Corrective Action Plans

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Corrective Action: Management will work with the U.S. Department of the Treasury to re-establish access to the online reporting portal. NPHE will also print copies of all reports filed to ensure that reports are readily available for inspection. Person Responsible: Christine Brock, Interim Executive...
Corrective Action: Management will work with the U.S. Department of the Treasury to re-establish access to the online reporting portal. NPHE will also print copies of all reports filed to ensure that reports are readily available for inspection. Person Responsible: Christine Brock, Interim Executive Director Estimated Completion Date: July 31, 2024
Corrective Action: Nambe Pueblo Housing Entity (NPHE) will develop comprehensive policies and procedures for maintaining and retaining applications for assistance, as well as all other source documentation necessary to support the eligibility determination process. This initiative aims to ensure acc...
Corrective Action: Nambe Pueblo Housing Entity (NPHE) will develop comprehensive policies and procedures for maintaining and retaining applications for assistance, as well as all other source documentation necessary to support the eligibility determination process. This initiative aims to ensure accuracy, transparency, and compliance with regulatory requirements throughout the eligibility assessment. The enhanced documentation process will provide a robust framework to verify applicant eligibility, maintain records for auditing purposes, and improve overall operational efficiency. Person Responsible: Christine Brock, Interim Executive Director Estimated Completion Date: July 31, 2024
Corrective Action: NPHE will review and update the procurement policies to ensure that they clearly outline the requirements for competitive negotiations and bids. We will conduct training sessions as needed for all relevant staff to reinforce the importance of obtaining and retaining documentation ...
Corrective Action: NPHE will review and update the procurement policies to ensure that they clearly outline the requirements for competitive negotiations and bids. We will conduct training sessions as needed for all relevant staff to reinforce the importance of obtaining and retaining documentation for competitive negotiations and bids. This training will include best practices for procurement and record-keeping. We will also establish a standardized process for conducting suspension and debarment checks on SAM.gov and ensure that documentation of the check is included in the procurement file. Person Responsible: Christine Brock, Interim Executive Director Estimated Completion Date: July 31, 2024
Corrective Action: Management will improve its internal controls and procedures in place to ensure that expenditures charged to federal award are appropriate and permissible under the provisions of the award agreement. Person Responsible: Christine Brock, Interim Executive Director Estimated Complet...
Corrective Action: Management will improve its internal controls and procedures in place to ensure that expenditures charged to federal award are appropriate and permissible under the provisions of the award agreement. Person Responsible: Christine Brock, Interim Executive Director Estimated Completion Date: July 31, 2024
2023-002 [2022‐002]—PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presente...
2023-002 [2022‐002]—PREPARATION OF SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Federal Agency: All presented in the Schedule of Expenditures of Federal Awards. Program Name: All presented in the Schedule of Expenditures of Federal Awards. Assistance Listing Nos. and Program Expenditures: All presented in Schedule of Expenditures of Federal Awards. Award Number and Program Award Year: All presented in Schedule of Expenditures of Federal Awards. Compliance Requirement: Other – Schedule of Expenditures of Federal Awards preparation Statement of Condition During our audit, we reviewed the Coalition’s federal grants report for the fiscal year and identified the federal grants, Assistance Listing #s (AL#s) and the amounts of the federal expenditures and all of the other items required to properly present the Schedule of Expenditures of Federal Awards (SEFA). We then had the finance staff of the Coalition confirm the correctness of the SEFA. Despite the confirmation of accuracy, additional federal expenditures and grouping of grant expenditures were identified after several reviews of the SEFA.Criteria 2 CFR 200.510 indicates that the auditee must prepare a schedule of expenditures of federal awards (SEFA) for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with 2 CFR 200.502, Basis for Determining Federal Awards Expended. Per 2 CFR 200.502, the determination of when a federal award is expended should be based on when the activity related to the federal award occurs. Generally, the activity pertains to events that require the non-federal entity to comply with federal statutes, regulations, and the terms and conditions of federal awards, such as expenditure/expense transactions associated with awards. In addition, 2 CFR Part 200.303 requires the program to establish and maintain effective internal controls over federal awards that provides reasonable assurance of compliance with federal statutes, regulations, and the terms and conditions of federal awards. Effect Without an established process governed by effective internal controls, the Coalition may not prevent or detect material misstatements on its SEFA in a timely manner. In addition, the errors could result in improper selections of major program(s) for the single audit and a substandard single audit. Cause Historically, the Coalition has requested the auditor assist in identifying accruals related to federal grant expenditures as the organization has maintained these records on a cash basis. As the organization has taken more responsibility on maintaining its federal grant expenditures on an accrual basis, an incomplete SEFA has been provided. Recommendation We recommend the Coalition prepare the Schedule of Expenditures of Federal Awards and submit this to the auditor for testing. The SEFA should include the name of the grant, name of grantor, the AL #, the pass-through number if applicable and a reconciliation of the federal revenues and expenditures to the Coalition’s general ledger. The Coalition staff should perform more detailed reviews of the reports to ensure they properly reflect grant receipts and expenditures. This review should be performed by someone other than the preparer and should include documented evidence of agreeing the reported data to the accounting records. We further recommend training for those individuals involved in the preparation and review of the reports to ensure they are fully aware of the requirements. View of Responsible Officials and Corrective Action Plan: The corrective Action Plan will be carried out in the 2024 Fiscal Year and information will be given to the auditors when requested for the next audit. The Coalition will ensure that all information needed for the SEFA is kept and entered accurately (this process has already begun). When the fiscal year closes out, the Coalition will provide the auditors with a test SEFA to confirm that the information we are collecting throughout the year and are asserting are the correct numbers for our federal grants, is indeed the correct information. Corrective Action Plan Timeline: Completed by December 13, 2024 (Final copy of the SEFA will not be given to the auditors until requested for the 2024 Audit) Designation Of Employee Position Responsible For Meeting Deadline: Executive Director will oversee this project and work directly with NMCEH finance staff work closely with the auditors to make sure that the information saved and shared is correct. Type of Finding: (F) Significant Deficiency in Internal Control over Compliance of Federal Awards. Questioned Costs: None
Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance Initial Fiscal Year Finding Occurred: 2023 Finding Summary: St. Francis does not currently have an internal control system to provide for a complete and accurate schedule of expenditures ...
Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance Initial Fiscal Year Finding Occurred: 2023 Finding Summary: St. Francis does not currently have an internal control system to provide for a complete and accurate schedule of expenditures of federal awards (the Schedule). The auditors assisted in the preparation of the Schedule. Responsible individuals: Mari Chambers, Chief Financial Officer Status: Ongoing. It is not cost effective to have an internal control system designed to provide for the preparation of the Schedule. We will continue to have our auditors assist in the preparation as part of the audit.
The Agency will implement controls to ensure proper review and approval is obtained on required grant reports prior to submission to the grantor. Anticipated Completion: September 30, 2024 Responsible Party: Belinda Mitchell, Executive Director
The Agency will implement controls to ensure proper review and approval is obtained on required grant reports prior to submission to the grantor. Anticipated Completion: September 30, 2024 Responsible Party: Belinda Mitchell, Executive Director
Finding Number: 2023-002 CFDA Number: 14.157 – Supportive Housing for the Elderly Recommendations: Periodically throughout the year management should perform a proof of the account to make sure it is correct. Management Response: The processing of Reserve Requests is usually ceased at the end of bud...
Finding Number: 2023-002 CFDA Number: 14.157 – Supportive Housing for the Elderly Recommendations: Periodically throughout the year management should perform a proof of the account to make sure it is correct. Management Response: The processing of Reserve Requests is usually ceased at the end of budget season to ensure accuracy. This error was overlooked while pending approval and execution of the new budget. A deposit will be made immediately to rectify the amount– this will be completed prior to the end of the current fiscal year.
Finding number 2023-001 CFDA Number:14.157 – Supportive Housing for the Elderly Recommendations: When preparing reserve requests management should match invoices to the request and make sure invoices not already paid are paid timely paid after the withdrawal is made and have not been used for previo...
Finding number 2023-001 CFDA Number:14.157 – Supportive Housing for the Elderly Recommendations: When preparing reserve requests management should match invoices to the request and make sure invoices not already paid are paid timely paid after the withdrawal is made and have not been used for previous requests. Management Response: Management’s internal process for tracking and reviewing Replacement Reserve requests was revised in October 2023. The procedure now involves internal reviews of invoices by two separate parties, as well as an on-going shared tracking system for requests, prior to submission to avoid duplication.
Identifying Number: Finding 2023-002 – Federal Funding Accountability and Transparency Act Reporting (Significant Deficiency) Finding: Reports in compliance with the Federal Funding Accountability and Transparency Act (FFATA) were not completed. U.S. Department of Health and Human Services, Head ...
Identifying Number: Finding 2023-002 – Federal Funding Accountability and Transparency Act Reporting (Significant Deficiency) Finding: Reports in compliance with the Federal Funding Accountability and Transparency Act (FFATA) were not completed. U.S. Department of Health and Human Services, Head Start Cluster: Assistance Listing Number 93.600 Name of contact person and title: David Chimahusky, CFO, GLCAP Anticipated completion date: July 31, 2024 Great Lakes Community Action Partnership’s response: Concur Great Lakes Community Action Partnership agrees with this finding and provided the following response and corrective actions: Corrective Actions Taken or Planned: Management agrees that ineffective controls resulted in missed reporting required by the Federal Funding Accountability and Transparency Act (FFATA). To correct this, management will review all current awards for reporting applicability and will develop procedures to ensure all future awards are evaluated for FFATA reporting requirements and submitted in a timely manner. Tracking of awards and FFATA submission dates will be maintained for regular secondary review. Person(s) Responsible for Implementation: David Chimahusky, CFO
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action pla...
Finding: 2023-003 - Oversight over cash management compliance requirement. Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has addressed the finding that its policies and procedures over reimbursement requests for federal funds lacked proper documentation of approvals according to the Uniform Guidance for federal grants. We have added a step in the online submission process with the Substance Abuse and Mental Health Services Agency (SAMHSA) to capture a screenshot of the reimbursement form to be approved before submission. Due to the timing of the FY 2022 Single Audit completion and the ending of the CCBHC contract, we were limited in the execution of this new procedure, however it is now part of our Single Audit accounting Policies and Procedures Manual. Anticipated completion date: Completed September 2023.
Finding: 2023-002 - Written policies required by the Uniform Guidance Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned:...
Finding: 2023-002 - Written policies required by the Uniform Guidance Contact Person(s): Dan Gehl, CFO (dgehl@cmhshare.org) Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreements. Corrective action planned: In September 2023, CLR has implemented written policies and procedures for Single Audit accounting that comply with the Uniform Guidance for federal grant payments, procurement, allowable costs, and compensation. They will also be posted online via the company website for access by all staff. Going forward, these policies will be reviewed and updated as needed following the general CLR process for all policies and procedures. Anticipated completion date: Completed September 2023.
Views of Responsible Individuals and Planned Corrective Action - Management is attempting to repay $35,248 into the replacement reserve over the next 12 months. Management is awaiting response from HUD regarding receiving the balance due for the voucher which was not paid in full. Completion date - ...
Views of Responsible Individuals and Planned Corrective Action - Management is attempting to repay $35,248 into the replacement reserve over the next 12 months. Management is awaiting response from HUD regarding receiving the balance due for the voucher which was not paid in full. Completion date - March 31, 2025 Contact person - Sonal Shah, Controller
Views of Responsible Individuals and Planned Corrective Action - Management is aware of the deposit requirements and has funded the delinquent amount. Completion date - March 20, 2024 Contact person - Sonal Shah, Controller
Views of Responsible Individuals and Planned Corrective Action - Management is aware of the deposit requirements and has funded the delinquent amount. Completion date - March 20, 2024 Contact person - Sonal Shah, Controller
Corrective Action Plan – Subrecipient Risk Assessment Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Jennifer Kennedy Title: Director, Sponsored Programs Finance Telephone: 617-638-2852 E-mail address: Jennifer.Kennedy@bmc.org Audit Report Reference: 2023...
Corrective Action Plan – Subrecipient Risk Assessment Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Jennifer Kennedy Title: Director, Sponsored Programs Finance Telephone: 617-638-2852 E-mail address: Jennifer.Kennedy@bmc.org Audit Report Reference: 2023-003 Anticipated Completion Date: September 30, 2024 Corrective Action Planned: The primary cause of the identified issue was due to personnel changes within Sponsored Programs Administration (SPA). This turnover led to a gap in recording and establishing the subrecipient risk assessment process before finalizing subaward agreements. However, SPA reviewed subrecipient single audit reports prior to issuing subaward agreements. 1) Review of Risk Assessments for current active subawards: SPA will conduct a review of all current subrecipients and document a risk assessment for each by the end of FY24. All new active subawards beginning October 1, 2024, will follow the updated SOPs and policies to ensure compliance and consistency. 2) Updating SOPs: SPA will update the Standard Operating Procedures (SOPs) pertaining to Subaward Issuance (Risk Assessments, Monitoring, Reporting, etc.) to ensure continuity and consistency, regardless of personnel changes. The updated SOPs will include specific steps for subaward issuance and will be reviewed and updated annually as necessary. In addition to the above actions, SPA is in the process of opening a new role for a Subaward Specialist who will be a dedicated FTE for subaward management. The new employee will pair with the SPA Associate Director as they onboard. This role will oversee subrecipient risk assessments, subaward issuance, and FFATA reporting. A centralized role will allow for consistency and expertise on all subrecipient management pre-award and non-financial post-award processes. This role will contribute to maintaining and updating current SOPs pertaining to subaward management and monitoring. By implementing these measures, we are confident in our ability to manage personnel changes effectively and ensure that critical functions, such as subrecipient risk assessments, are carried out with the highest level of accuracy and compliance.
Corrective Action Plan – Infor Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Marley Crowell Title: Senior Director, Finance Systems Telephone: 617-780-6400 E-mail address: marley.crowell@bmc.org Audit Report Reference: 2023-002 Anticipated Completion Da...
Corrective Action Plan – Infor Fiscal Year Ended September 30, 2023 Program name: Research and Development Audit Contact: Marley Crowell Title: Senior Director, Finance Systems Telephone: 617-780-6400 E-mail address: marley.crowell@bmc.org Audit Report Reference: 2023-002 Anticipated Completion Date: September 30, 2025 Corrective Action Planned: 1) For the Infor user access review deficiency: a. Management has scoped and performed limited access reviews in FY2024 related to privileged administrative access. b. Management has worked to identify financially significant Infor user security roles in order to properly scope and implement business user access reviews starting in FY2024, noting that the implementation timeframe will span FY2024 and FY2025. c. IT management will be working with operational management to educate as to how to properly perform access reviews, and then to implement those reviews starting in FY2024 and FY2025. d. Once reviews have been performed, IT management will assess the results and terminate any access deemed to be unnecessary. As part of this process IT management will perform risk assessment procedures for these users if deemed necessary (e.g. if no other controls are in place to mitigate the perceived risk, etc.). 2) For the access termination deficiency: a. Management completed an education session for BMC leaders in FY24 which included the importance of the termination process including timeliness of employee terminations by the business to HR and IT via the established pathways of communication of these items. b. The established process would automatically allow for very timely termination of access provided that initial notification was timely. c. Communication and/or education about timely termination of employees will be repeated at intervals throughout the year in order to reinforce the message and account for changes in management personnel, who are tasked with this process.
Corrective Action Plan – Workday Fiscal Year Ended September 30, 2023 Program name: Research and Development Cluster (R&D) and Provider Relief Fund (PRF) (93.498) Audit Contact: Matthew O’Connor Title: Senior Director, Human Resources Operations & Analytics Telephone: 617-638-8495 E-mail address: ...
Corrective Action Plan – Workday Fiscal Year Ended September 30, 2023 Program name: Research and Development Cluster (R&D) and Provider Relief Fund (PRF) (93.498) Audit Contact: Matthew O’Connor Title: Senior Director, Human Resources Operations & Analytics Telephone: 617-638-8495 E-mail address: Matthew.OConnor@bmc.org Audit Report Reference: 2023-001 Anticipated Completion Date: December 31, 2024 Corrective Action Planned: 1) For the Workday change review, management has been re-educated on the importance of this review as well as how to complete it completely and timely. Management will perform this review for the fiscal year ended September 30, 2024 and each subsequent fiscal year. Additionally, this review will be timely reviewed by somebody separate from the preparer and the documentation of the review and subsequent approval will be retained in BMC’s records. 2) For the access provisioning deficiency, management has been re-educated on the importance of following policy with respect to granting new access to Workday, including that this granting of access be appropriately documented and approved prior to the date of provisioning said access. Additionally, documentation of the approval of access will be properly retained in the company’s records.
Finding 404938 (2023-001)
Significant Deficiency 2023
Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.568 Low Income Home Energy Assistance Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of taking the LIHEAP Operators Guide and creating an Action Policy/Procedure manual ...
Federal Agency: U.S. Department of Health and Human Services Federal Program: 93.568 Low Income Home Energy Assistance Responsible Official Jennifer Beloff, Chief Program Officer Plan Detail Action is in the process of taking the LIHEAP Operators Guide and creating an Action Policy/Procedure manual updating /highlighting findings from current and past audits for staff to keep current and for new staff to review when they start working in the LIHEAP program. At the start of the LIHEAP program year, the Energy Director will meet with all staff and review program highlights, changes and new instructions and have staff signoff having participated in the meeting. Anticipated Completion Date June 30, 2024
CORRECTIVE ACTION PLAN: The Organization will adopt procedures that allow for the timely tracking of refundable advances, to ensure funds are properly expended during the period of performance.
CORRECTIVE ACTION PLAN: The Organization will adopt procedures that allow for the timely tracking of refundable advances, to ensure funds are properly expended during the period of performance.
Condition: During our audit, we noted that there is a lack of segregation of duties in the accounts payable and cash disbursement process. We noted that one employee had the ability to receive invoices, record expenses in the general ledger, write and sign checks, and reconcile internal accounting r...
Condition: During our audit, we noted that there is a lack of segregation of duties in the accounts payable and cash disbursement process. We noted that one employee had the ability to receive invoices, record expenses in the general ledger, write and sign checks, and reconcile internal accounting records. Additionally, our test of cash disbursements identified 5 out of 8 federal expenditures tested that lacked proper approval by an appropriate level of management outside of the cash disbursements accounting function. Corrective Action Planned: The Airport Director will begin reviewing and documenting approval for all expenses and financial reconciliations. Effective immediately, check signing ability will be removed from the employee responsible for the accounts payable process. In addition, management will evaluate current office personnel and determine if accounting functions can be segregated between current personnel or if an addition of an employee is needed. Anticipated Completion Date: Review and approval action plans will be implemented immediately (as of the date of the auditor’s report). In addition, management will begin an immediate evaluation of current personnel and job functions as it relates to the accounting process. Person Responsible for Corrective Action Plan: Barry Griffith, Airport Director Telephone: (256) 383-2270
We are aware of the condition and will review procedures to make changes when appropriate and cost effective.
We are aware of the condition and will review procedures to make changes when appropriate and cost effective.
Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting o...
Going forward, our internal policies and procedures will be updated to comply with the requirements in place for entities receiving federal awards. Additionally, we believe our new general ledger and payroll integrated software will provide better control and clarity to our recording and reporting operations. We will consult with other agencies of similar size and construct, as well as the Michigan Association of Local Public Health in areas where guidance is needed to return to strict compliance.
View Audit 311309 Questioned Costs: $1
We take the findings and recommendations of the disinterested third party auditor very seriously. Going forward, all federal awards will be reconciled quarterly to ensure they comply with the Schedule of Financial Assistance and individual grant funding requirements. We will work with our auditors e...
We take the findings and recommendations of the disinterested third party auditor very seriously. Going forward, all federal awards will be reconciled quarterly to ensure they comply with the Schedule of Financial Assistance and individual grant funding requirements. We will work with our auditors early to determine acceptable documentation requirements and do random sampling internally, throughout the year, to determine appropriateness of all cash receipts, general expenditures, payroll expenditures, and allocated costs.
U.S. Department of Health and Human Services 2023-001 COVID-19 Provider Relief Fund (PRF) – Assistance Listing No. 93.498 Recommendation: We recommend Saint Joseph’s Living Center, Inc. enhance its review of PRF reporting information in any applicable future grant reporting submissions in order to...
U.S. Department of Health and Human Services 2023-001 COVID-19 Provider Relief Fund (PRF) – Assistance Listing No. 93.498 Recommendation: We recommend Saint Joseph’s Living Center, Inc. enhance its review of PRF reporting information in any applicable future grant reporting submissions in order to avoid errors going forward. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We plan to implement an enhanced process for review of reporting requirements for future grant reporting submissions. Name(s) of the contact person(s) responsible for corrective action: Ginny Person, Administrator Planned completion date for corrective action plan: July 2024 If the U.S. Department of Health and Human Services has questions regarding this plan, please call Ginny Person at 860-456-1107.
The City will review SAM.gov for suspension and debarment vendors. The City will document evidence of completion.
The City will review SAM.gov for suspension and debarment vendors. The City will document evidence of completion.
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