavirus. The Mano...
The Manor agrees with the finding. The Manor reported expenses in its period 1 submission of $798,256 which included all skilled nursing supplies expenses and an allocation of dining supplies which all of which were not necessarily used to prevent, prepare for, and respond to coronavirus. The Manor was able to provide direct costs used to prevent, prepare for, and respond to coronavirus that totaled $908,131 of which $266,251 were reported in period 2, thus $156,376 was over reported in period 1. Cornwall Manor agrees with the finding and misinterpreted the guidance but was able to substantiate $641,880 of expenses reported in period 1 as direct costs used to prevent, prepare for, and respond to coronavirus. Additionally, the Manor reported $740,727 of lost revenues in the period 1 report that could be applied against the PRF payments. Procedures have been implemented to ensure that all future reporting will only include direct costs used to prevent, prepare for, and respond to coronavirus.
View Audit 14852 Questioned Costs: $1
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization claimed expenses that were reimbursed by other funding sources. These exp...
Finding 2021-005 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization claimed expenses that were reimbursed by other funding sources. These expenses were improperly included in the HHS Special Report which caused the report to be inaccurate. Responsible Individuals: Renee Henry, Director of Finance Corrective Action Plan: The Organization will implement internal control policies to ensure all amounts reimbursed by other funding sources are adequately documented and reduced from the eligible expenditure listing and ensure are properly recorded in the report required to be submitted to the federal agency. The Organization will also implement a review process to ensure all key line items are necessary, correct, meet the requirements of the federal program, and are properly recorded in the reports required to be submitted to the federal agency. Anticipated Completion Date: March 31, 2024
View Audit 13756 Questioned Costs: $1
Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization’s final lost revenue calculation identified as eligible and claimed under...
Finding 2021-004 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan Federal Financial Assistance Listing: #93.498 Finding Summary: The Organization’s final lost revenue calculation identified as eligible and claimed under the Provider Relief Fund program did not agree to the amount claimed in the report submitted to the Department of Health and Human Services for Period 1. Responsible Individuals: Renee Henry, Director of Finance Corrective Action Plan: Management will implement a control process and policy which includes monitoring over amounts reported relating to lost revenue amounts and the related calculation. Anticipated Completion Date: March 31, 2024
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