Corrective Action Plans

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Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has take...
Management Response: CLUES’ financial management detected an oversight in billing a specific unallowable cost to certain grants that fund our Behavioral Health (“BH”) clinics. The oversight was promptly investigated, and we immediately remedied the situation with the affected funders. CLUES has taken action to prevent similar potential errors in the future. Two of our grants account for the majority of the improper billing total. The funders agreed that we can charge other billable expenses not previously covered. CLUES expended all funds with the funder’s approval. This matter was resolved and reported to the funder’s satisfaction. Action taken in response to finding: Management immediately identified the scope of the billing discrepancy, contacted the funders to resolve it, and have incorporated training and monitoring procedures internally to ensure we do not inadvertently bill such unallowable costs again. Proper review processes have been implemented to detect and prevent similar findings in the future. Name of the contact person responsible for corrective action: Ryan Robinson (VP of Finance & Administration) Planned completion date for corrective action plan: This matter was resolved in May 2024.
Finding 400835 (2023-006)
Significant Deficiency 2023
Company-wide reports are submitted monthly to the Board of Directors for approval. Reports that are submitted are separated by grant, so that the Board of Directors can see the activity in each grant for each month during the fiscal year. The reports submitted to the funders by Marlon Mitchell are t...
Company-wide reports are submitted monthly to the Board of Directors for approval. Reports that are submitted are separated by grant, so that the Board of Directors can see the activity in each grant for each month during the fiscal year. The reports submitted to the funders by Marlon Mitchell are taken from the financial reports that are approved by the Board of Directors. In addition, Marlon does not enter the financial information, nor does he prepare the monthly reports submitted to the Board. He serves as a fourth set of eyes on the information before the reports are submitted to the funders. Khayriyah Mitchell enters all of the revenue and expenditures into the accounting system, Shanelle Herman reconciles the bank and credit card accounts and runs the reports for the Board of Directors, the Board reviews and approves the financial statements, and Marlon Mitchell uses the approved financial information to create the reports to the grant funding agencies.
It is the policy that either Marlon Mitchell or James Kilgore approves expenditures of the programs. FirstFollowers is not in the habit of initialing the invoices, so we will purchase a stamp to provide physical evidence that the invoice requests and/or receipts have completed the review steps. Eith...
It is the policy that either Marlon Mitchell or James Kilgore approves expenditures of the programs. FirstFollowers is not in the habit of initialing the invoices, so we will purchase a stamp to provide physical evidence that the invoice requests and/or receipts have completed the review steps. Either Marlon or James will date/initial with the approval stamp. All the contractors and employees have a yearly review of their salary and/or hourly rates. Those contracts are written and kept in the files of FirstFollowers and were provided to CliftonLarsonAllen upon request. We will continue to update these contracts each fiscal year and ensure that the contracts are reviewed by the Board of Directors and noted in the minutes.
The Organization is in the process of developing a procurement policy and suspension and debarment policies that aligns with Uniform Guidance.
The Organization is in the process of developing a procurement policy and suspension and debarment policies that aligns with Uniform Guidance.
In June 2021, a procedure was implemented to ensure thorough documentation of participant eligibility within the program. The current audit revealed deficiencies in documentation for clients enrolled in the grant prior to June 2021. The organization will conduct a comprehensive review of all grant p...
In June 2021, a procedure was implemented to ensure thorough documentation of participant eligibility within the program. The current audit revealed deficiencies in documentation for clients enrolled in the grant prior to June 2021. The organization will conduct a comprehensive review of all grant participants to address and rectify any documentation gaps, including those enrolled before June 2021.
USD #250 has implemented new procedures to ensure that information provided to the Food Service Director is correct. Personnel have been trained in the poper way to run reports under the District's accounting system. In addition, the Director of Business Operations will review the annual food serv...
USD #250 has implemented new procedures to ensure that information provided to the Food Service Director is correct. Personnel have been trained in the poper way to run reports under the District's accounting system. In addition, the Director of Business Operations will review the annual food service report prepared by the Food Service Director before it is submitted to the Kansas Department of Education.
2023-004 – WIOA Cluster – Subrecipient Financial Monitoring This finding recommends the Organization completes subrecipient financial monitoring for FY23 for the WIOA cluster to comply with the grant compliance requirements, to implement additional controls over subrecipient monitoring going forward...
2023-004 – WIOA Cluster – Subrecipient Financial Monitoring This finding recommends the Organization completes subrecipient financial monitoring for FY23 for the WIOA cluster to comply with the grant compliance requirements, to implement additional controls over subrecipient monitoring going forward, and to verify that subrecipients get all required audits completed. The Organization is working toward completing this subrecipient financial monitoring and will continue to improve controls in this area during FY24.
Finding No. Name of Responsible Official Management’s Response to Findings Description of Corrective Action 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding for CFDA 93.498 where Period 5 Provider Relief Funds (PRF) were excluded on the original SE...
Finding No. Name of Responsible Official Management’s Response to Findings Description of Corrective Action 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding for CFDA 93.498 where Period 5 Provider Relief Funds (PRF) were excluded on the original SEFA and an adjustment of $9,234,533 was required. 2023-001 John Proni, Director of Finance_x0002_Hospital Division Management agrees with the finding and the corrected amount on the federal SEFA. On the original draft of the SEFA, for CFDA 93.914 expenses were included from February 2024 dates of service. An adjustment of $152,329 was required Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Anticipated Completion Date Completion of SEFA for Fiscal Year 2024 will be completed in first quarter 2025.
Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actio...
Management acknowledges the delay in completing the FYE 2023 audit and filing the Data Collection Form (SF-SAC) on time. We have since completed the audit and submitted the required documentation to the Federal Audit Clearinghouse. To prevent recurrence of this issue the following corrective actions will be implemented: -Establish a detailed timeline for the audit process, including key milestones and deadlines -Conduct regular progress review to ensure adherence to the timeline -Allocate additional resources to the finance departments as needed during critical periods to ensure timely completion of tasks -Improve communication between the audit team and mangement to promptly address any issues that may cause delays. Responsible Party: Ed Gonzalez, CFO, will be responsible for overseeing the implementation and execution of this corrective action plan. Estimated Completion Date: The corrective actions outlined above are expected to be fully implemented by May 31, 2024. We are committed to ensuring compliance with all financial reporting obligations and will take the necessary steps to prevent future occurrences of such delays.
Late Filing of Required Reporting of Federal Awards/Grant. CAL-PEP Inc.’s Data Collection Form and Reporting Package was not submitted to the Federal Clearinghouse within extended due date. Corrective Action Plan: Policy and Procedures on the submittal of Data Collection Form and Reporting Package t...
Late Filing of Required Reporting of Federal Awards/Grant. CAL-PEP Inc.’s Data Collection Form and Reporting Package was not submitted to the Federal Clearinghouse within extended due date. Corrective Action Plan: Policy and Procedures on the submittal of Data Collection Form and Reporting Package to the Federal Clearing House within extended due date had been established. Policy is shown below: The reporting package for the Federal clearing house must be submitted 30 days after receipt of auditor's report, or 9 months after end of the fiscal year whichever comes first, (February). In order to meet the deadline, a request to start the company audit will be arrange at the earliest, by August every year. In case an Audit Report is expected not to be receive within 9 months after fiscal year, a written extension must be submitted by the Finance Manager.
Finding 2023-002: Reporting - Significant Deficiency in Internal Control over Compliance Management agrees with the finding and the auditor's recommendation. Contact Person responsible for corrective action: Patrick Williams Deputy Finance Director pwilliams@clackamas.us 971-325-5392 Corrective Acti...
Finding 2023-002: Reporting - Significant Deficiency in Internal Control over Compliance Management agrees with the finding and the auditor's recommendation. Contact Person responsible for corrective action: Patrick Williams Deputy Finance Director pwilliams@clackamas.us 971-325-5392 Corrective Action Planned: Procedures will be incorporated into the County workflow to provide additional monitoring, oversight, and record retention related to reporting. These will include: -Compiling a comprehensive inventory of grants and reporting deadlines, including for reporting submitted by departments -Timely monitoring for the status of reporting and tracking of extensions. -Obtain copies of all grant reports and documentation of extensions -Report status of pending and/or delinquent reports due to funding sources at quarterly Finance/Performance Clackamas Check-in meetings with Health, Housing, & Human Services Director's Office. Anticipated Completion Date: September 30th, 2024
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pomeroy School District No. 110 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Fe...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pomeroy School District No. 110 September 1, 2022 through August 31, 2023 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2023-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal suspension and debarment requirements. Name, address, and telephone of District contact person: Kelly McKeirnan, Business Manager 121 S. 10th St. Pomeroy, Washington 99347 (509) 843-3393 Corrective action the auditee plans to take in response to the finding: The District is committed to ensuring grant programs comply with federal regulations regarding suspension and debarment. In response to the audit finding, the District is taking the following corrective actions to address the audit recommendations: * Program staff will check the federal System for Award Management (SAM.gov) prior to the contract execution date. The contractor verification documentation will be maintained in each contract file. Due to the audit finding being issued late in the fiscal year 2024 audit cycle, the District was not able to fully implement corrective actions during the 2024 audit period. The District anticipates full compliance with the suspension and debarment requirement by fiscal year 2025. Anticipated date to complete the corrective action: 10/31/2024
U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are ...
U.S. Department of Health and Human Services Southern Illinois Healthcare Foundation respectfully submits the following corrective action plan for the year ended December 31, 2023. Audit period: January 1, 2023 – December 31, 2023 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF HEALTH AND HUMAN SERVICES 2023 – 001 Consolidated Health Centers Recommendation: Management should adhere to or revise the Organization’s existing procurement policy and implement a system of processes and internal controls to ensure that the appropriate level of documentation is maintained based on the procurement methodology selected for a transaction of contract. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Hospital will ensure that controls are put into place to ensure procurement procedures are followed. Name of the contact person responsible for corrective action: John Jeffries, CFO. Planned completion date for corrective action plan: January 1, 2024. If the Department of Health and Human Services has questions regarding this plan, please call John Jeffries at 618-332-5324.
The Executive Director and Senior Director of Finance will work with the Controller to update the procedures for the SEFA incorporating additional steps that share the responsibility for recording Federal Expenses and Revenue in line with the needs of the SEFA report.
The Executive Director and Senior Director of Finance will work with the Controller to update the procedures for the SEFA incorporating additional steps that share the responsibility for recording Federal Expenses and Revenue in line with the needs of the SEFA report.
The Executive Director and Senior Director of Finance will engage with all team members whose responsibilities include posting to the OC0 General Ledger; updates will be completed on the procedure to provide clarifications where needed. A general step by step process/guide for reviewing ledgers for...
The Executive Director and Senior Director of Finance will engage with all team members whose responsibilities include posting to the OC0 General Ledger; updates will be completed on the procedure to provide clarifications where needed. A general step by step process/guide for reviewing ledgers for common mistakes and methods of investigation will be incorporated into the procedure. Training will be completed for those who are authorized to post to the general ledgers and corrective actions will be issued as errors are identified. The Controller will continue to complete monthly reviews of the ledger in accordance with the updated procedures.
Finding 2023-001: Allowable costs – significant deficiency in internal controls over compliance and compliance finding. Management Response CCGD was issued monitoring findings by HHSC for the monitoring period October 2021 (FY 21) -November 2022 (FY 22) in April 2023. As a result of that finding, CC...
Finding 2023-001: Allowable costs – significant deficiency in internal controls over compliance and compliance finding. Management Response CCGD was issued monitoring findings by HHSC for the monitoring period October 2021 (FY 21) -November 2022 (FY 22) in April 2023. As a result of that finding, CCGD received a finding in its 2022 audit. Because of the timing of the findings, as noted in the 2023 audit report, there was not time to resolve the issue before 2023. Therefore, even though the below described plan was implemented in 2023, immediately upon receipt of the initial finding, CCGD was still issued a finding in its FY2023 audit. The notification was received in the 7th month of fiscal year 2023, the following plan has been implemented. o Timesheet and GL mismatch i. Management Response: 1. Perform an audit of existing setup of HRIS-Paycom system to determinecause of mismatch 2. If needed, reimplement Paycom with required setup or change vendors 3. All departments along with respective service categories werereestablished in Paycom to only display employees applicable servicecategories based their respective grants. 4. Conduct quarterly audits of timesheets and GL to ensure there are nomismatches. 5. Time study was performed on quarterly basis to ensure individualperformance complies with funders mandate. ii. Progress Update - GL and Timesheet Mismatch: 1. Audit of existing setup to review the following: a. Department(s) - revised department names/descriptions i. Made changes to all applicable employees’ setup. b. Home Allocation(s) – revised home allocation(s)i. Revised/edited the default home allocation description ii. Assigned correct default home allocation to employees c. Service Categories i. Revised/edited service categories assigned to each department 2. Observations: a. Following Paycom updates, CCGD experienced technical challenges due to software glitches which continued to result in timesheet and GL mismatches. CCGD is continuing to work with Paycom to identify and eliminate the problem. b. CCGD subsequently sought assistance from Paycom in the troubleshooting process. 3. Departmental training of timekeeping process a. Personalized standard operating procedures used b. Real-time examples/instruction provided to staff in training session(s) 4. Post-training audits conducted to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheetsiii. Future Steps and Anticipated Timeline: 1. Continuation of post-training audits to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheets 2. With an anticipated deadline completion date of December 31, 2023, for adherence of full compliance, CCGD effectively implemented system updates prior to this deadline to ensure payroll processing is now based on the actual time and effort performed. iv. Progress Update – Performance Activity Report 1. To provide further back up to time and effort, an additional option in Paycom was enabled for staff to enter notes on day-to-day activity. 2. Departmental training on this goal was performed and completed as of March 31, 2024. 3. Continuation of post-training audits to include: a. Timecard/sheet review b. GL review and comparison of timecards and sheets v. Post implementation plan and observation: CCGD is fully committed to complying with funders and audit standards. Furthermore, CCGD will continue to monitor and identify any potential errors in its payroll reporting to bring a timely solution if required. Furthermore, minor reporting errors occur in payroll GL reports on a random basis. The errors appear to be technical, and as such, we are currently working with Paycom to resolve this issue. Additionally, CCGD will continue to perform time study to ensure that all salary expenses and allocations are adhered to the respective program budget. Parties Responsible: Chief Executive Officer, Chief Financial Officer, and Director - Human Resources
LATE FILING OF 2022 DATA COLLECTION FORM; PROBLEM - THE ANNUAL REPORTING REQUIREMENTS OF THE FEDERAL AUDIT CLEARINGHOUSE WERE NOT MET IN RELATION TO THE CERTIFICATION OF THE 2022 DATA COLLECTION FORM.; CORRECTIVE ACTION - OUR YMCA MANAGEMENT TEAM WILL WORK CLOSELY WITH OUR AUDIT FIRM TO FILE AND CER...
LATE FILING OF 2022 DATA COLLECTION FORM; PROBLEM - THE ANNUAL REPORTING REQUIREMENTS OF THE FEDERAL AUDIT CLEARINGHOUSE WERE NOT MET IN RELATION TO THE CERTIFICATION OF THE 2022 DATA COLLECTION FORM.; CORRECTIVE ACTION - OUR YMCA MANAGEMENT TEAM WILL WORK CLOSELY WITH OUR AUDIT FIRM TO FILE AND CERTIFY THE 2022 DATA COLLECTION FORM ALONGSIDE THE FILING AND CERTIFICATION OF THE 2023 DATA COLLECTION FORM TO ENSURE COMPLIANCE WITH THE REPORTING REQUIREMENTS OF THE UNIFORM GUIDANCE.; TIMELINE - THE 2022 DATA COLLECTION FORM WILL BE FILED AND CERTIFIED NO LATER THAN 30 DAYS AFTER THE RELEASE OF THE AUDITED FINANCIAL STATEMENTS. IN THIS CASE, THE FORM WILL BE FILED BY JULY 5, 2024.; MONITORING FOR FUTURE COMPLIANCE - OUR YMCA MANAGEMENT TEAM WILL ENSURE THAT PROCESSES ARE IN PLACE TO WORK WITH OUR AUDIT FIRM EACH YEAR SUBSEQUENT TO 2024 TO ENSURE THAT THE DATA COLLECTION FORM IS FILED AND CERTIFIED TIMELY AND IN ACCORDANCE WITH REQUIREMENTS OF THE UNIFORM GUIDANCE.
2023-002 – Equipment and Real Property Management Policy Planned Corrective Action: Management is working on creating and implementing policies and procedures surrounding equipment and real property management. Name of Contact Persons: Darla Burkett, Executive Director, Angie Warren, Finance Manag...
2023-002 – Equipment and Real Property Management Policy Planned Corrective Action: Management is working on creating and implementing policies and procedures surrounding equipment and real property management. Name of Contact Persons: Darla Burkett, Executive Director, Angie Warren, Finance Manager and Teri Ortiz, Grants Specialist Anticipated completion date: June 30, 2024
The Organization did not maintain signed annual recertification forms for the tenant files tested during the audit and did not maintain all of the information such as the EIV reports in the files to support the data used in its preparation.
The Organization did not maintain signed annual recertification forms for the tenant files tested during the audit and did not maintain all of the information such as the EIV reports in the files to support the data used in its preparation.
The year-end financial statements prepared for the Organization’s board members and management to assess ongoing operating results are not prepared in accordance with accounting principles generally accepted in the United States of America, in that they do not include certain year-end adjusting entr...
The year-end financial statements prepared for the Organization’s board members and management to assess ongoing operating results are not prepared in accordance with accounting principles generally accepted in the United States of America, in that they do not include certain year-end adjusting entries, a statement of cash flows, and full note disclosures.
The management of Jude’s Place Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, Accordingly, management will regularly reconcile its deposits for the reserve for replacement and ensure that all required deposits to the reserve for replacement are made during the ...
The management of Jude’s Place Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, Accordingly, management will regularly reconcile its deposits for the reserve for replacement and ensure that all required deposits to the reserve for replacement are made during the year. A deposit has been made to correct the shortage.
The management of Jude’s Place Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, Accordingly, management will complete and document all annual recertifications, will maintain all documentation in tenant files to support the 50059 forms, will review all tenant file...
The management of Jude’s Place Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, Accordingly, management will complete and document all annual recertifications, will maintain all documentation in tenant files to support the 50059 forms, will review all tenant files and report any discrepancies to HUD, and will make the necessary adjustments to tenant rent and rental subsidy calculations on the 50059 forms as soon as possible.
The Organization will continue to rely on Deming, Malone, Livesay & Ostroff, PSC to prepare the year-end financial statements and related note disclosures. The Organization will review and accept responsibility for the financial statements and note disclosures.
The Organization will continue to rely on Deming, Malone, Livesay & Ostroff, PSC to prepare the year-end financial statements and related note disclosures. The Organization will review and accept responsibility for the financial statements and note disclosures.
The management of Adams-Bodine Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will complete and document all annual recertifications, will maintain all documentation in tenant files to support the 50059 forms and 9887/9887-A forms, will ...
The management of Adams-Bodine Apartments, Inc. accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will complete and document all annual recertifications, will maintain all documentation in tenant files to support the 50059 forms and 9887/9887-A forms, will review all tenant files and report any discrepancies to HUD, and will make the necessary adjustments to tenant rent and rental subsidy calculations on the 50059 forms as soon as possible.
The Organization will continue to rely on Deming, Malone, Livesay & Ostroff, PSC to prepare the year-end financial statements and related note disclosures. The Organization will review and accept responsibility for the financial statements and note disclosures.
The Organization will continue to rely on Deming, Malone, Livesay & Ostroff, PSC to prepare the year-end financial statements and related note disclosures. The Organization will review and accept responsibility for the financial statements and note disclosures.
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