Corrective Action Plans

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Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-006 Special Tests and Provisions Significant Deficiency in Internal Co...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-006 Special Tests and Provisions Significant Deficiency in Internal Control Over Compliance Finding Summary: The Organization did not request prior approval from HUD before entering into a finance lease agreement. A finance lease is identified in the Mortgage Note Insured by HUD as the incurrence of additional indebtedness which, by terms of the agreement, should be approved by HUD in advance of entering into such agreements. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: The Organization has enhanced internal control policies to ensure all lease agreements are evaluated to determine whether the lease should be accounted for as an operation or finance lease prior to entering into the lease. If the lease is concluded to be a finance lease, HUD should be notified, and the Organization should request and receive approval from HUD prior to entering into the lease agreement. Anticipated Completion Date: June 1, 2024
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-005 Special Tests and Provisions Significant Deficiency in Internal Co...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-005 Special Tests and Provisions Significant Deficiency in Internal Control Over Compliance Finding Summary: The Organization did not retain documentation of review and approval of certain invoices or Purchase Orders. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: The Organization has enhanced internal control policies to ensure all cash disbursements are reviewed and approval is documented prior to payment to ensure that all payments are necessary and correct. Anticipated Completion Date: June 1, 2024
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-004 Reporting Material Weakness in Internal Control Over Compliance an...
Cognizant or Oversight Agency for Audit U.S. Department of Housing and Urban Development Mortgage Insurance – Hospitals Federal Assistance Listing/CFDA #14.128 Findings Relating to Federal Awards and Questioned Costs Finding 2023-004 Reporting Material Weakness in Internal Control Over Compliance and Material Noncompliance Finding Summary: The Department of Housing and Urban Development (HUD) requires a quarterly reporting of financial and statistical data. Amounts reported under “All Non‐Operating Revenue” and “Other Changes in Fund Balance” in the Organization’s third quarter report submitted to HUD were not reconciled to and did not agree with the underlying financial data. The internal financial statements do not present all of the information that is required in the HUD quarterly reports and the differing information was all put to one line on the HUD quarterly report when the differences should have been evaluated and documented. Responsible Individuals: Charles Roeder, Vice President Finance/CFO Corrective Action Plan: To ensure the accuracy of the report, the Organization approved the policy Review of Reports Filed with Federal Agencies which details that the preparer of the report will submit it to the CFO or delegated staff member different from the preparer to review and formally approve before the report is filed with the federal agency. A different staff member will document and date the review and when formal approval was received and maintain a file on the process. Anticipated Completion Date: September 30, 2024
Management is in the process of assessing the organizational structure, capacity to provide adequate financial reporting. With Board review and approval of the Council’s financial funding sources, the Council will provide training additional training support the new fiscal officer. The fiscal office...
Management is in the process of assessing the organizational structure, capacity to provide adequate financial reporting. With Board review and approval of the Council’s financial funding sources, the Council will provide training additional training support the new fiscal officer. The fiscal officer will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. All enhancements will be implemented by July 31, 2024.
Finding 2023-001- Controls over Grant Reporting and Monitoring (Repeat Finding) Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewe...
Finding 2023-001- Controls over Grant Reporting and Monitoring (Repeat Finding) Procedures for reconciling grant reports on a quarterly basis have been developed. This includes a report created for each grant from the accounting system by the fiscal department. This report is available to be reviewed by the director or assistant director of the agency before being submitted to the grantor. A report comparing the cash request amounts made to the grantor to the general ledger has been implemented effective October 31, 2023. A procedure has also been developed to periodically monitor adherence to various grant requirements, as well as the development of documentation to support personnel activity tied to grants. The fiscal department implemented these effective January 1. 2024.
Association will develop more detailed policies for subrecipient monitoring, including responses to and consequences for subrecipient noncompliance, as well as procedures for reconciling monthly expenditure reports and drawdown requests to supporting documentation. Policies will be reviewed and appr...
Association will develop more detailed policies for subrecipient monitoring, including responses to and consequences for subrecipient noncompliance, as well as procedures for reconciling monthly expenditure reports and drawdown requests to supporting documentation. Policies will be reviewed and approved by the finance committee.
Views of Responsible Officials: District Bridges is currently researching time-tracking options, specifically for employees whose salaries are covered, full or partially, by federally-funded grants.
Views of Responsible Officials: District Bridges is currently researching time-tracking options, specifically for employees whose salaries are covered, full or partially, by federally-funded grants.
Views of Responsible Officials: During our FY22 audit, GRF expressly noted that for an organization our size, tracking grant expenses outside of Quickbooks was understandable and acceptable. During this FY23 audit, GRF changed its stance and said we had to report grant expenses in Quickbooks. This s...
Views of Responsible Officials: During our FY22 audit, GRF expressly noted that for an organization our size, tracking grant expenses outside of Quickbooks was understandable and acceptable. During this FY23 audit, GRF changed its stance and said we had to report grant expenses in Quickbooks. This should be removed as a finding, as District Bridges was following the advice of GRF from the FY22 audit. It is unconscionable to discredit an organization after they followed the firm's advice. Additionally, over the last few months, we have consulted several other nonprofit finance experts, as well as peer organizations that receive federal funds, to see tracking templates and procedures, and understand best practices. We are currently exploring more robust grant expense tracking softwares based on their recommendations, but they all noted that spreadsheet tracking was acceptable for an organization of our size.
We will monitor monthly to ensure deposits to Replacement Reserve are done on a timely basis.
We will monitor monthly to ensure deposits to Replacement Reserve are done on a timely basis.
December 31, 2023 Corrective Action Plan Finding Number: 2023-001 Condition: As of the audit testing date, Easterseals had obtained the key data elements required under the Transparency Act for subawards issued during the year but had not reported the data using the FFATA FSRS Tool. Planned Correc...
December 31, 2023 Corrective Action Plan Finding Number: 2023-001 Condition: As of the audit testing date, Easterseals had obtained the key data elements required under the Transparency Act for subawards issued during the year but had not reported the data using the FFATA FSRS Tool. Planned Corrective Action: Management has updated our procedures to ensure FFATA subaward reporting requirements are completed in a timely manner. Management has also updated the Easterseals Prime Award Checklist and Grantee Subrecipient Checklist to include the reporting of the subrecipient awards in the FFATA reporting system is performed in a timely manner, consistent with the FFATA reporting requirements. Contact person responsible for corrective action: Glenda F. Oakley, Chief Financial Officer Anticipated Completion Date: Completed
Finding 404842 (2023-003)
Significant Deficiency 2023
Guild
MN
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifyin...
Finding Summary: Guild’s controls did not operate as designed, which resulted in overbilling reimbursement for services in one month during 2023. Corrective Action Plan: Each receipt from this payer will be reconciled with the general ledger in the month received. In addition, the payer is modifying their payment support to show any payer-initiated adjustments. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024
Finding 404826 (2023-002)
Material Weakness 2023
Guild
MN
Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: Working with all Rental Assistance staff, we will develop a standard for documentation and a chec...
Finding Summary: Guild’s controls did not operate as designed, which resulted in rent reasonableness tests not being performed timely and/or reviewed before the rent being paid. Corrective Action Plan: Working with all Rental Assistance staff, we will develop a standard for documentation and a checklist for signing off by the responsible official. Responsible Individuals: Keith Rachey, Chief Financial Officer Anticipated Completion Date: Completed and staff trained by September 2024
While the entry of the poverty tables into our case management system is largely an administrative matter, LAWV will engage in review of this process in the future. Both LAWV’s Grants and Trainings Manager and LAWV’s Access to Services Manager will review the poverty tables following import in the c...
While the entry of the poverty tables into our case management system is largely an administrative matter, LAWV will engage in review of this process in the future. Both LAWV’s Grants and Trainings Manager and LAWV’s Access to Services Manager will review the poverty tables following import in the coming years. Furthermore, Legal Server has issued guidance that their case management system can import this information automatically as it serves numerous programs that are recipients of LSC funding. By using Legal Server’s automatic import feature to annually update the poverty tables and by adding the review by two LAWV managers, we believe that this will address the issue prospectively so that an incident such as this will not be repeated.
CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in g...
CORRECTIVE ACTION PLAN: We will take the necessary steps to get clear deadlines from the awarding agency on the reporting dates for Head Start and update our formal reporting schedule with those dates. The Head Start Fund Accountant will work with the Administrative Assistant/Facilities Manager in gathering the necessary information earlier in the year for the yearly property reporting (SF-429). The Head Start Fund Accountant will email copies of these reports to the Director of Head Start to ensure compliance.
Finding 404822 (2023-003)
Significant Deficiency 2023
Criteria: According to 2 CFR section 200.318(c) and 48 CFR sections 52.203-13 and 52.303-16, an entity should have written standards of conduct to cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts. According to 2 ...
Criteria: According to 2 CFR section 200.318(c) and 48 CFR sections 52.203-13 and 52.303-16, an entity should have written standards of conduct to cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts. According to 2 CFR section 200.214, an entity is subject to the non-procurement debarment and suspension regulations. Condition: During our testing of federal award expenditures, it was noted that there were no formal written policies in place for standards of conducts covering conflict of interests for employees engaged in the selection, award, and administration of contracts nor to determine if a vendor is suspended or disbarred. Recommendation: The City should create policies and procedures for applicable requirements in order to comply with Federal regulations including procedures that cover conflicts of interest and govern the performance of its employees engaged in the selection, award, and administration of contracts and for procedures to determine whether vendors have been suspended or debarred prior to entering into contracts or purchase orders for all transactions and maintain documentation supporting this verification View of Responsible Officials and Planned Corrective Action: 1. Develop Comprehensive Policies and Procedures:  Policy Development: Create policies that align with federal, state, and municipal regulations governing conflicts of interest and employee conduct in contract selection, award, and administration.  Conflicts of Interest Policy: Define clear guidelines and procedures for identifying, disclosing, managing, and mitigating conflicts of interest among employees involved in contracting activities.  Contract Administration Procedures: Establish detailed procedures that encompass the entire contract lifecycle, ensuring compliance with federal, state, and municipal requirements at every stage.  Training and Awareness: Conduct training sessions for employees involved in contracting to ensure understanding and adherence to the newly developed policies, procedures and current bid law regulations set forth by the State of Alabama. 2. Implement Procedures for Vendor Evaluation and Debarment Checks:  Vendor Evaluation Process: Develop standardized procedures for evaluating vendors before entering into contracts, including criteria for assessing qualifications, capabilities, and compliance with regulatory requirements.  Debarment Check Procedure: Establish a systematic procedure to verify whether potential vendors have been suspended or debarred by federal, state, or municipal authorities prior to initiating contract negotiations.  Documentation Requirements: Specify the documentation that must be collected and maintained to demonstrate compliance with vendor evaluation and debarment check procedures. 3. Maintain Comprehensive Documentation:  Document Retention Policy: Create a policy outlining requirements for retaining all documentation related to contracts, including vendor evaluations, debarment checks, contract awards, modifications, and performance records.  Centralized Documentation Management: Implement a centralized system or repository for storing and managing contract-related documentation, ensuring accessibility, security, and compliance with retention policies.  Audit Trail: Maintain a clear audit trail for all contract-related activities, documenting decisionmaking processes and actions taken to ensure accountability and compliance. 4. Monitoring and Compliance Oversight:  Monitoring Mechanisms: Establish mechanisms for ongoing monitoring of compliance with federal, state, and municipal regulations, as well as internal policies related to conflicts of interest, contract administration, and vendor debarment checks.  Regular Audits: Conduct regular audits of contract management practices and documentation to identify any deviations from established procedures and regulatory requirements.  Reporting and Accountability: Implement a reporting structure that provides regular updates to management and stakeholders on compliance status, audit findings, and corrective actions taken to address deficiencies. 5. Continuous Improvement and Adaptation:  Feedback and Review: Encourage feedback from employees involved in contract management to identify opportunities for improving policies, procedures, and compliance practices.  Benchmarking: Benchmark contract management practices against industry standards, best practices, and regulatory changes to continuously enhance processes and ensure alignment with evolving requirements.  Adaptation to Changes: Stay informed about updates and changes in federal, state, and municipal regulations impacting conflicts of interest, contract administration, and vendor management, and update policies and procedures accordingly.
The County Grants Manager will ensure that all subrecipients receiving $750,000 in Federal Funds undergo a Single Audit as required by 2 CFR Part 200. The Grants Manager will review the SEFA and contact all necessary subrecipients for their audits. Name of Contact Person: Kristi D. Bosch, Grants ...
The County Grants Manager will ensure that all subrecipients receiving $750,000 in Federal Funds undergo a Single Audit as required by 2 CFR Part 200. The Grants Manager will review the SEFA and contact all necessary subrecipients for their audits. Name of Contact Person: Kristi D. Bosch, Grants Manager Anticipated Completion Date: 12/31/2024
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under ...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s final expenditure listing identified as eligible and claimed under the Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution program (the program) was not reviewed and approved by a separate individual outside of the preparer. Additionally, the Hospital claimed mortgage reimbursements as expenditures under the program. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. Anticipated Completion Date: June 30, 2024
View Audit 311195 Questioned Costs: $1
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separat...
Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital’s lost revenue calculation was not reviewed and approved by a separate individual outside of the preparer. The Hospital’s lost revenue calculation was based upon actual revenue billed and reported within the Hospital’s electronic medical records (EMR) system which does not consider monthly or quarterly adjustments. The Hospital’s special report submitted to the Department of Health and Human Services for Period 4 TIN#460255944 was not reviewed and approved by a separate individual outside of the individual who inputted and submitted the report. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: A Grant Award Policy and Procedure Manual was established which includes, but not limited to, outlined internal controls around the review, approval, and tracking of grants/awards allowable expenses and reporting. The Hospital did not have Period 2 or Period 3 reporting requirements. The Phase 4 special report was submitted without review and approval over the report and lost revenue calculation due to limited personnel in finance. The Hospital does not have any additional special reports to complete for this federal program. Anticipated Completion Date: June 30, 2024
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a sep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: The Hospital’s requests for reimbursement under the Community Facilities Grant Agreement were not reviewed and approved by a separate individual. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Hospital personnel will compile the initial requests for reimbursement with the help of Management to provide proof of invoices and payments. The final request for reimbursement will then be verified by Management prior to requesting reimbursement to the Communities Facilities Grant Coordinator. Anticipated Completion Date: June 30, 2024
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeep...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Finding Summary: Management maintained the reserve amount in the cash sweep general fund account which was not established as a separate bookkeeping account or as a separate bank account. The Hospital had excess cash available to cover the required reserve amount. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will establish a separate bookkeeping account in the general ledger to establish the correct reserve amount of cash within its general operating bank account. The reserve account will be part of total cash in the bank to maximize interest earned on the reserve balance. Anticipated Completion Date: June 30, 2024
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Dis...
Federal Agency Name: Department of Agriculture Program Name: Communities Facilities Loans and Grants Cluster Federal Financial Assistance Listing #10.766 Federal Agency Name: Department of Health and Human Services Program Name: COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Financial Assistance Listing #93.498 Finding Summary: The Hospital does not have an internal control system designed to provide for a complete and accurate schedule of federal expenditures of federal awards being audited. As auditors, Eide Bailly LLP was requested to assist with the preparation of the schedule. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: It is not cost effective to have an internal control system designed to prepare the schedule of expenditures of federal awards. We requested that our auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. We have designated a member of management to review the drafted schedule of expenditures of federal awards, and we have reviewed with and agree with the final Schedule of Expenditures of Federal Awards. A Grant Award Policy and Procedure Manual was implemented defining tracking and reporting of awards to ensure accurate and up-to-date communication of award requirements. This communication will include implementing additional processes to improve our internal controls over identifying and reporting of expenditures in compliance with the Schedule of Expenditures of Federal Awards (SEFA) if applicable. We will provide staff training annually for any updates or adjustments to the policy. Anticipated Completion Date: Ongoing
he County agrees with the recommendation and will continue to work with the Procurement Services Department to ensure acceptable documentation has been retained. We will also discuss additional review procedures with the responsible departments for all contract awards with federal funding.
he County agrees with the recommendation and will continue to work with the Procurement Services Department to ensure acceptable documentation has been retained. We will also discuss additional review procedures with the responsible departments for all contract awards with federal funding.
View Audit 311191 Questioned Costs: $1
The County agrees with the recommendation and will work with the Grant Administrator to implement policies and procedures to ensure all pre-award payments occur within the grant timelines.
The County agrees with the recommendation and will work with the Grant Administrator to implement policies and procedures to ensure all pre-award payments occur within the grant timelines.
View Audit 311191 Questioned Costs: $1
The County will review the monitoring plan related to the program and will ensure these procedures are done timely and meet the federal requirements for monitoring subrecipients.
The County will review the monitoring plan related to the program and will ensure these procedures are done timely and meet the federal requirements for monitoring subrecipients.
COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no d...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds– Assistance Listing No. 21.027 Recommendation: The County should review and enhance internal controls and procedures to ensure that evaluation of independent audits is performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Division of Grants Management requires annual reports from all SLFRF subrecipients. We will be requesting a copy of all annual audits from the subrecipients for the most recent completed year. The accountant team will review audit reports for any findings of note. We recognize that some subrecipients will not have their most recent audit completed and will allow those who need extra time to submit their audits by the fall. Name(s) of the contact person(s) responsible for corrective action: Ashley Meyer Planned completion date for corrective action plan: 6/30/2024
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