Corrective Action Plans

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Finding Reference Number: 2023-001   Description of Finding:As required by 2 CFR 200.328, the auditee failed to submit the required Federal Financial Report (“SF425”) for two of their awards by the required due date of January 31, 2024.  Corrective Action: The Organization concurs with this find...
Finding Reference Number: 2023-001   Description of Finding:As required by 2 CFR 200.328, the auditee failed to submit the required Federal Financial Report (“SF425”) for two of their awards by the required due date of January 31, 2024.  Corrective Action: The Organization concurs with this finding and recognizes that the required SF425 reports for two awards were not submitted by the due date of January 31, 2024.   SEMI constantly communicates with the program managers for these awards and meets weekly to discuss project progress. The Organization has commonly received extensions for these reporting deadlines; however, this has not been documented in writing.   SEMI will evaluate process improvements to provide accounting information to the SEMI R&D team two weeks after the reporting period end date. This will help ensure sufficient time for the reports to be prepared and submitted 30 days after the reporting end date. If additional time is needed, SEMI will obtain prior written approval for report submission extension.   Name of Responsible Person: Kevin Bauer (Chief Financial and Business Operations Officer)  Melissa Grupen-Shemansk (Vice President, Technology Communities)  Anticipated Completion Date: The Organization anticipates completing the corrective action by Q4 2024.
Finding 497528 (2023-001)
Significant Deficiency 2023
Oregon Tilth, Inc. respectfully submits the following corrective action plan for the year ending December 31, 2023. Audit: January 1, 2023 to December 31, 2023. The finding from the schedule of findings is discussed below. The finding is numbered with the number assigned in the schedule. FINDING - F...
Oregon Tilth, Inc. respectfully submits the following corrective action plan for the year ending December 31, 2023. Audit: January 1, 2023 to December 31, 2023. The finding from the schedule of findings is discussed below. The finding is numbered with the number assigned in the schedule. FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department Agriculture 2023-001 Market Protection and Promotion – Assistance Lising #10.163 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: The issue with late Federal Funding Accountability and Transparency Act Subaward Reporting was identified by the auditors during the testing and review of documents during our first Single Audit. Management understood the importance of Immediate action and steps were taken to create and implement appropriate procedures, policies and controls. Action Plan: In order to prevent further tardiness with the submission of the obligated sub-recipient funding, a recurring Asana task item was created that reminds the Grant Finance Manager to submit the report 10 days before the end of the month following the obligation of funds. In addition, the Finance & Administration Director has also created a calendar task and reminder to be the stop gap check, and to approve the pdf of submitted reports before the close of the month. An addendum to the Fiscal Policies and Controls guide was sent to the board Finance Committee on Sept. 9th, 2024 that immediately implements the policy and details the oversight procedure for the submission and approval of reports. The sub-recipient FSRS FFATA excel worksheet schedule has been enhanced to include a page that details the month of the award, number of subrecipients and date the report was filed for that month. There is now a self-reporting column that indicates if the report was filed late. And lastly, the Grants Financial Manager has been ordered to insert written procedures into the Grant Internal Controls guide. Name(s) of the contact people responsible for correction action: Renee Kempka, Finance & Administration Director Abigail Soto, Grants Financial Manager Plan completion date for corrective action plan: September 30, 2024
Finding 497522 (2023-001)
Significant Deficiency 2023
Nā Puʻuwai agrees with the Auditor's advice and as a result, in June of 2024, we began the transition process to our new accounting team, Accumulus, and are confident that moving forward, we will comply fully with timely financial reporting requirements.
Nā Puʻuwai agrees with the Auditor's advice and as a result, in June of 2024, we began the transition process to our new accounting team, Accumulus, and are confident that moving forward, we will comply fully with timely financial reporting requirements.
Adventist Health implemented an action plan and established internal controls last year, following the conclusion of 2022 UG audit. Since the program has ended, no action is required at this time. We have also worked with HRSA to address any issues and findings from previous years. In the future,...
Adventist Health implemented an action plan and established internal controls last year, following the conclusion of 2022 UG audit. Since the program has ended, no action is required at this time. We have also worked with HRSA to address any issues and findings from previous years. In the future, similar programs will be managed by the Grants Management team, utilizing the established internal controls.
Finding 497516 (2023-005)
Significant Deficiency 2023
o As of June 30, 2024, LifeWire has implemented a new software package called VELA in which direct services staff enter their actual time worked to contracts, which is then reviewed and approved by their supervisors and reported to Finance staff for payroll processing. By December 31, 2024, the Fina...
o As of June 30, 2024, LifeWire has implemented a new software package called VELA in which direct services staff enter their actual time worked to contracts, which is then reviewed and approved by their supervisors and reported to Finance staff for payroll processing. By December 31, 2024, the Finance staff will ensure all 2024 actual hours worked toward contracts have been reviewed and approved by all direct services staff whose time is billed and approved by their supervisors. o Name of Responsible Individual: Jeannette Biffle, Controller
Finding 497511 (2023-004)
Significant Deficiency 2023
o By September 30, 2024, following the guidance of our CoC contract manager, the LifeWire Finance staff will have revised and resubmitted CoC RFRs submitted in 2024 to reflect match funds appropriately. All RFRs will indicate written documentation of review and approval by the Co-ED of Organizationa...
o By September 30, 2024, following the guidance of our CoC contract manager, the LifeWire Finance staff will have revised and resubmitted CoC RFRs submitted in 2024 to reflect match funds appropriately. All RFRs will indicate written documentation of review and approval by the Co-ED of Organizational Operations for match fund calculations and support required by our funders. Documentation of reports, review and approval is filed and maintained appropriately. o Name of Responsible Individual: Jeannette Biffle, Controller
Finding 497510 (2023-003)
Significant Deficiency 2023
o As of September 9, 2024, all outstanding required semiannual reports have been drafted by the Controller, approved by the Co-ED of Organizational Operations and submitted to HUD. All future required HUD reporting will be drafted by the Controller, reviewed and approved by the Co-ED of Organization...
o As of September 9, 2024, all outstanding required semiannual reports have been drafted by the Controller, approved by the Co-ED of Organizational Operations and submitted to HUD. All future required HUD reporting will be drafted by the Controller, reviewed and approved by the Co-ED of Organizational Operations, and subsequently submitted by the Controller by stated deadlines. Submitted reports will be filed and maintained appropriately. o On June 6, 2024 LifeWire requested to begin the close out process for this grant and is awaiting further instruction from HUD. When the close-out process is completed, no further reporting will be required for this grant. o Name of Responsible Individual: Jeannette Biffle, Controller
Finding 497505 (2023-002)
Material Weakness 2023
LifeWire’s advocacy team always strives to place survivors into housing where rent is reasonable and in line with fair market rates in eastern Washington. Though it was observed that all rents paid were comparable similar units in the area, our documentation was insufficient to prove we had performe...
LifeWire’s advocacy team always strives to place survivors into housing where rent is reasonable and in line with fair market rates in eastern Washington. Though it was observed that all rents paid were comparable similar units in the area, our documentation was insufficient to prove we had performed these analyses. o After this oversight was brought to our attention, as of June 30, 2024, LifeWire has trained the Housing Team staff on the necessity of completing rent reasonableness evaluations for every participant placed in housing where their rent is paid by the Continuum of Care program. Rent reasonableness assessments are completed by participants’ assigned advocate, reviewed and approved by their supervisor, signed and dated in PDF format, and filed and maintained appropriately. o As of June 30, 2024, LifeWire has implemented an additional 90-day documentation review for every participant in this program. At the 90-day mark, supervisors on the Housing Team review all participant documents to ensure that all compliance requirements are met. o Name of Responsible Individual: Jeannette Biffle, Controller
View Audit 320262 Questioned Costs: $1
Finding 497504 (2023-001)
Significant Deficiency 2023
o LifeWire’s Senior Accountants, Controller and Co-EDs carefully review all costs charged to contracts to ensure they fall within the appropriate contract period. As of September 9, 2024, all 2024 contract charges are captured in the correct periods. o If the staff of LifeWire has any question about...
o LifeWire’s Senior Accountants, Controller and Co-EDs carefully review all costs charged to contracts to ensure they fall within the appropriate contract period. As of September 9, 2024, all 2024 contract charges are captured in the correct periods. o If the staff of LifeWire has any question about the permissibility of a given charge, we will reach out to the contract manager, obtain clarification and/or permission in writing, and ensure that documentation is filed and maintained appropriately. If we are unable to obtain this permission, we will find another funding source for the charge or find alternate methods of supporting survivors’ needs. o Name of Responsible Individual: Jeannette Biffle, Controller
The Project is relatively small with only one administrative staff. Further the Board of Directors is a volunteer board and not a managing board. It does not have the time nor expertise to provide the necessary services to correct the internal control deficiencies noted. The Board of Directors has r...
The Project is relatively small with only one administrative staff. Further the Board of Directors is a volunteer board and not a managing board. It does not have the time nor expertise to provide the necessary services to correct the internal control deficiencies noted. The Board of Directors has reviewed this issue, and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies. As such, the Board of Directors accepts this finding.
Recommendation: We recommend the Society to establish an official written policy for subrecipient monitoring that is in line with the requirements of the Uniform Guidance. The policy should contain components for compliance with and references to Federal requirements, such as review of reports reque...
Recommendation: We recommend the Society to establish an official written policy for subrecipient monitoring that is in line with the requirements of the Uniform Guidance. The policy should contain components for compliance with and references to Federal requirements, such as review of reports requested from the subrecipient regarding project status, reviewing invoices to ensure spending is limited to expenses involving approved projects, and proper approval procedures key personnel perform to ensure these invoices are valid. Management Response and Corrective Action Plan Management's Response: We appreciate the auditor's thorough review and recommendations regarding our subrecipient monitoring processes. Legal Aid Society of San Bernardino is committed to maintaining the highest standards of compliance with federal regulations and ensuring proper oversight of subawards. We acknowledge the importance of having a comprehensive written policy that aligns with the requirements set forth in 2 CFR part 200, Appendix XI, Compliance Supplement May 2023, sections 3-M-1 and 3-M-2. Corrective Action Plan: 1. Formalize written policy: We will document our existing subrecipient monitoring practices into a comprehensive written policy that fully aligns with 2 CFR part 200, Appendix XI, Compliance Supplement May 2023, sections 3-M-1 and 3-M-2. This policy will include: a. Detailed procedures for reviewing financial and programmatic reports from subrecipients b. Guidelines for following up on and addressing any identified deficiencies c. Clear references to relevant Federal requirements 2. Standardize subaward agreements: We will develop a standardized subaward agreement template that incorporates all required elements as specified in the Uniform Guidance. This will ensure consistency and compliance across all subawards. 3. Enhance approval protocols: We will fortify our existing two-party approval system and bill.com submission process for payments. This reinforced procedure will ensure rigorous oversight and thorough validation of all subrecipient expenses, maintaining a robust checks and balances system that aligns with federal compliance requirements. 4. Implement regular reporting: We will continue our practice of requesting 6-month and end-of-year reports from subrecipients. This will help us monitor processes, identify any budget or client service deviations, and ensure ongoing compliance with subrecipient monitoring requirements. 5. Establish policy review process: We will implement an annual review of our subrecipient monitoring policies to ensure they remain current with any changes in Federal regulations. Planned Implementation Date: November 30, 2024 Responsible Person: Pablo Ramirez, Executive Director
Finding 497462 (2023-002)
Significant Deficiency 2023
Finding 2023‐002 Condition We selected three monthly submissions of GEARS and SPARC reports across multiple programs received by the Wisconsin Department of Human Services and the Wisconsin Department of Children and Families. One of the three GEARS and SPARC reports tested was not reviewed by an in...
Finding 2023‐002 Condition We selected three monthly submissions of GEARS and SPARC reports across multiple programs received by the Wisconsin Department of Human Services and the Wisconsin Department of Children and Families. One of the three GEARS and SPARC reports tested was not reviewed by an independent person before submission for reimbursement. Our sample was not statistically valid. Corrective Action Plan Corrective Action Planned: In September 2023, a review process was established and implemented starting with the August Claim to ensure that required reports are reviewed by someone other than the preparer of the reports prior to submission. Name(s) of Contact Person(s) Responsible for Corrective Action: Reports prepared by Kozue Bush, Finance Manager, will be reviewed by Chad Lillethun, FMS Division Administrator prior to submission. Anticipated Completion Date: Review process was implemented with the August 2023 claim.
Finding 497461 (2023-004)
Significant Deficiency 2023
Finding 2023‐004 Condition Both of the two reports selected for testing contained a contractor that was incorrectly reported as a subaward. Our sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Effective with the 2024 third quarter reporting, the contractor incorr...
Finding 2023‐004 Condition Both of the two reports selected for testing contained a contractor that was incorrectly reported as a subaward. Our sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Effective with the 2024 third quarter reporting, the contractor incorrectly reported as a subaward with Treasury was corrected. Name(s) of Contact Person(s) Responsible for Corrective Action: Jillian Stacey, Housing Program Specialist, made the correction. Anticipated Completion Date: July 2024
Finding 497460 (2023-003)
Significant Deficiency 2023
Finding 2023‐003 Condition Both of the two subawards selected for testing did not contain the required elements found in 2 CFR Part 200.332(a). The sample selected was not statistically valid. Corrective Action Plan Corrective Action Planned: The County will create Subrecipient Agreements for all pr...
Finding 2023‐003 Condition Both of the two subawards selected for testing did not contain the required elements found in 2 CFR Part 200.332(a). The sample selected was not statistically valid. Corrective Action Plan Corrective Action Planned: The County will create Subrecipient Agreements for all providers that are identified as pass‐through entities and amend their contracts to add the agreement to existing contracts. Name(s) of Contact Person(s) Responsible for Corrective Action: Jillian Stacey, Housing Program Specialist, and Dylan Seitz, Accountant Anticipated Completion Date: September 30, 2024.
Management understands the recommendations and is actively addressing the deficiencies identified by the auditors. Management has implemented improved internal processes over the past year to better track and allocate staff time across all grants, including federal grants, and maintain detailed tim...
Management understands the recommendations and is actively addressing the deficiencies identified by the auditors. Management has implemented improved internal processes over the past year to better track and allocate staff time across all grants, including federal grants, and maintain detailed time tracking for all staff that determine payroll allocations. Management recognizes there is further need to directly link time tracking to payroll allocation, and that we need more standardized bi-monthly supervisory approval processes for staff time tracking, and management approval of payroll allocations on a consistent basis. Management is implementing a new, significantly more robust financial accounting system that will standardize time tracking, payroll allocation and approval processes all within one system. This system was determined as a need at the beginning of 2024, and we have conducted a multi-month review and analysis process to identify the best system for our organizational needs. The system will be in place and fully operational within six (6) months and we expect it will directly address and remediate current challenges in all of the areas identified by the auditors. Anticipated Completion Date: December 2024
Condition: Controls in place were not adequate to ensure support for suspension and debarment check was retained. Planned Corrective Action: The Authority will work to establish a control that will ensure suspension and debarment checks are retained. Contact person responsible for corrective acti...
Condition: Controls in place were not adequate to ensure support for suspension and debarment check was retained. Planned Corrective Action: The Authority will work to establish a control that will ensure suspension and debarment checks are retained. Contact person responsible for corrective action: Shedreka Miller Anticipated Completion Date: 12/31/2024
Condition: Controls in place were not adequate to ensure the Authority complied with all requirements under 2 CFR. Planned Corrective Action: The Authority will work to establish a written procedure to follow requirements in 2 CFR 200.305. Contact person responsible for corrective action: Shedrek...
Condition: Controls in place were not adequate to ensure the Authority complied with all requirements under 2 CFR. Planned Corrective Action: The Authority will work to establish a written procedure to follow requirements in 2 CFR 200.305. Contact person responsible for corrective action: Shedreka Miller Anticipated Completion Date: 12/31/2024
The City will no longer rely on state or federal agencies’ determinations or safeguards to ensure vendor eligibility as it relates to suspension and debarment when participating in intergovernmental cooperative purchasing agreements and will continue to follow its other existing internal controls to...
The City will no longer rely on state or federal agencies’ determinations or safeguards to ensure vendor eligibility as it relates to suspension and debarment when participating in intergovernmental cooperative purchasing agreements and will continue to follow its other existing internal controls to ensure compliance with suspension and debarment requirements. Before entering into transactions expected to exceed $25,000 of federal funding, the City will: 1. Check for exclusions using the General Services Administration’s SAM.gov website (or that site’s successor), or 2. Collect a certification from the vendor indicating that the vendor is not suspended or debarred from governmental contracts, or 3. Include a clause within the contract with the vendor. The clause will indicate that the vendor is not suspended or debarred from governmental contracts.
Finding 497433 (2023-006)
Significant Deficiency 2023
2023-006: Procurement and Suspension and Debarment Requirements, Significant Deficiency and Noncompliance The City will improve its record‐keeping procedure to ensure that evidence of verification of contractors’ eligibility under the provisions of CFR 536.270‐4 is always maintained. The corrective ...
2023-006: Procurement and Suspension and Debarment Requirements, Significant Deficiency and Noncompliance The City will improve its record‐keeping procedure to ensure that evidence of verification of contractors’ eligibility under the provisions of CFR 536.270‐4 is always maintained. The corrective action will be fully implemented during the Fiscal Year 2023/2024 audit. The contact persons for this corrective action are Martin Martinez (Management Analyst ‐ Public Services) and Sabrina Chavez (Director of Community Services) of the City of Perris.
Finding 497432 (2023-005)
Significant Deficiency 2023
2023-005: Subaward Reporting Requirements for Federal Funding Accountability and Transparency Act (FFATA), Significant Deficiency and Noncompliance The City will implement monitoring procedures to ensure timely reporting of subaward information in line with the requirements of the Federal Funding Ac...
2023-005: Subaward Reporting Requirements for Federal Funding Accountability and Transparency Act (FFATA), Significant Deficiency and Noncompliance The City will implement monitoring procedures to ensure timely reporting of subaward information in line with the requirements of the Federal Funding Accountability and Transparency Act. The City’s Grants Manager will monitor the status of the subaward reporting on a quarterly basis to ensure effectiveness of the reporting procedures. The corrective action will be fully implemented during the Fiscal Year 2024/2025 audit. The contact persons for this corrective action are Sara Cortes‐dePavon (Grants Manager) and Michele Ogawa (Director of Economic Development and Housing Department) of City of Perris.
The sliding fee adjustment errors resulted from manual errors made by billing staff. Going forward, we will implement a process to ensure any manual adjustments are reviewed prior to be posted. We believe this will significantly reduce the risk for manual calculation errors going forward. Further, w...
The sliding fee adjustment errors resulted from manual errors made by billing staff. Going forward, we will implement a process to ensure any manual adjustments are reviewed prior to be posted. We believe this will significantly reduce the risk for manual calculation errors going forward. Further, we will implement a process to periodically review sliding fee adjustments throughout the year for accuracy.
All assets will be checked after entry into the inventory system to ensure that the correct account code is input into the inventory system. We will compare the coding on the inventory item to the purchase order that ties to the item. The person checking the code will place a check mark and initia...
All assets will be checked after entry into the inventory system to ensure that the correct account code is input into the inventory system. We will compare the coding on the inventory item to the purchase order that ties to the item. The person checking the code will place a check mark and initial the inventory item packet once complete. This will also ensure the proper management of the inventory asset for disposition and deletion.
The District will check all prevailing wage rates for all contractors that work on projects that are governed by the Davis Bacon Act. All Davis Bacon projects will include a list of contractors on the project to ensure completeness of the Prevailing Wage Reports.
The District will check all prevailing wage rates for all contractors that work on projects that are governed by the Davis Bacon Act. All Davis Bacon projects will include a list of contractors on the project to ensure completeness of the Prevailing Wage Reports.
2023-002 Allowable Activities/Cost Principles US Department of Education - AL #84.010 Title I Grants to Local Education Agencies Condition: The District was not in compliance wllh lhe Uniform Guidance as it was noted that management of the District was not preparing time and effort dastribution reco...
2023-002 Allowable Activities/Cost Principles US Department of Education - AL #84.010 Title I Grants to Local Education Agencies Condition: The District was not in compliance wllh lhe Uniform Guidance as it was noted that management of the District was not preparing time and effort dastribution records and could not produce source documentation to support the time and etfort applied to payroll expense that was charged to Tatle I Grants to Local Education Agencies. Cause: The District's internal controls to identify and document employees that require support for time and effort charged to Title I Grants to Local Education Agencies were not effective for the year ended June 30, 2023. Auditor Recommendation: We recommend the District review their internal controls to strengthen processes and improve procedures. We recommend the District complete all required time and effort certilications in a timely manner. Plan of Action: Ashland School District wall identify administrative-level staff to oversee federal programs, including Title l, to ensure compliance with all relevant Uniform Guidance activities. Dastrict and building staff will review guidelines and documentation requirements for all federal programs to improve record keeping and to allow appropriate review of federal program activities. Date of lmplementation: lmmediately and ongoing. lf there are any questions regarding this plan, please contact Scott Whitman by email at Scott.Whitman@ashland.k12.or.us or by phone at 54 1 482-281 1.
View Audit 320164 Questioned Costs: $1
2023-002 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserves, it was not fully funded. Cause: Yearly budget...
2023-002 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserves, it was not fully funded. Cause: Yearly budgeted transfers were not made to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account.
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