Corrective Action Plans

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All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years...
All new client’s eligibility documents are reviewed by the Lead Case Manager to ensure that every required document for eligibility is in place. These clients were given a 30-day eligibility initially, allowing them time to collect required documents for complete eligibility. This was done for years, allowing clients to be seen by a medical provider quickly. This practice ended in 2023. 30-day eligibility is no longer allowed.
2023-004: Underfunded Resident Security Deposit Account Condition: The Partnership’s resident security deposit account is under-funded by $2,442 during the year ended December 31, 2023. Management’s Corrective Actions: Management has since fully funded the security deposit account and established pr...
2023-004: Underfunded Resident Security Deposit Account Condition: The Partnership’s resident security deposit account is under-funded by $2,442 during the year ended December 31, 2023. Management’s Corrective Actions: Management has since fully funded the security deposit account and established procedures to ensure that the account is properly funded moving forward.
2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish...
2023-003: Internal Controls over Cash Management Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management’s Corrective Actions: Management is working to establish the policies and procedures for reviewing and approving reimbursement claims to ensure that the claims are properly prepared and submitted timely.
We agree in part to this finding. The deficiency exists with approval of transactional funds that are utilized for the transportation and food voucher programs. Historically, authorization to purchase has been deemed as approval and this year some of those documentation processes were not consiste...
We agree in part to this finding. The deficiency exists with approval of transactional funds that are utilized for the transportation and food voucher programs. Historically, authorization to purchase has been deemed as approval and this year some of those documentation processes were not consistently followed, as mentioned being done verbally or during other discussions that were not documented. We did not make any food voucher purchases without discussion prior to purchasing. That being said, we can formalize an approval process that is documented. Additionally, we will review our transportation program policies to ensure that a proper approval process is in place and continues to be supported by the processes we have in place.
Finding 2023-004: Reporting The auditors noted the following areas for improvement: ● The SDA could not provide evidence of an internal review and approval on submitted performance metric report. ● The SDA was unable to provide proof of submission for one NT-106 performance metric report and three N...
Finding 2023-004: Reporting The auditors noted the following areas for improvement: ● The SDA could not provide evidence of an internal review and approval on submitted performance metric report. ● The SDA was unable to provide proof of submission for one NT-106 performance metric report and three NT-110 performance metric reports. ● The SDA submitted 2 reports late, one for NT-108 and one for NT-110. The auditors recommend the following: 1. Management implements procedures to ensure all required reports are prepared, reviewed, and submitted on time, with supporting documentation maintained in compliance with grant agreements. SDA Response ● Cook County has acknowledged receipt of all of the SDA performance grant reporting in a timely manner, however was unable to produce the specific submission information due to a change in the County system to GovGrants to the level requested by the SDA auditor. ● The delay in submission for the NT-108 report was due to the Cook County system change to GovGrants. The delay in submission to NT-110 is acknowledged, with the note that the due date for NT-110 metrics was shortened compared to the prior year. SDA Corrective Actions Management has fully transitioned to GovGrants for all metric and financial reporting, which will permit self-access to the data for all submitted reports in 2024. For NT-110, the SDA continues to document submission via email in addition to keeping track of all reports in Sharepoint. These actions aim to resolve this finding in all future audits. The full implementation of our checklist tool and quarterly review will further enhance our compliance.
Finding 2023-003: Procurement The auditors noted the following areas for improvement: ● The SDA did not perform timely debarment or suspension checks for some contractors hired. ● The SDA could not justify the rationale for selection of 2 awarded contracts as part of the BGS request for qualificati...
Finding 2023-003: Procurement The auditors noted the following areas for improvement: ● The SDA did not perform timely debarment or suspension checks for some contractors hired. ● The SDA could not justify the rationale for selection of 2 awarded contracts as part of the BGS request for qualification process. ● Note: The auditors provided a suggested recommendation to update all 1099 contract language to include reference to the specific 2 CFR 200 Appendix II reference. The auditors recommend the following: 1. Management should adhere to written procurement policies and maintain sufficient documentation, including justification memos and debarment/suspension verification, to support federally funded procurement decisions. SDA Response The SDA accepts the above findings with notes on those findings, and would like to add the following information for context: • Stronger implementation and compliance efforts are required from Management to ensure the adopted procurement procedures are followed. SDA Corrective Actions The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits. The Director of Finance and Administration will also meet with all business line leads to provide additional training and support on the procurement process, including requesting additional information for all active contracts for 2024. Lastly, Management will immediately update 1099 contract agreements to include specific CFR language in 1099 as suggested by the auditors.
Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent ve...
Finding 2023-002: Internal Controls over Allowable Costs The auditors noted the following areas for improvement: ● Time & Effort Certifications (T&E) were missing from 18 out of 40 tested contractor invoices. ● All payroll for W-2 employees was billed to grants based on a percentage of time spent versus actual time spent. ● From a list of 244 clients, 21 client intake forms (used to determine eligibility for services) for Business Growth Services clients were unable to be produced. The auditors recommend the following: 1. Management to implement procedures to ensure all expenditures, including personnel costs, are properly reviewed, approved, and supported with documentation in accordance with federal regulations. SDA Response The SDA accepts the above findings and would like to add the following information for context: ● The requirement to collect T&E forms wasn’t initially established until the completion of the 2022 audit and after the departure of some personnel. Management attempted to collect T&E forms from prior contractors, but was not successful in securing the specific forms identified by the auditors. ● The SDA created a payroll classification document during 2023 which outlined T&E for all W-2 employees at a set rate for the year. This document, however, was not accepted by the auditors as evidence of actual hours expended on each grant, resulting in this finding. ● The SDA onboarded a new Director of Business Growth Services (BGS) in 2023, which led to changes in both the operational structure and the nature of the data collected for BGS activities. During this period, a data migration took place to a newer version of Salesforce that was built specifically for the SDA. Unfortunately, some data was either lost or unmapped during the migration process, leading to discrepancies in the completeness of historical records. SDA Corrective Actions Management is committed to continue training for personnel to ensure timely completion and compliance of hiring as well as time and effort documentation going forward. The SDA is implementing a new checklist tool to bolster compliance. This checklist will help the Director of Finance and Administration identify and correct any missing compliance well in advance of the next audit. In addition, Management is implementing a new quarterly review process to assess both compliance and financial accounts. The new quarterly review process will ensure documentation is maintained and accounted for each transaction, particularly for restricted grants, to minimize any post-close adjustments. The combination of both the new checklist tool and review process will support continued timeliness and eliminate this finding in future audits.
View Audit 323067 Questioned Costs: $1
Finding 500284 (2023-007)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year:...
Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." Condition: During testing, 2 of the 60 samples selected had an individual approving their own timecard. Questioned costs: None. Context: A sample of 60 was made from a population of over 250 paychecks processed during the year with costs charged to the major program. Out of the 60 timecards that were sampled, there were two instances where the individual whose timecard was being reviewed also approved their own timecard. Cause: At the time of these payroll runs, the Organization did not have procedures in place to identify an appropriate approver for the Executive Director's timecards. Effect: Without appropriate segregation of duties around the approval of timecards, there is an increased risk of errors and fraud in the timekeeping and payroll process, which could result in inaccurate financial reporting and misappropriation of funds. Repeat Finding: No. Recommendation: CLA recommends that another individual with knowledge of the Executive Director's time and effort on the various programs approve his timecards. The Organization has already identified a member of the executive team to perform such functions and will implement the change going forward. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The organization has implemented a policy such that no employee can approve their own timecard. As noted above, the organization has identified an appropriate executive team member to approve the Executive Director’s timecard. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024 If you have any questions regarding this plan, please call Gary Slater at 305-213-8829.
Finding 500283 (2023-006)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification N...
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.313(d)(2) states that a physical inventory of property must be taken and the results reconciled with the property record at least once every two years. Condition: During testing, it was noted that a physical inventory and reconciliation with the property records had not been performed. Questioned costs: None. Context: A sample of 4 was made from a population of 4 pieces of equipment purchased with funds from the major program (entire population). Of the 4 sampled, all belonged to a population of assets that had not been part of a formal physical inventory and property reconciliation. Cause: The Organization does not currently have procedures in place to perform a formal inventory count and reconciliation with the property records at least once every two years. Effect: Without periodic equipment counts, the Organization is in noncompliance with federal regulations around Equipment and Real Property Management. In addition, there is an increased risk of errors and inaccuracies in the inventory records and an increased risk of fraud or theft going undetected. Repeat Finding: No. Recommendation: CLA recommends that the Organization adopt policies and procedures that include performing a formal inventory count and reconciliation back to the property records at least once every two years, in compliance with 2 CFR 200.313(d)(2). The inventory count should be documented and signed by the individual performing the count as a form of attestation to the amounts recorded. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The organization has strengthened their property record policy to include a formal inventory count and reconciliation on an annual basis in compliance with 2 CFR 200.313(d)(2). This inventory also includes description of the condition of the property and documented signature by the individual performing the inventory. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Finding 500282 (2023-005)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification N...
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.302(a) on Financial management states that "... the other non-Federal entity's financial management systems, including records documenting compliance with Federal statutes, regulations, and the terms and conditions of the Federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions; and the tracing of funds to a level of expenditures adequate to establish that such funds have been used according to the Federal statutes, regulations, and the terms and conditions of the Federal award". Condition: During testing, 2 of the 5 samples selected did not include sufficient documentation to agree all amounts requested for reimbursement for the month in question to the expenditures listed in the general ledger detail by program. Questioned costs: Unknown. Context: A sample of 5 monthly reimbursement requests were taken from a population of 13. Of the 5 sampled, two were insufficiently supported to agree the amounts requested for reimbursement for the month in question to the expenditures listed in the general ledger detail by program. Cause: The Organization was using a cumulative profit and loss to file monthly reimbursement requests (beginning of the year through the reimbursement month). In addition, profit and loss reports were not consistently saved at the time the reports were prepared for reimbursement for January and February 2023. Effect: The Organization is currently in noncompliance with federal regulations with regard to adequate documentation. Without adequate documentation in place to ensure costs are evidenced and reconcile to the expenditures documented in the underlying accounting information that is used to prepare the SEFA, the Organization could incorrectly charge expenditures to the federal program, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-005. Recommendation: Starting in March 2023, the Organization has already implemented a new process for the preparation of monthly reimbursement requests, including documentation retention. Point-in-time reports (i.e., profit and losses) are saved at the time of report preparation. This has enhanced clarity of costs attributable to each monthly period and reduces the chance that costs will be missed when requesting for reimbursement. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. As noted above, we believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we continue to review and strengthen our internal controls and training for admin staff for preparing reimbursement requests. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Finding 500281 (2023-004)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification ...
Type of Finding: Significant Deficiency in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.303(a) states that a non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO)." In addition, 2 CFR 200.329(c)(1) states that “the non-federal entity must submit performance reports at the interval required by the Federal awarding agency or pass-through entity to best inform improvements in program outcomes and productivity”. Per the award agreement for contract W912DW-20-2-0003, "Recipient shall submit to the Agreement Administrator (see paragraph 1.2.1) progress reports on a quarterly basis utilizing the form included in Attachment B of this agreement. Reports are due no later than 30 days following the end of each reporting period. A final performance progress report shall be submitted within 90 days after the expiration date of the award." Condition: During testing it was noted that 3 of the 6 financial reports tested did not include documentary evidence of Executive Director review and approval. In addition, 2 of the 2 performance reports tested were filed after the filing deadline. Questioned costs: None. Context: A sample of 6 was made from a population of 17 financial reports, and a sample of 2 was made from a population of 4 performance reports. Of the 6 financial reports sampled, 3 did not have documentary evidence of Executive Director review and approval. Of the 2 performance reports sampled, both were filed after the submission deadline date. Cause: Late filing is due to a lack of adherence to the due dates as defined within the contract terms. The Organization does not have adequate controls in place to document the Executive Director's review and approval of the Federal Financial Reports (SF-425). Effect: Not filing reports on a timely basis can present risks, such as outdated and unreliable information or the inability to detect potential fraud or irregularities. In addition, delayed reports can impede regulatory authorities' ability to monitor compliance, detect patterns or trends, and assess risks in a timely manner. Without adequate documentary evidence around the review of financial reports, there is an increased risk of errors and fraud in the reporting process, which could result in inaccurate financial reporting and misappropriation of funds. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-004. Recommendation: CLA recommends for the Organization to place emphasis on stronger controls around the timely filing of required reports, such as retaining a monthly checklist of required reconciliations and reports. CLA also recommends implementing a procedure that documents the Executive Director's review and approval of the Federal Financial Reports (SF-425s), whether that be via an email chain or retaining a copy that also includes the Executive Director's signature on the report. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and strengthened our internal controls and training to all staff around the timely filing of required reports. This has included creating a calendar of required reconciliations and reports for all agreements. Further, we have updated our procedure for review, approval, and documentation of Federal Financial Reports. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Finding 500280 (2023-003)
Significant Deficiency 2023
Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year:...
Type of Finding: Significant Deficiency in Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: The Organization, as part of their stated controls, require that expenditures must be approved by the ED, CFO, or program directors / managers. In addition, § 200.303(a) requires the Organization to establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Condition: During our testing, it was noted that 12 of 60 samples did not include sufficient records to substantiate approval of the disbursement. Questioned costs: None. Context: A sample of 60 was made from a population of over 250 disbursements charged to the major program. Of the 60 sampled costs, 12 did not have sufficient records to substantiate adequate approval. Cause: Approvals are not maintained for ACH transactions. Effect: Without adequate controls in place to ensure costs are reasonable and intended for the program charged, the Organization could incorrectly charge expenditures to the federal program, report fraudulent expenditures, or not request appropriate reimbursement that the Organization is entitled to under the terms of the grant. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-003. Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence should be obtained and retained by the Organization as proof of oversight of expenditure of federal funds. CLA would also recommend the use of an AP voucher, or similar, for each type of disbursement that leaves the Organization (check, ACH, EFT, credit card, etc.) to improve documentary evidence that costs are being reviewed and approved for appropriateness. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls and training for all staff on documenting evidence of approvals, including obtaining and retaining necessary documentation and proof of expenditure oversight for federal funds to ensure there is adequate evidence that costs are being reviewed and approved for appropriateness. As noted above, we have added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. We are also investigating an AP voucher process through our existing accounting software. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Type of Finding: Material Weakness in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number...
Type of Finding: Material Weakness in Compliance and Internal Control over Compliance Federal Agency: U.S. Department of Defense Federal Program Name: Conservation and Rehabilitation of Natural Resources on Military Installations Assistance Listing Number: 12.005 Federal Award Identification Number and Year: H79TI083313 - 2020 Award Period: September 28, 2020, through September 27, 2025 Criteria or specific requirement: 2 CFR 200.320 requires non-federal entities to have and use documented procurement procedures. 2 CFR 200.318(i) states that "the non-Federal entity must maintain record sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price". In addition, 2 CFR 200.320(a)(2)(i) states that "... If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity". Furthermore, 2 CFR 200.320(b) states that "When the value of the procurement for property or services under a Federal financial assistance award exceeds the SAT, or a lower threshold established by a non-Federal entity, formal procurement methods are required. Formal procurement methods require following documented procedures. Formal procurement methods also require public advertising unless a non-competitive procurement can be used in accordance with § 200.319 or paragraph (c) of this section.". Condition: During our testing, it was noted that the Organization was not performing suspension and debarment checks prior to entering into vendor contracts to ensure the vendor was not listed in the suspended or debarred database maintained by the General Services Administration. In addition, the Organization does not have an established procurement policy nor procedures in place at the time of the audit in compliance with Uniform Guidance. Questioned costs: None. Context: For procurement, a sample of 8 was made from a population of 30 procurement transactions charged to the major program that exceeded $3,000 (the Organization's procurement policy after 2023 and below the minimum micropurchase threshold before it was increased by the FAR to $10,000 for those with a written established policy). Of the 8 sampled procurement selections, three did not retain an adequate number of price comparisons prior to exercising the procurement, four did not follow the formal procurement methods for proposals when required, and all lacked evidence of controls over procurement considerations. For suspension and debarment, a sample of 3 was made from a population of 3 (entire population) suspension and debarment transactions charged to the major program. Of the 3 sampled, all were not checked for suspension or debarment prior to entering into the transaction. Cause: Prior to completing the prior year’s audit, staff were not aware of the specific compliance requirements and procedures for procurement, suspension, and debarment status. Effect: Purchases may occur that do not follow the procurement, suspension and debarment standards as required by Uniform Guidance, and contracts to vendors that had been suspended or debarred could be awarded and not detected. Repeat Finding: The finding is a repeat of a finding in the immediately prior year. Prior year finding number was 2022-002. Recommendation: We recommend the Organization ensure its current process to review potential contractors for suspension and debarment is taking place prior to entering into transactions with such entities. The Organization has already taken steps to address considerations around procurement by implementing a Procurement Approval form. CLA recommends the use of this form, including signature, and emphasizes the importance of retaining adequate price rate quotations, RFP documentation, sole-source evidence, and price analyses in accordance with their established thresholds. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Previous corrective actions were completed in April 2024 upon receipt of our FY 2022 Audit from CLA. We believe these corrective actions would have captured most, if not all, of the findings if they were in place for the entire FY23 period. That said we have further reviewed and expanded our internal controls around procurement, suspension, and debarment, including the process for reviewing potential contractors for suspension and debarment. Specifically, we have added language in all agreement templates to ensure we are in accordance with Uniform Guidance. As noted, we have also added a procurement approval form and a standardized process for approval signature, quotes, sole source evidence and price analyses. As part of that effort, we have also updated threshold amounts for micro-purchase, small purchase, and procurement standards to be consistent with FAR and we are providing additional training to staff. Name(s) of the contact person(s) responsible for corrective action: Gary Slater Planned completion date for corrective action plan: 10/1/2024
Corrective Action: ABHS plans to optimize technology to improve the month-end closing process and allow for reconciliations to be performed on a consistent basis. Person Responsible: Alethea Velasquez, Chief Financial Officer, and CLA Estimated Completion Date: December 31, 2024
Corrective Action: ABHS plans to optimize technology to improve the month-end closing process and allow for reconciliations to be performed on a consistent basis. Person Responsible: Alethea Velasquez, Chief Financial Officer, and CLA Estimated Completion Date: December 31, 2024
View Audit 323061 Questioned Costs: $1
The hospital was not aware that this was a required filing and asked the audit team for support in filing this year. As a result, an action plan has been developed so that this is done internally in 2024.
The hospital was not aware that this was a required filing and asked the audit team for support in filing this year. As a result, an action plan has been developed so that this is done internally in 2024.
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, ...
Over the past three years the hospital has been working hard to overcome a very hard financial turnaround. As a result, days cash on hand has been extremely low and there has been no way for the facility to make payroll, vendor payments, and debt payments, while maintaining a debt reserve. However, over the past 12 months we have started to reap the reward of the hard work through operationally increasing revenue, reducing costs, and being more strategic on service lines. This will allow for us to hit the reserve amounts in 2025, while maintaining the cash flow needed for operations.
This was rectified mid-way through the 2023 year, when all covenants were reviewed with the USDA and Colliers Mortgage team. As a result, these reports have now been sent timely to USDA starting at the end of 2023 and have continued since then. The annual debt reserve calculation has not been provid...
This was rectified mid-way through the 2023 year, when all covenants were reviewed with the USDA and Colliers Mortgage team. As a result, these reports have now been sent timely to USDA starting at the end of 2023 and have continued since then. The annual debt reserve calculation has not been provided as that was not brought to the hospital’s direct attention during our bi-weekly USDA meetings. However, going forward these will be added.
Finding 2023-003: The Corporation did not complete an affirmative fair housing marketing plan (HUD Form 935.2A) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The affirmative fair housing marketing plan should be completed for th...
Finding 2023-003: The Corporation did not complete an affirmative fair housing marketing plan (HUD Form 935.2A) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The affirmative fair housing marketing plan should be completed for the period beginning September 1, 2023 and submitted to HUD for approval. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will complete the affirmative fair housing marketing plan and submit to HUD for approval.
Finding 2023-002: The Agent did not complete a management entity profile (HUD Form 9832) upon the change in management agents effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management entity profile should be completed for the period beginning September ...
Finding 2023-002: The Agent did not complete a management entity profile (HUD Form 9832) upon the change in management agents effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management entity profile should be completed for the period beginning September 1, 2023. Action(s) Taken or Planned on the Finding: The Agent concurs with the recommendation and will complete the management entity profile.
Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive app...
Finding 2023-001: The Corporation did not obtain a HUD approved management certification (HUD Form 9839-B) for the new management agent effective beginning September 1, 2023. Comments on the Finding and Each Recommendation: The management certification should be submitted to HUD for retroactive approval for the period beginning September 1, 2023. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will submit the management certification to HUD for approval retroactively.
View Audit 323052 Questioned Costs: $1
Until August 2023, the College followed its regular schedule for updating students’ enrollments in the NSLDS enrollment reporting system. The updates were always performed on time every 30 days at the beginning of each month. The process began each month with NSLDS generating a list of students that...
Until August 2023, the College followed its regular schedule for updating students’ enrollments in the NSLDS enrollment reporting system. The updates were always performed on time every 30 days at the beginning of each month. The process began each month with NSLDS generating a list of students that needed to be updated. Only students who received Title IV funds appeared on the list. Our procedure to update the students in NSLDS was done manually, and it involved running a report on the NSLDS website to update each student individually with his or her corresponding enrollment status. Sometimes students did not appear in the NSLDS database during the semester that they started until months after they started. The timing of appearance in the database depended on when the student’s aid was disbursed. Once the student appeared in the database, the College would update the enrollment and indicate that the effective date of the status went back to a date before the student appeared on the database. The College believes this is the reason why it appears that it was late in reporting the two students cited, since they did not appear on the database at the beginning of the term when they started classes but rather at a later date. The College stopped reporting manually to NSLDS as of August 2023 and started reporting electronically via the Clearinghouse in September 2023. This process involves reporting on all students, not just those on the NSLDS database. For example, the auditors identified a student who was reported on time to the Clearinghouse pursuant to that new process, but who did not appear on the NSLDS database until almost 3 months later. The new process allowed the auditors to see the reporting trail. The College believes this same situation happened to the two students cited. Unfortunately, the manual process of reporting to NSLDS does not provide the same audit trail as does the new electronic process using the Clearinghouse. Now that the College is using the Clearinghouse process, this issue should not recur.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures.
Management agrees with the finding and is in process of developing and implementing the appropriate policies and procedures.
Management agrees with the finding and made the required deposit in October 2023. Management is in process of incorporating procedures to ensure that all required surplus cash deposits are made timely in the future. There was no required deposit for calendar year 2023.
Management agrees with the finding and made the required deposit in October 2023. Management is in process of incorporating procedures to ensure that all required surplus cash deposits are made timely in the future. There was no required deposit for calendar year 2023.
LSNYC will ensure that the proper accounting period is selected for all subsidiary ledger entries, as well as all journal entries, before posting is approved into the general ledger. We will also train relevant staff on the importance of recording transactions in the correct period in order to minim...
LSNYC will ensure that the proper accounting period is selected for all subsidiary ledger entries, as well as all journal entries, before posting is approved into the general ledger. We will also train relevant staff on the importance of recording transactions in the correct period in order to minimize the likelihood of mistakes.
View Audit 323047 Questioned Costs: $1
This expense was reallocated to LSC in accordance with LSNYC's Cost Allocation Plan, which was developed to comply with LSC regulations on cost allocations and situations where funders will not cover certain costs. In this situation, the initial funder did not allow capital expenses, which is why th...
This expense was reallocated to LSC in accordance with LSNYC's Cost Allocation Plan, which was developed to comply with LSC regulations on cost allocations and situations where funders will not cover certain costs. In this situation, the initial funder did not allow capital expenses, which is why the expense was then allocated to LSC. In the future, we will get advance approval for expenses that we know will get allocated to LSC before they are purchased.
View Audit 323047 Questioned Costs: $1
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