Corrective Action Plans

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Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation me...
Recommendation We recommend that management: ▪ Implement procedures requiring complete supporting documentation for all costs charged to federal awards ▪ Ensure costs are reviewed for allowability, reasonableness, and allocability prior to recording ▪ Establish and document formal cost allocation methodologies ▪ Require approval and documentation of all journal entries affecting federal programs ▪ Provide training to staff on Uniform Guidance cost principles (2 CFR 200 Subpart E) ▪ Conduct periodic internal reviews to ensure compliance
Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...
Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.
U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the...
U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will update procurement procedures to require documented SAM.gov verification for vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Ben Bass, CEO Planned completion date for corrective action plan: May 2026
U.S Department of Health and Human Services 2022-002 - Procurement - Assistance Listing No. 93.243 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement util...
U.S Department of Health and Human Services 2022-002 - Procurement - Assistance Listing No. 93.243 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/services and then utilizing an approved vendors list. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will ensure the Organization follows the Procurement policy for any future acquistions over the threshold of $15,000 enumerated in the policy and obtain bids and document the selection process. Name(s) of the contact person(s) responsible for corrective action: Manuel Burrola, Accountant Planned completion date for corrective action plan: May 2026
REFERENCE # 2022-009 SPECIAL TEST – ACCOUNTABILITY FOR USDA FOODS– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will ensure the documentation related to inventory counts are reviewed and maintained. Action Date: Ongoin...
REFERENCE # 2022-009 SPECIAL TEST – ACCOUNTABILITY FOR USDA FOODS– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will ensure the documentation related to inventory counts are reviewed and maintained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants t...
REFERENCE # 2022-008 ELIGIBILITY– MATERIAL WEAKNESS – MATERIAL NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure sub-recipient agreements are retained and the distribution sites maintain sign-in sheets requiring participants to self-certify that they meet the grant eligibility requirements. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division wi...
REFERENCE # 2022-007 ALLOWABLE COST– MATERIAL WEAKNESS - NONCOMPLIANCE Program Name/ALN The Food Distribution Cluster Corrective Action Plan: The Division will take steps to ensure that proper evidence of review is maintained for the food distribution reports and the sign-in sheets . The division will ensure proper documentation of the weight of items distributed is retained. Action Date: Ongoing Final Implementation Date: 09/30/2026 Name and Phone # Of Person Responsible for Implementation: Claudia Pardo, Captain, Divisional Finance Secretary (916) 563-3745
REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget p...
REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US T...
REFERENCE # 2022-004 CASH MANAGEMENT – MATERIAL WEAKNESS- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Non-Federal Entities Other Than States- Non-federal entities must minimize the time elapsing between the transfer of funds from the US Treasury or pass-through entity and disbursement by the non-federal entity for direct program or project costs and the proportionate share of allowable indirect costs, whether the payment is made by electronic funds transfer, or issuance or redemption of checks, warrants, or payment by other means (2 CFR section 200.305(b)). What constitutes minimized elapsed time for funds transfer will depend on what payment system/method a non-federal entity uses. Under the advance payment method, federal awarding agency or pass-through entity payment is made to the non-federal entity before the non-federal entity disburses the funds for program purposes (2 CFR section 200.3). A non-federal entity must be paid in advance provided that it maintains, or demonstrates the willingness to maintain, both written procedures that minimize the time elapsing between the transfer of funds from the US Treasury and disbursement by the non-federal entity, as well as a financial management system that meets the specified standards for fund control and accountability (2 CFR section 200.305(b)(1)). Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division receives advance funds from the pass-through agency and incurred program expenditures. Of the Sixty (60) files selected for testing We noted that the Division: (1) Does not have written procedures that minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Questioned Costs: Cannot be determined Recommendation: We recommend Division minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Corrective Action Plan: The Division will strive to minimize the time elapsing between the transfer of funds from the Pass-through entity and disbursement by the Division. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, ...
REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, it does state that the determination of when an award is expended must be based on when the activity related to the federal award occurs. Uniform Guidance also states for Grants, cost reimbursement contracts, cooperative agreements, and direct appropriation type of contracts, the federal expenditure or expense should be reported when the transaction occurs. Uniform Guidance further states, the auditee should also be able to reconcile amounts presented in the financial statements to related amounts in the schedule of expenditures of federal awards. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division report to the pass-through entity on an accrual basis. Division’s schedule of expenditures of federal awards is presented on the accrual basis of accounting. Of the Sixty (60) files selected for testing: • Five (5) prior year expenditures were included in Division’s current year schedule of expenditures of federal awards. Questioned Costs: Cannot be determined Recommendation: We recommend Division report program expenditures in the year expenditures were accrued. Corrective Action Plan: The Division will report program expenditures in the year expenditures were accrued. Step 1 Action Date: Ongoing Final Implementation Date:h 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
REFERENCE # 2022-002 EQUIPMENT AND REAL PROPERTY MANAGEMENT – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Solution Grant Program (ALN # 14.231) Compliance Requirements- Equipment Management -- Grants and Cooperative Agreements Equipment means tangible personal property, includin...
REFERENCE # 2022-002 EQUIPMENT AND REAL PROPERTY MANAGEMENT – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Solution Grant Program (ALN # 14.231) Compliance Requirements- Equipment Management -- Grants and Cooperative Agreements Equipment means tangible personal property, including information technology systems, having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds the lesser of the capitalization level established by the non-federal entity for financial statement purposes or $5,000 (2 CFR section 200.1). Title to equipment acquired by a non-federal entity under grants and cooperative agreements vests in the non-federal entity subject to certain obligations and conditions (2 CFR section 200.313(a)). Non-federal entities other than states must follow 2 CFR sections 200.313(c) through (e) which require that: (b) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). (c) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years (2 CFR section 200.313(d)(2)). Condition/Context: Based on our review of the Equipment and Real Property Management compliance requirements, we noted that the Division has written policies regarding Equipment and Real property management. We noted that, Division’s property records did not include all required elements as required by (2 CFR section 200.313(d)(1)). We also noted that, physical inventory of the property was not performed and thus the results were not reconciled with the property records at least once every two years (2 CFR section 200.313(d)(2)). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: • include a description of the property, a serial number or other identification number, the source of funding for the property (including the federal award identification number), who holds title, the acquisition date, cost of the property, percentage of federal participation in the project costs for the federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property. • A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. Corrective Action Plan: Divisional Headquarters and the local units will include all relevant information on the master vehicle list and take a physical inventory at leas once every two years. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
FEDERAL AWARDS – CORRECTIVE ACTION PLAN REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT – MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per § 200.318 General procurement standards. (a) The Non-Federal entity must have and u...
FEDERAL AWARDS – CORRECTIVE ACTION PLAN REFERENCE # 2022-001 PROCUREMENT SUSPENSION AND DEBARMENT – MATERIAL WEAKNESS- NON-COMPLIANCE Program Name/ALN Emergency Solutions Grant Program (ALN # 14.231) Criteria: As per § 200.318 General procurement standards. (a) The Non-Federal entity must have and use documented procurement procedures, consistent with State, local, and tribal laws and regulations and the standards of this section, for the acquisition of property or services required under a Federal award or subaward. The non-Federal entity's documented procurement procedures must conform to the procurement standards identified in §§ 200.317 through 200.327. (d) The Non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Condition/Context: Condition: Based on our review of the Procurement compliance requirements, we noted that the Division has written procurement policies and competitive policies as required by CFR § 200.318 General procurement standards. We selected five (5) vendors for procurement Suspension and Debarment compliance testing of total population of 5 vendors subject to procurement and we were not provided with Procurement comparative bids therefore, we were unable: • To verify that the procurement method used was appropriate based on the dollar amount and conditions specified in 2 CFR section 200.320. • To Verify that procurements provide full and open competition (2 CFR section 200.319 and 48 CFR section 52.244-5). Questioned Costs: Cannot be determined Recommendation: We recommend that the Division must: (1) Use documented procurement procedures, consistent with State, and local, laws and regulations and the standards, for the acquisition of property or services required under a federal award or subaward. (2) The Division must maintain records sufficient to detail the history of procurement. These records should include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. Corrective Action Plan: The Division will work with Territorial Headquarters to document procedures as outlined in the Recommendations above. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of ...
In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of two years were unable to schedule annual financial audits timely. At the time when the FY 2022 single Audit was due, we had not even completed our FY2020 Audit hence the delay. Currently, the hospital is working toward getting caught up with the annual financial audits to get back on track with our policy. We just completed FY 2023 and are working on FY 2024. We hope to be done with FY 2025 and FY 2026 in the Fall of calendar year 2026.
The hospital staff member – reimbursement analyst- who no longer works for the hospital - submitted PRF reports in the portal within timelines, but he did not save copies of the reports. We were only able to get the blank templates from his company folder. I confirmed with the then chief compliance ...
The hospital staff member – reimbursement analyst- who no longer works for the hospital - submitted PRF reports in the portal within timelines, but he did not save copies of the reports. We were only able to get the blank templates from his company folder. I confirmed with the then chief compliance officer for Sheridan Community Hospital that she signed the reports in the portal before they were submitted. During the audit, we were unable to produce these reports, however, we are in the process of retrieving these reports from the HRSA portal to keep with our records as proof that it was completed per the auditor’s recommendation above.
The audit report on the financial statements for the year ended June 30, 2022 was issued on April 15, 2026, The Data Collection form and reporting package will be submitted within 5 business days thereafter.
The audit report on the financial statements for the year ended June 30, 2022 was issued on April 15, 2026, The Data Collection form and reporting package will be submitted within 5 business days thereafter.
The Seminary has developed, with the assistance of our outsourced vCIO and vChief Security Officer, a comprehensive security plan which meets the standards required by the Gramm- Leach-Bliley Act.
The Seminary has developed, with the assistance of our outsourced vCIO and vChief Security Officer, a comprehensive security plan which meets the standards required by the Gramm- Leach-Bliley Act.
The Financial Aid Director, in conjunction with the Registrar, will review all student withdrawals to ensure that R2T 4 calculations are completed on time. At the midpoint of the semester and other review will be done to ensure that all calculations were completed and on time.
The Financial Aid Director, in conjunction with the Registrar, will review all student withdrawals to ensure that R2T 4 calculations are completed on time. At the midpoint of the semester and other review will be done to ensure that all calculations were completed and on time.
The Registrar will review all leaves of absence to ensure that all paperwork is completed. This occurred during a period of transition within the Registrars Office and collection of paperwork is checked and verified more thoroughly now.
The Registrar will review all leaves of absence to ensure that all paperwork is completed. This occurred during a period of transition within the Registrars Office and collection of paperwork is checked and verified more thoroughly now.
CORRECTIVE ACTION PLAN (Concerning Finding 2022-002) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-002. Subsequent to the audit period and notificatio...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-002) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-002. Subsequent to the audit period and notification of the finding on January 15, 2026, the County developed a formal Subrecipient Monitoring Policy intended to ensure compliance with the requirements of 2 CFR 200.214 and 2 CFR 200.332. The policy establishes procedures for subrecipient versus contractor determination, required subaward agreement elements, Debarment and Suspension verification, risk assessment, ongoing monitoring activities, Single Audit determination and follow-up, and enforcement of corrective actions. The policy is scheduled to be presented for formal adoption at the next available County Commissioner meeting on February 18, 2026. Upon adoption and implementation, these measures are expected to strengthen internal controls over subrecipient monitoring and reduce the risk of future noncompliance with federal award requirements. Anticipated Completion Date: February 18, 2026
CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-001. Subsequent to the audit period and notice of t...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-001) Contact Person Responsible for Corrective Action: Dana L. Gendreau, Interim County Administrator Corrective Action: The County of Aroostook has initiated corrective action to address Finding 2022-001. Subsequent to the audit period and notice of the finding January 15, 2026, the County developed a comprehensive Federal Grant Procurement Policy that fully complies with the procurement standards of 2 CFR 200.317–327, including clearly defined micro-purchase and small-purchase thresholds and required procurement methods. The revised policy also establishes mandatory procedures for verifying and documenting contractor eligibility through Debarment and Suspension reviews using SAM.gov prior to contract award and requires inclusion of applicable federal contract provisions. The policy will be presented for formal adoption at the next available County Commissioner meeting scheduled for February 18, 2026. Upon adoption, these measures will strengthen internal controls over procurement compliance and reduce the risk of future noncompliance with federal procurement requirements. Anticipated Completion Date: February 18, 2026
It is recommended that Management should implement procedures and controls to ensure that the required reports are submitted.
It is recommended that Management should implement procedures and controls to ensure that the required reports are submitted.
Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation Date: December 31, 2025.
Corrective Action and Explanation - The City of Newark will comply with the Auditor's recommendation. Implementation Date: December 31, 2025.
It is recommended that the Budget Expenditure Report for Appropriations and Appropriation Reserves be reconciled with the General Ledger monthly.
It is recommended that the Budget Expenditure Report for Appropriations and Appropriation Reserves be reconciled with the General Ledger monthly.
In addition, the differences between Federal and State Program Bar and the Manually maintained worksheet be reconciled and adjusted.
In addition, the differences between Federal and State Program Bar and the Manually maintained worksheet be reconciled and adjusted.
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