Corrective Action Plans

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The Alliance purchased and implemented a new grant management software in February 2022 which has sub-recipient grant award and monitoring features. The alliance has also updated their financial and monitoring policies in Fiscal Year 2023. These updates were not active for the entire fiscal year 202...
The Alliance purchased and implemented a new grant management software in February 2022 which has sub-recipient grant award and monitoring features. The alliance has also updated their financial and monitoring policies in Fiscal Year 2023. These updates were not active for the entire fiscal year 2022. The Alliance will continue to monitor implementation of these new policies and procedures to ensure compliance.
Management agrees with the finding and acknowledges the incorrect account code was used. The oversight was related to a change of School Business Managers and the error went unnoticed. Jeff Froehlich, School Business Manager has made the correction on February 2, 2024 and going forward the Federal A...
Management agrees with the finding and acknowledges the incorrect account code was used. The oversight was related to a change of School Business Managers and the error went unnoticed. Jeff Froehlich, School Business Manager has made the correction on February 2, 2024 and going forward the Federal Award has been coded to the correct account. After each deposit, a review is completed to ensure the correct account was utilized.
We agree with this finding and will document approval for changes in budgets with subgrantees.
We agree with this finding and will document approval for changes in budgets with subgrantees.
We agree with this finding and will include the relevant information in our subawards in the future.
We agree with this finding and will include the relevant information in our subawards in the future.
We agree with this finding and will prepare a complete SEFA prior to future audits.
We agree with this finding and will prepare a complete SEFA prior to future audits.
We agree with this finding and are in the process of preparing for and completing the June 30, 2023 and June 30, 2024 audits. We plan to have the June 30, 2024 single audit filed by the deadline date.
We agree with this finding and are in the process of preparing for and completing the June 30, 2023 and June 30, 2024 audits. We plan to have the June 30, 2024 single audit filed by the deadline date.
Niagara Area Management Corporation has hired a new Chief Financial Officer and Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months...
Niagara Area Management Corporation has hired a new Chief Financial Officer and Director of Finance. NAMC has also engaged a new public accounting firm. It is NAMC policy to submit the annual audited financial statements and the data collection form to the Federal Audit Clearinghouse within 9 months after year-end.
Niagara Area Management Corporation has created a policy to ensure grant submissions will be reviewed by the department manager submitting for the grant, and the Chief Financial Officer to ensure that proper documentation is maintained, and that evidence and approval is documented. In regards to the...
Niagara Area Management Corporation has created a policy to ensure grant submissions will be reviewed by the department manager submitting for the grant, and the Chief Financial Officer to ensure that proper documentation is maintained, and that evidence and approval is documented. In regards to the Provider Relief Fund and American Rescue Plan, the grant was a one-time submission, so the finding cannot be repeated.
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
View Audit 361721 Questioned Costs: $1
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
View Audit 361721 Questioned Costs: $1
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Go...
Individual(s) Responsible: Chelsea BadHawk, Chief Financial Officer Action: Management will prepare and implement an internal control system that provides effective oversight of operations, reporting, and compliance. The systems and controls will be designed based on standards set forth in the Government Accountability Office Green Book. Anticipated Completion Date: 12/31/2025.
Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the Organizations parent company (Total Health Care, Inc.). Org...
Management has updated its PRF documentation to include a lost revenue calculation in accordance with PRF guidance. The calculation fully supports the PRF funding received. Future reporting submissions will be prepared with oversight by the Organizations parent company (Total Health Care, Inc.). Organization contact persons responsible for corrective action: Richard Greene, CFO Anticipated completion date: Correction action has been completed and is awaiting feedback from HRSA on how to submit updated lost revenue calculation.
The Organization agrees with the finding and recognizes the importance of accurate financial and programmatic reporting in compliance with federal grant requirements. To address this issue, the Organization is strengthening its internal controls surrounding the preparation and review of all financia...
The Organization agrees with the finding and recognizes the importance of accurate financial and programmatic reporting in compliance with federal grant requirements. To address this issue, the Organization is strengthening its internal controls surrounding the preparation and review of all financial and programmatic reports submitted to granting agencies. Specifically, the finance department and program staff will implement a joint review process to reconcile reported expenditures and program statistics --such as patient counts --against underlying financial and operational records prior to submission. A standardized reporting checklist will be developed to ensure that all data points are verified for accuracy and that supporting documentation is retained and reviewed. In addition, staff responsible for grant reporting will receive training on federal reporting requirements, including those outlined in 45 CFR 75.342, to ensure consistency and compliance across all submissions. These steps will help ensure that all future reports accurately reflect grant expenditures and program outcomes, minimizing the risk of misreporting and ensuring transparency and accountability. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
The Organization concurs with the finding and acknowledges the need to improve its internal controls and procedures related to procurement and compliance with federal suspension and debarment requirements. To address this, the Organization will revise its procurement policies to ensure that all pur...
The Organization concurs with the finding and acknowledges the need to improve its internal controls and procedures related to procurement and compliance with federal suspension and debarment requirements. To address this, the Organization will revise its procurement policies to ensure that all purchases of goods or services charged to federal awards --including those exceeding the $10,000 threshold --are subject to proper competitive procurement practices, in accordance with 45 CFR 75.329 and 2 CFR 180. Clear documentation requirements will be established and enforced for all procurement decisions, including price comparisons, vendor selection criteria, and justification for sole-source procurement, where applicable. Furthermore, the Organization will implement formal procedures to verify that all vendors are not suspended, debarred, or otherwise excluded from participation in federal programs. This will include performing and documenting verification against the System for Award Management (SAM.gov) prior to engaging vendors for federally funded procurements. All relevant staff will receive targeted training on these updated procurement and compliance procedures to ensure consistent application across the Organization. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developin...
The Organization agrees with the finding and acknowledges the need for strengthened internal controls and documentation related to time and effort reporting, as well as the allocation of expenditures to federally funded grant programs. To address the deficiencies noted, the Organization is developing and implementing formal time and effort reporting procedures to ensure that personnel costs charged to federal grants are supported by actual activity records and certified by employees on a regular basis. This will include the adoption of time distribution systems that comply with 2 CFR Part 200 Subpart E and the requirement for supervisory approval of time reports. Additionally, the Organization will revise its expenditure review and approval processes to require that all costs charged to federal programs are supported by appropriate documentation, including vendor invoices and receipts. Staff involved in grant management and accounting will receive training on federal cost principles, documentation requirements, and period of performance compliance. A document retention policy in accordance with 2 CFR 200.334 will also be established to ensure that all supporting documentation is maintained and readily available for audit and program oversight. Organization Contact Person Responsible for Corrective Action: Joseph Koehler, Director of Finance Anticipated Completion Date: June 30, 2025
View Audit 361677 Questioned Costs: $1
Action Taken: The Company will vigorously review the requirements with the Human Resources Department representatives to enable them to obtain a good understanding of all requirements included in the grant agreement and ensure they have evidence of compliance with such requirements for future refere...
Action Taken: The Company will vigorously review the requirements with the Human Resources Department representatives to enable them to obtain a good understanding of all requirements included in the grant agreement and ensure they have evidence of compliance with such requirements for future reference.
Action Taken: The Company will vigorously review the requirements with the Human Resources Department representatives to enable them to obtain a good understanding of all requirements included in the grant agreement and ensure they have evidence of compliance with such requirements for future refere...
Action Taken: The Company will vigorously review the requirements with the Human Resources Department representatives to enable them to obtain a good understanding of all requirements included in the grant agreement and ensure they have evidence of compliance with such requirements for future reference.
Finding 570541 (2022-002)
Significant Deficiency 2022
The Mayor and Council review monthly financial statements and budget reports to review and question the City Manager and Finance Director accordingly. The City Manager also performs supervisory checks on many areas. Due to the size of the City, the lack of segregation of duties will always exist, ...
The Mayor and Council review monthly financial statements and budget reports to review and question the City Manager and Finance Director accordingly. The City Manager also performs supervisory checks on many areas. Due to the size of the City, the lack of segregation of duties will always exist, but the City has instituted these safeguards to better monitor the City's financial reporting.
Finding 570535 (2022-001)
Significant Deficiency 2022
The City staff works with the Auditor in the preparation and subsequently reviews and approves all statements and disclosures before issuance. The city will accept this condition and concentrate on the reivew approval process.
The City staff works with the Auditor in the preparation and subsequently reviews and approves all statements and disclosures before issuance. The city will accept this condition and concentrate on the reivew approval process.
Finding 570503 (2022-003)
Significant Deficiency 2022
FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting ...
FINDING 2022-003 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Significant Deficiency Condition: The City did not have proper controls in place to ensure that the annual report was accurately filled out and agreed to underlying detail. Context: Variances to key line items were noted when comparing the Form RD442-2 and Form RD442-3 to supporting documents. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that reports agree to underlying detail. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.
Finding 570502 (2022-002)
Significant Deficiency 2022
FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compli...
FINDING 2022-002 Information on federal program: Subject: Water and Waste Disposal Systems for Rural Communities - Equipment and Real Property Management Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: 92-02 92-03 Pass-Through Entity: NIA Compliance Requirements: Equipment and Real Property Management Audit Findings: Significant Deficiency Condition: An effective internal control system was not in place at the City to ensure compliance with requirements related to the grant agreement and the Equipment and Real Property Management compliance requirement. Context: The City did not maintain an updated asset listing that reflects the construction in process balance related to the project funded with federal funds. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that the capital asset listing is maintained throughout the year and CIP is tracked. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The completion will go into effect during 2025.
Finding 570479 (2022-001)
Significant Deficiency 2022
Finding Number: 2022-001 Anticipated Completion Date: The corrective action plan was implemented in May 2023. Responsible Contact Person: Kristy Ramey, Executive Director Corrective Action Plan: Upon identifying the unauthorized payroll transactions, the Organization reinstated its intern...
Finding Number: 2022-001 Anticipated Completion Date: The corrective action plan was implemented in May 2023. Responsible Contact Person: Kristy Ramey, Executive Director Corrective Action Plan: Upon identifying the unauthorized payroll transactions, the Organization reinstated its internal control policies for payroll transaction cycle, which includes a review of all hours and rates by supervisors and the Executive Director. This occurs prior to the submission of payroll data to the Organization’s third-party payroll processor. An additional control procedure includes the review of changes made to the payroll system regarding new employees and any changes to pay rates.
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