Corrective Action Plans

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The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save ...
The Director of Finance and Accounting Manager are working with the Billing Specialists to ensure all invoices are filed in a timely manner to funders. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. These conversations occurred with the team in July 2024.
The Director of Finance and Accounting Manager will work with the Grants and Contract Accountant to coordinate grant kickoff meetings with Program Directors and Managers to ensure they have procedures in place to meet the requirements for the agreement. These meetings will be held in August and Sept...
The Director of Finance and Accounting Manager will work with the Grants and Contract Accountant to coordinate grant kickoff meetings with Program Directors and Managers to ensure they have procedures in place to meet the requirements for the agreement. These meetings will be held in August and September.
The District continues to have segregation of duties as a priority. We accept the auditor’s guidance and continue to keep the task of segregation of duties as a priority.
The District continues to have segregation of duties as a priority. We accept the auditor’s guidance and continue to keep the task of segregation of duties as a priority.
Finding 485089 (2022-002)
Material Weakness 2022
Name of Auditee: Town of Union, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2022 CAP Prepared by: Jennifer Lindsay, Comptroller Phone: (607) 786-2931 (2) Audit Finding 2022-002 - The Town had significant variances between its quarterly Cor...
Name of Auditee: Town of Union, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2022 CAP Prepared by: Jennifer Lindsay, Comptroller Phone: (607) 786-2931 (2) Audit Finding 2022-002 - The Town had significant variances between its quarterly Coronavirus State and Local Fiscal Recovery Funds (ARPA) reports submitted to the United States Department of the Treasury (the Treasury), and its expenditures in its accounting software. (a) Implementation Plan of Actions - The Town will reconcile its ARPA reports submitted to the Treasury to its accounting software to ensure that the ARPA reports are accurate. (b) Implementation Date - This will be implemented for the year ended December 31, 2024. (c) Persons Responsible for Implementation - The Comptroller and the Town Board.
The Board of Directors recognizes the importance of ensuring that the accounting period is "closed" in a timely manner to meet the requirement of Section 320(a) of 0MB Circular A- 133. Therefore, the Board has reorganized the accounting department beginning with the hiring of a new staff accountant....
The Board of Directors recognizes the importance of ensuring that the accounting period is "closed" in a timely manner to meet the requirement of Section 320(a) of 0MB Circular A- 133. Therefore, the Board has reorganized the accounting department beginning with the hiring of a new staff accountant. These changes will ensure the accounting period is "closed" in a timely manner to meet all requirements of Section 320(a) of 0MB Circular A-133. The Board will implement the above procedure immediately, however, due to the backlog for the audit completions, the change in procedures will become effective for the 9/30/2023 year-end.
Finding 2022-005 – Completion and Submission of Annual Single Audit – Significant Deficiency/Non-Compliance Corrective Action: The Budget and Finance Office is comprised of a limited number of accountants. The Budget & Finance offices has also been struggling with staffing shortages that have dela...
Finding 2022-005 – Completion and Submission of Annual Single Audit – Significant Deficiency/Non-Compliance Corrective Action: The Budget and Finance Office is comprised of a limited number of accountants. The Budget & Finance offices has also been struggling with staffing shortages that have delayed certain reporting requirements. County Management is working to obtain proper staffing levels and skillset within the Department of Budget and Finance so that audit responsibilities are completed within prescribed timeframes. Responsible for Implementing Corrective Action: Department of Budget & Finance
Finding 2022-004 – Uniform Guidance Subrecipient Monitoring – Significant Deficiency/Non-Compliance Corrective Action: The County has met with Children & Youth to discuss in detail the process of monitoring Title IV-E activities. As a result of such, a formalized plan was implemented including a Su...
Finding 2022-004 – Uniform Guidance Subrecipient Monitoring – Significant Deficiency/Non-Compliance Corrective Action: The County has met with Children & Youth to discuss in detail the process of monitoring Title IV-E activities. As a result of such, a formalized plan was implemented including a Sub-Recipient Monitoring Agreement for FY 2022-2023. Responsible for Implementing Corrective Action: Budget & Finance, Purchasing Joinder Board
Comment Title: Meal Claims. Corrective Action Plan: We will implement procedures to ensure this does not happen again. Contact Person, Title, Phone Number: Holly Fischer, Business Manager (641) 923-2718. Anticipated Date of Completion: Immediately
Comment Title: Meal Claims. Corrective Action Plan: We will implement procedures to ensure this does not happen again. Contact Person, Title, Phone Number: Holly Fischer, Business Manager (641) 923-2718. Anticipated Date of Completion: Immediately
Comment Title: Food Service Contract. Corrective Action Plan: We are working with the food service management company to resolve these issues. Contact person, Title, Ohone Number: Holly Fischer, Business Manager, (641) 932-2718. Anticipated Date of Completion: Immediately
Comment Title: Food Service Contract. Corrective Action Plan: We are working with the food service management company to resolve these issues. Contact person, Title, Ohone Number: Holly Fischer, Business Manager, (641) 932-2718. Anticipated Date of Completion: Immediately
Comment Title: Segregation of Duties. Corrective Action Plan: We will evaluate this and attempt to segregate duties as much as possible. Contact Person, Title, Phone Number: Holly Fischer, Business Manager (641) 923-2718. Anticipated Date of Completion: Immediately
Comment Title: Segregation of Duties. Corrective Action Plan: We will evaluate this and attempt to segregate duties as much as possible. Contact Person, Title, Phone Number: Holly Fischer, Business Manager (641) 923-2718. Anticipated Date of Completion: Immediately
Correction action planned: When HRSA opens the portal again the numbers will be updated to estimates using the gross revenues by payor and the yearly contractual adjustments amounts. If the portal does not open again the facility will calculate net patient revenues, using estimates, in a separate fi...
Correction action planned: When HRSA opens the portal again the numbers will be updated to estimates using the gross revenues by payor and the yearly contractual adjustments amounts. If the portal does not open again the facility will calculate net patient revenues, using estimates, in a separate file to be sent to HRSA upon request. Anticipated completion date: upon request. Contact person responsible for correction action: Tesa Anewishki, CEO.
Finding 484835 (2022-003)
Significant Deficiency 2022
Corrective Action Plan Date: August 13, 2024 Cognizant or Oversight Agency: Corporation for National and Community Service L.A. Works, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Armanino...
Corrective Action Plan Date: August 13, 2024 Cognizant or Oversight Agency: Corporation for National and Community Service L.A. Works, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Armanino, LLP 11766 Wilshire Blvd. 9th Floor Los Angeles, CA 90025 Audit period: December 31, 2022 The findings from the December 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS-MAJOR PROGRAM SIGNIFICANT DEFICIENCY 2022-003 The Uniform Guidance Cost principles require that organizations identify, in their accounts, all Federal awards received and expended. Recommendation: Management should ensure that grant expenses are allocated within the accounting software on a monthly basis, or, if preferred, when each payroll is processed. Action Taken: Once brought to our attention, we shifted our approach and are now fully in compliance. For the 2023 year, payroll delineation has been allocated monthly within the accounting software and for the 2024 year, payroll delineation has been allocated as payroll is processed. Name of responsible person: Name Ellen Tiep Title Finance Manager, L.A. Works Anticipated completion date: Completed as of December 31, 2023. If the Corporation for National and Community Service has questions regarding this plan, please call Deborah Brutchey, (213) 481-5376. Sincerely yours, Deborah Brutchey Executive Director L.A. Works
2022-001 Underpayment of the contingent mortgage As of December 31, 2022, $173,798 had been paid through the refinancing of the mortgage on April 26, 2022, which is 26 days after the 90-day period. Surplus cash was paid off with the close of the mortgage in the refinance. Karen Burkett, Managing Age...
2022-001 Underpayment of the contingent mortgage As of December 31, 2022, $173,798 had been paid through the refinancing of the mortgage on April 26, 2022, which is 26 days after the 90-day period. Surplus cash was paid off with the close of the mortgage in the refinance. Karen Burkett, Managing Agent
Reporting of 2021 Community Development Block Grant Condition: The City did not record revenue and expenditures for the 2021 Community Development Block Grant (CDBG) in a capital projects fund. The expenditure of CDBG funds was not included on the original schedule of expenditures of federal awards...
Reporting of 2021 Community Development Block Grant Condition: The City did not record revenue and expenditures for the 2021 Community Development Block Grant (CDBG) in a capital projects fund. The expenditure of CDBG funds was not included on the original schedule of expenditures of federal awards (SEFA). Correction Action Plan: The City agrees with this finding and will more closely review missing check numbers to ensure all revenue and expenditures are recorded.
Management is consiering its options for further appeals to the department of Labor for review. Management will work to ensure proper policies and procedures are established and followed by December 31, 2024
Management is consiering its options for further appeals to the department of Labor for review. Management will work to ensure proper policies and procedures are established and followed by December 31, 2024
View Audit 317675 Questioned Costs: $1
May 3, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports...
May 3, 2024 Re: SAMHSA Notice of Award for 6H79SM083161-01M003 MTBH submitted our budget based on anticipated salary costs for new hires, which we believe stayed at or below our actual costs. We made available all necessary documentation requested from payroll, grant-related expenses, grant reports and timekeeping records to Wade Stables P.C for review. We did not have the grant in our financial software as we were beginning a migration to new software during the early stages of the grant; therefore, we tracked that grant on an excel spreadsheet that annually was provided to our auditors. Most of the staff assigned to the grant were full-time staff, so time allocation was easily tracked. For the few staff that were part-time we had designated codes in our Electronic Medical Record to identify work done on behalf of the grant. In response to Finding 2022-001- B Allowable Costs, we agree with the Statement of Cause citing the exponential growth of the organization regarding preparedness for a first-time grant award of this size being our largest challenge. Initially we were informed we had not received the grant then, due to additional COVID funding, we were invited to participate in the grant with a very short turnaround to finalize budgets and hire staff. Our salaries are consistent with the positions designated in the grant and in a few cases our staff salaries exceeded the allowable costs; therefore, those allowable costs were used to calculate the drawdown. MTBH did not have an established de minimis rate; therefore, we used the 10% designated rate associated with the grant. The interactive Budget Narrative Form template, required per SAMHSA guidelines, had 10% built into the template. If afforded future opportunities to secure a SAMSHA grant, we would be better positioned to execute the financial management in our SAGE software to segregate costs for the purpose of tracking the expenditures associated agency grant operations. Currently all agency expenditures have transferred into SAGE by our Vice President of Finance, Jenny Haught MBA, which would also be the Responsible Official to fiscally manage future grants. Respectfully, Angela Caraway, VP of Clinical Operations
Corrective Action Plan for Finding 2022-003 We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above ...
Corrective Action Plan for Finding 2022-003 We are in receipt of the findings required to be reported by the single audit for Period 1 reporting for payments received from the Provider Relief Fund (PRF), specifically, regarding discrepancies in the reporting requirements and auditing for the above period for the PRF. Management does not dispute the finding. The district will work to develop policies over financial reporting for future periods for PRF reporting and auditing. The district will perform detailed analysis of the reporting requirements in accordance with the guidelines set forth by HRSA. The hospital CEO, Cecil Gaither, will oversee this to ensure that this is accomplished. The district will also provide its’ consultants any information to be submitted to HRSA for accuracy. The district has already begun implementing the new procedures and is confident that all future submissions will be correct. The District had enough expenditures for Period 1 and 4 funding received to cover any disqualified lost revenues that were utilized as a basis for the funds received. The corrective action plan will be implemented by May 31, 2024.
View Audit 317591 Questioned Costs: $1
Finding: 2022-001 Material Weakness over SEFA Preparation Federal Agency: U.S. Department of State Federal Program: Overseas Refugee Assistance Program for Near East (ALN 19.519) Contact Person: Corey Dillow, Senior Managing Director, Financial Controller Criteria 2 CFR 200.510 (b)(3) requires ...
Finding: 2022-001 Material Weakness over SEFA Preparation Federal Agency: U.S. Department of State Federal Program: Overseas Refugee Assistance Program for Near East (ALN 19.519) Contact Person: Corey Dillow, Senior Managing Director, Financial Controller Criteria 2 CFR 200.510 (b)(3) requires non-Federal entities receiving Federal award to (at minimum) provide total Federal awards expended for each individual Federal program and the Assistance Listings Number. Internal controls around the identification of ALNs and reporting of the SEFA should ensure proper presentation for each ALN number. Condition and Context During our planning meetings with management, we were notified that an award was recorded to an incorrect ALN in the 2022 Schedule of Expenditures of Federal Awards. The 2022 Schedule of Expenditures of Federal Awards was corrected and an additional major program, Overseas Refugee Assistance Program for Near East (ALN 19.519), was identified. Corrective Action: As result of the finding, management will be implementing the below steps to further refine internal controls in the identification and reporting of ALNs in the SEFA by: 1. Reinforcing the importance of ALN assignment and tracking through training. 2. Including the ALN attribute as a required element for award setup reviews. 3. Conducting periodic checks of ALNs to source agreements. 4. Documenting and performing additional SEFA data quality checks. Anticipated Completion Date: July 2024
Action Item Title 2022-004 – Reporting Compliance Requirement Reporting Status (Open: In-process) Condition: Pass-Through Entity Reporting Requirements – The Corporation submitted just two reports during the year, the first and second required submission. Single Audit Reporting Packages – The ...
Action Item Title 2022-004 – Reporting Compliance Requirement Reporting Status (Open: In-process) Condition: Pass-Through Entity Reporting Requirements – The Corporation submitted just two reports during the year, the first and second required submission. Single Audit Reporting Packages – The Corporation did not comply with the Single Audit Reporting Package submission requirements for the years ended June 30, 2022, and 2023. Identified root cause: Lack of understanding of reporting compliance requirements for federal awards. Fiscal year 2022 was the first year for the Corporation to be subjected to a single audit compliance requirement for receiving and expending COVID-19 public health emergency programs. Grantee resolution plan: Pass-Through Entity Reporting Requirements – On July 1, 2022, the Corporation began submitting the monthly requested reports, subject to the Puerto Rico Fiscal Agency and Financial Advisory (AAFAF, as its Spanish acronym), the pass-through entity, required guidelines when funds are obligated. Single Audit Reporting Packages – The Corporation will submit the outstanding Single Audit Reporting Packages. Completion Date: Pass-Through Entity Reporting Requirements - Corrected Single Audit Reporting Packages – August 2024 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
Action Item Title 2022-003 – Procurement Policies and Covered Transactions Compliance Requirement Procurement, Suspension, and Debarment Status (Open: In-process) Condition: General Procurement Standards - Written Policies – The Corporation has an outdated institutional procurement manual appr...
Action Item Title 2022-003 – Procurement Policies and Covered Transactions Compliance Requirement Procurement, Suspension, and Debarment Status (Open: In-process) Condition: General Procurement Standards - Written Policies – The Corporation has an outdated institutional procurement manual approved in 2014 that lacks written policies to ascertain compliance with the provisions of federal statutes, regulations, or the terms and conditions of federal awards regarding procurement, suspension, and debarment requirements. Suspension and Debarment - Covered Transaction – From a population of nineteen disbursements, we selected nine disbursements to ascertain compliance with 2 CFR section 180.220 by examining the procurement documents provided by the Corporation. From that sample, we identified nine instances in which the SAM.gov registration verification process was not performed. Of the nine instances, we found eight suppliers properly registered, but one supplier appears as validated as unique and existing but not registered in SAM.gov. Identified root cause: Lack of understanding of procurement compliance requirements for federal awards. Fiscal year 2023 was the first year for the Corporation to be subjected to a single audit compliance requirement for receiving and expending COVID-19 public health emergency programs Grantee resolution plan: General Procurement Standards - Written Policies – With the implementation of Law No. 73 of 2019, previous processes established by regulation are repealed and rendered ineffective. In addition, the Corporation will adopt procurement policies in compliance with the federal regulations. Suspension and Debarment - Covered Transaction - Currently, the Corporation is verifying and requesting all suppliers with contracts of $25,000 and over with evidence of being active at SAM.gov. Also, the Corporation is verifying if the supplier is suspended or debarred to do business with the Federal government. Completion Date: General Procurement Standards - Written Policies – By June 30, 2025 Suspension and Debarment - Covered Transaction – Corrected in FY2023. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
Action Item Title 2022-002 – Financial Management and Internal Controls Compliance Requirement Allowable Costs/Cost Principles Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining the activities allowed or unallowed and the allowability of...
Action Item Title 2022-002 – Financial Management and Internal Controls Compliance Requirement Allowable Costs/Cost Principles Status (Open: In-process) Condition Written Policies The Corporation has no written policies for determining the activities allowed or unallowed and the allowability of costs as described in subpart E, Cost Principles of 2 CFR Part 200. Identified root cause It is the first year for the Corporation to be subjected to a single audit compliance requirement. However, since the Commonwealth of Puerto Rico (the Commonwealth) filed for Title III under the PROMESA, all the instrumentalities of the Commonwealth had to reduce their staff as part of the Fiscal Plan to reduce expenditures. This has disrupted the segregation of duties, which is a key control. Grantee resolution plan Written Policies The Corporation received federal funds for the first time in 2022. For the purposes of purchases or acquisitions, the Corporation is governed by Law of the General Service Administration for the Centralization of Government Purchases in Puerto Rico, Law No. 73 of 2019, which establishes the uniform purchasing process for acquisitions by the Commonwealth. The Corporation will adopt regulations for the use and disbursement of federal funds and comply with the federal regulations. Completion Date Written Policies By June 30, 2025 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
In response to the negative finding of the prior year deficiency noted in the audits, immediate actions have been taken by L2020 to address the issues and prevent reoccurrence in the future. The individuals who were previously responsible for financial reporting and cash management during the audit ...
In response to the negative finding of the prior year deficiency noted in the audits, immediate actions have been taken by L2020 to address the issues and prevent reoccurrence in the future. The individuals who were previously responsible for financial reporting and cash management during the audit are no longer employed at L2020. Going forward, Rebecca “Kawehi” Inaba, appointed as the Executive Director in late 2021, will take charge of ensuring that L2020 remains compliant with all financial requirements, including conducting audits in a timely manner. The organization expresses confidence in her ability to keep L2020 up to date with all financial obligations. In an effort to enhance control and oversight, L2020 will be instituting a quality control review process for all forthcoming report submissions. This measure aims to identify any discrepancies or delays in submissions, enabling corrective actions to be taken promptly. L2020 remains dedicated to upholding transparency and accountability in their financial practices. These proactive steps are crucial in enhancing processes and performance. The organization appreciates understanding and support as they strive for improved financial management practices at L2020.
Abrupt transitions in management caused a lapse in organizational knowledge, but new leadership has taken the proper steps to be audit-ready at all times. An in house bookkeeper position is in the process of being filled and an outside bookkeeper has been hired.
Abrupt transitions in management caused a lapse in organizational knowledge, but new leadership has taken the proper steps to be audit-ready at all times. An in house bookkeeper position is in the process of being filled and an outside bookkeeper has been hired.
2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. The new system performs an automated allowance calculation; however, a manual distribution of the allowance is required to record the adjustment in the pr...
2022-001 Provider Relief Fund Reporting of Lost Revenue Corrective action planned: The District moved to a new EHR in the first quarter of 2021. The new system performs an automated allowance calculation; however, a manual distribution of the allowance is required to record the adjustment in the proper period. Unbilled receivables are not adjusted by the system; therefore, a manual journal entry is required to record the allowance. The District was not familiar with the system design and the distribution was not recorded in each month. A manual journal entry must be performed at the end of each month to distribute the allowance in the proper period. The District’s monthly closing procedures have been modified to record the allowance at the end of each month. Anticipated completion date: February 17, 2023 Contact person responsible for corrective action: Kim Manus, Chief Financial Officer
Westside Family Healthcare recognizes the importance of timely reporting, especially reporting required under the Uniform Guidance. Unusual circumstances were present durnig this audit period, including key staffing vacancies exacerbated by a change in accounting systems. The switch to a new account...
Westside Family Healthcare recognizes the importance of timely reporting, especially reporting required under the Uniform Guidance. Unusual circumstances were present durnig this audit period, including key staffing vacancies exacerbated by a change in accounting systems. The switch to a new accounting system was done in part to ensure reporting can be done efficiently and timely. The conversion to the new system is complete. In addition, staffing vacancies have been partially filled.
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