Corrective Action Plans

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Management Response #2022-012: Due to staff turnover in prior years and inadequate handover procedures, the Federal Funding Accountability and Transparency Act (FFATA) reports were not filed with the granting agencies as required. Corrective Action Plan: The Grants program department will develop p...
Management Response #2022-012: Due to staff turnover in prior years and inadequate handover procedures, the Federal Funding Accountability and Transparency Act (FFATA) reports were not filed with the granting agencies as required. Corrective Action Plan: The Grants program department will develop procedures to ensure that we are compliant in the timely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports. This will be monitored and audited by the Vice President of the grants program at regular intervals. In additional the grants program staff will provide monthly updates to the Finance grants team as to the status of submission as well as copying the team on all submission. Responsible Party: Erin Flior, CSDO
Management Response #2022-011: Due to turnover of several key financial executives and personnel, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Corrective Action Plan: A procedure will be implemented whereby a secondary review by a Health Center Director ...
Management Response #2022-011: Due to turnover of several key financial executives and personnel, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Corrective Action Plan: A procedure will be implemented whereby a secondary review by a Health Center Director or designee at the respective care site. The approver will sign and date the application or self-attestation form. Training of the appropriate staff will be provided with monitored. Responsible Party: Tracy Harrison, COO
Management Response #2022-010: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, wh...
Management Response #2022-010: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: In mid-2023, the company established policies and procedures that formally document the current compliance practices that are in place for dissemination and training throughout the organization. Detailed in the procedures was a hard stop by the manager of procurement that would require three bids prior to a purchase order being created. Once a vendor is selected, the manager of the procurement will send the vendor information to the compliance department to check for debarments and federal eligibility requirements. Added to the procedures is the creation of a central repository platform to keep all bids and price analysis performed for each vendor. To further enhance compliance, all Accounts Payable invoices that are designated for grant funding are routed for approval to the respective grants program manager prior to payment being made via the WorkPlace software. Responsible Party: Tamara Barnes, CFO
Management Response #2022-009: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, wh...
Management Response #2022-009: Due to the staff shortages and turnover in FY2020-2022 the company did not have adequate personnel in place to monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Additionally, documents were not stored centrally, which made it extremely difficult to find supporting documentation. Corrective Action Plan: The following action plans have since been implemented: • During the fourth quarter in 2022, finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • During the fourth quarter in 2022 a new process was implemented to track grant related activities. Prior to any drawdown, the expenses are pulled from the G/L and reviewed. The expenses are entered into a spreadsheet and totaled based on the applicable federal award which has been assigned a client ID in the accounting system. The finance team is notified of the amount due to be drawn for each federal award. That amount is entered into the accounting system as an accounts receivable entry. This process has been formally documented. • Project Budget Reports have been created for each federal award. These reports include the budget, expenses for each month and the revenue (drawdown) incurred for each month. The reports will be reviewed and reconciled by the grants administration staff and finance monthly to ensure all agree with the allocated costs and costs and are in compliance with grant regulations. Once approved by both teams the reports will be routed for signatures. This process was launched in July 2022. • Supporting documentation for all draws will be maintained on a shared network drive so that an adequate audit trail will be established. This drive will be backed up on a regular basis by the Information Technology team. Responsible Party: Tamara Barnes, CFO
Management Response #2022-007: The pandemic and subsequent shift to remote work saw a disruption on the previous workflow of reviewing and approval of federal programs financial reports prior to submission to the granting agency. Staff turnover in key financial positions also contributed to the depa...
Management Response #2022-007: The pandemic and subsequent shift to remote work saw a disruption on the previous workflow of reviewing and approval of federal programs financial reports prior to submission to the granting agency. Staff turnover in key financial positions also contributed to the departure in following the processes that were in place and I sufficiently documented. This practice continued into FY2021 which also had similar issues. Corrective Action Plan: In FY2022, the following steps were implemented to ensure there is proper review and approval of reports required under the federal programs prior to submission. • The Vice President of Grants Management and Senior Director of Finance, which reside in two different departments, will work collaboratively with their teams to ensure that federal financial and programmatic reports are accurate and have adequate support and thereby strengthen the internal controls. • All federal and programmatic reports will go through an approval process requiring the signature of a senior programmatic leader and a senior finance leader. Responsible Party: Tamara Barnes, CFO
Management Response #2022-006: Due to turnover of several key financial executives and personnel, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Corrective Action Plan: Due to the staff turnover and shortage in 2020-2021, this process was not consistently ...
Management Response #2022-006: Due to turnover of several key financial executives and personnel, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Corrective Action Plan: Due to the staff turnover and shortage in 2020-2021, this process was not consistently maintained or documented. The following action items have been or will be taken: • In 2022, finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • The grants finance department will also create actual to budget reports in accordance with HRSA guidelines for fringe costs. • The report will be reconciled monthly based on fringe costs allowed by the grant as it relates to the employee class such as part time or providers that may have additional benefits. Adjustments will be recorded in the GL (General Ledger) accordingly. Responsible Party: Tamara Barnes, CFO
Management Response #2022-005: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations but due to staff turnover in FY2021-22, the process was not consistentl...
Management Response #2022-005: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations but due to staff turnover in FY2021-22, the process was not consistently followed. Corrective Action Plan: The following action items have been or will be taken: • In 2022, the finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • Monthly time and effort reports to include recorded time worked under each grant will be sent to the employee and require employee and supervisor approval. • As of 2022 salary/wages are allocated to federal grants based on actual costs received from payroll. • Finance Management will also create actual to budget reports in accordance with HRSA (Health Resources and Services Administration) guidelines for salaries/wages and hours. The report will be reconciled monthly. • Human Resources department will collaborate with the Grants and Finance teams to ensure grants hours is added as an option within the timekeeping system for accurate recording for FY24. Responsible Party: Tamara Barnes, CFO
Management Response #2022-004: Due to staff shortages and turnover in FY2020-21 and continuing into FY2022, the company did not have adequate personnel in place to properly monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Corrective Action Pla...
Management Response #2022-004: Due to staff shortages and turnover in FY2020-21 and continuing into FY2022, the company did not have adequate personnel in place to properly monitor or document grant activity. Formal documentation of policies and procedures were also deficient. Corrective Action Plan: The following action items have been established. • In 2022, the finance team delineated and expanded positions whose primary responsibility is to monitor and manage all grant activities. • In 2022 Project Budget Reports have been created for each federal award. These reports include the budget, expenses foreach month and the revenue (drawdown) incurred foreach month. The reports will be reviewed and reconciled by the grants administration staff and finance monthly to ensure all agree with the allocated costs and that costs follow compliance and grant regulations. This will allow timely reconciliation of grants before year end for FFRs, SEFA preparation, audit, reporting package and data collection for FAC. Responsible Party: Tamara Barnes, CFO
Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 Explanation: Management c...
Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update FFATA reporting procedures to document and maintain documentation of Supervisory review and approval of FFATA data preparation. Completion Date: March 29, 2023 Explanation: Management concurs that although it already enhanced policies to comply with an OJJDP/OCFO recommendation resolved in 2023, which included a two-step review and approval process for subrecipient awards involving the Executive Team, grantor procedures will be updated as recommended to include a third step to specify review and approval of subrecipient FFATA data prior to submission. The Supervisor or member of the Executive Team will capture review and approval of FFATA data with an email including the approved list attached. When FFATA reporting is submitted by staff, the list will be updated with the date submitted and returned to the Supervisor to confirm timeliness. Regarding the 12 subrecipient awards for Court Appointed Special Advocates selected for testing FFATA submission requirements, 9 out of 12 reports were submitted by the last day of the month following the start of the grant period.
Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to specify documentation and maintenance of such documentation of the review and approval of costs allocated to federal grants within the grant funding period. 2) Update grant policies to include subrecipient periodic s...
Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to specify documentation and maintenance of such documentation of the review and approval of costs allocated to federal grants within the grant funding period. 2) Update grant policies to include subrecipient periodic submission of supporting documentation. Completion Date: July 10, 2024 Explanation: Management concurs that the procedures should specify documentation and maintenance of such documentation of the review and approval of costs allocated/charged to the federal grant within the grant funding period. Grant policies and procedures have been updated to include subrecipient periodic submission of general ledger or other financial documentation supporting expenditures during the period.
Responsible: Thomas Hoover, CFO Corrective Actions: Upload the 2022 reporting package to the Federal Audit Clearinghouse. Completion Date: August 14, 2024 Explanation: Management concurs that the reporting package was not submitted to the Federal Award Clearinghouse within the deadline due to t...
Responsible: Thomas Hoover, CFO Corrective Actions: Upload the 2022 reporting package to the Federal Audit Clearinghouse. Completion Date: August 14, 2024 Explanation: Management concurs that the reporting package was not submitted to the Federal Award Clearinghouse within the deadline due to the completion of the closeout of a joint OJJDP/OCFO October 2022 monitoring visit report that resulted in a delay in the FY22 Single Audit being conducted and completed.
Responsible: Thomas Hoover, CFO Corrective Actions: Update procurement policies to include a checklist of required documentation to improve internal controls in established policies. Completion Date: July 10, 2024 Explanation: The Procurement policy has been updated with a step to complete a ch...
Responsible: Thomas Hoover, CFO Corrective Actions: Update procurement policies to include a checklist of required documentation to improve internal controls in established policies. Completion Date: July 10, 2024 Explanation: The Procurement policy has been updated with a step to complete a checklist of required documents stored with supporting documentation.
View Audit 317239 Questioned Costs: $1
Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update subrecipient award agreements to ensure the final approved scope of work or project description is specified. Completion Date: March 29, 2023 Explanation: Policies and procedures were ...
Responsible: Denice Hairston, Chief Quality, Compliance and Accountability Officer Corrective Actions: Update subrecipient award agreements to ensure the final approved scope of work or project description is specified. Completion Date: March 29, 2023 Explanation: Policies and procedures were updated in 2023 in response to an OJJDP/OCFO recommendation to ensure subaward files contain the requisite components for the award agreement. In addition to these updates, which include a master file checklist, National CASA/GAL has updated the subrecipient Terms & Conditions agreement to include CFR requirements as recommended.
Responsible: Thomas Hoover, CFO Corrective Actions: Update Finance policies to specify that documentation of review and approval of both the costs charged and the allocation methods of costs charged to federal grants be maintained. Completion Date: March 29, 2023 Explanation: Policies have bee...
Responsible: Thomas Hoover, CFO Corrective Actions: Update Finance policies to specify that documentation of review and approval of both the costs charged and the allocation methods of costs charged to federal grants be maintained. Completion Date: March 29, 2023 Explanation: Policies have been in place over the coding of costs allocated to federal grants in compliance with CFR 200 and were enhanced in 2023 in response to an OJJDP/OCFO recommendation. Review and approval of costs after being approved by an authorized signer takes place in multiple steps and concludes with preparation of reimbursements and financial grant reports (FFR). In order to further demonstrate compliance as recommended, Management has updated Finance policies to capture the documentation and maintenance of such documentation of Supervisory review and approval.
Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to document and maintain the documentation of Supervisory review and approval of journal entries charging payroll costs to federal grants; 2) Update Finance policies to review estimates of accrued costs charged to feder...
Responsible: Thomas Hoover, CFO Corrective Actions: 1) Update Finance policies to document and maintain the documentation of Supervisory review and approval of journal entries charging payroll costs to federal grants; 2) Update Finance policies to review estimates of accrued costs charged to federal grants at calendar/fiscal year end to determine whether true-ups to actual costs are necessary. Completion Date: March 29, 2023 Explanation: 1) Review of allocated payroll costs: Payroll processing and recording of costs charged to federal grants has in practice, consistently involved multiple review and approval steps by at least two employees. Detailed records of these steps are maintained in Finance records for each payroll, including the allocated grant costs. However, Management acknowledges that an additional step be added to capture the documentation of review and approval of the payroll journal entries that allocate payroll costs to federal grants. This step was put in place in 2023 to resolve a recommendation from OJJDP/OCFO. Supervisor review and approval is captured directly in the general ledger system. Finance policies have been updated to codify this additional step as recommended. 2) Procedure for trueing up estimates: Three of sixty transactions tested showed that payroll costs were accrued at year end based on the approved grant budget but were not trued up in the new accounting period based on actual costs. The total variance of the three transactions was $6.20. Finance policies have been updated to include evaluating year-end accruals to determine whether a true-up is necessary in the new period as recommended.
Responsible: Sally Erny, Deputy CEO Corrective Action: Document and maintain documentation of Supervisory review and approval of grant reports. Completion Date: July 10, 2024 Explanation: Since the inception of National CASA/GAL receiving federal funding, procedures and practices were in place f...
Responsible: Sally Erny, Deputy CEO Corrective Action: Document and maintain documentation of Supervisory review and approval of grant reports. Completion Date: July 10, 2024 Explanation: Since the inception of National CASA/GAL receiving federal funding, procedures and practices were in place for the review and approval of performance reports and SF-425s (FFRs). This practice includes the involvement of multiple staff in the organization participating in the development and review of these documents and a knowledgeable staff member with appropriate authority approving the document. There are many points of approval through the development of the reports. In terms of the FFRs, the Accounting Director is responsible for preparing a Pivot table showing the expenses for the grant for both the quarterly and inception to date periods and to update the data worksheet for the quarterly FFR report. The Controller confirms that the cumulative expenses indicated on the quarterly FFR report data worksheet match the inception to date information in the accounting ledger and then approves the report. The Accounting Director submits the FFR report through the Grants Management System. In 2023 a policy, as part of the Operations SOPs, was put in place that in addition to the various staff who work on developing the performance report, OJJDP performance reporting would be reviewed and approved and documented as such, by the Project Manager and appropriate Chief Officer. This policy formalized what had been happening in practice over many years. While we acknowledge that this policy of documentation was not in place in 2022, the practice of review and approval was. In 2023 and going forward, we have improved documenting the approval processes for the FFRs and performance reports.
In the response for Finding# 2022-001, the College described the events that led to the excess funds on hand. The institution did not any earn interest on these funds. The College now recognizes that the approach used in Finding# 2022-01 is unallowable and will confine its future drawdowns of federa...
In the response for Finding# 2022-001, the College described the events that led to the excess funds on hand. The institution did not any earn interest on these funds. The College now recognizes that the approach used in Finding# 2022-01 is unallowable and will confine its future drawdowns of federal funds to actual, not speculative, expenditures. The Board will implement the above procedure immediately.
The College does not dispute this finding. The finding pertains to the College’s efforts to renovate its historic library to make it more accessible and user-friendly. To fund the project's initial phase, the renovations required the aggregation and carry-over of Title IIIB funds over multiple fisca...
The College does not dispute this finding. The finding pertains to the College’s efforts to renovate its historic library to make it more accessible and user-friendly. To fund the project's initial phase, the renovations required the aggregation and carry-over of Title IIIB funds over multiple fiscal year periods. Before the commencement of construction, the Title IIIB program officer was informed of the College’s intent to dedicate the aggregated funds to the project. There was no indication from the Department of Education that such use would be an inappropriate practice. Because no blueprints or other construction documents were available for the mid-1950s era building, the College, and the construction professionals it utilized, anticipated that the project would experience unknown conditions and unanticipated material and equipment supply delays during the construction period that would increase the cost of the project. Some unknown conditions included a significant floor height discrepancy between building sections and extensive rock formations in the excavation area. The recording and reconciliation errors noted by the auditor above reflect the College’s attempt to ensure that it had sufficient cash on hand during the project to meet both anticipated and unanticipated expenses. Additionally, a second phase of the library modernization project involving HVAC, window system, and flooring upgrades was planned even before the beginning of the initial phase of construction. While few of the second-phase improvements were ultimately included in the initial stage, the College has proceeded with the remaining second-phase enhancements, including replacing existing windows and flooring. These items will be expensed in the next quarter (October-December 2022). The College now recognizes that the approach described above is unallowable, and will confine its future drawdowns of federal funds to actual, not speculative, expenditures. The Board will implement the above procedure immediately.
The District will be redistributing duties in the coming year due to a new staff member. This will separate accounts payable, accounts receivable, payroll, and general ledger.
The District will be redistributing duties in the coming year due to a new staff member. This will separate accounts payable, accounts receivable, payroll, and general ledger.
Finding 481007 (2022-004)
Significant Deficiency 2022
Finding 2022-004 Finding Summary: In our testing of reporting, we did not have a documented control in place to review reports prior to submission for reporting directly to Department of Treasury. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will adopt contro...
Finding 2022-004 Finding Summary: In our testing of reporting, we did not have a documented control in place to review reports prior to submission for reporting directly to Department of Treasury. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will adopt controls to have a review process added before the required reports for federal programs are submitted to federal or state agencies. Anticipated Completion Date: December 31, 2024
Finding 481006 (2022-003)
Significant Deficiency 2022
Finding 2022-003 Finding Summary: In testing of procurement, suspension, and debarment, the auditors noted that the City’s procurement policy followed state law which is some cases is less restrictive than federal law. They also noted that the policy does not include the required contract provisions...
Finding 2022-003 Finding Summary: In testing of procurement, suspension, and debarment, the auditors noted that the City’s procurement policy followed state law which is some cases is less restrictive than federal law. They also noted that the policy does not include the required contract provisions that are needed in contracts with federal grants. Responsible Individuals: Douglas Heinrich, Finance Officer Corrective Action Plan: We will assess if we need to adopt a policy for procurement if we receive federal grants in the future. We will be aware of the contract requirements to ensure they are included in contracts which involve federal money. Anticipated Completion Date: December 31, 2024
All future federal expenditures will be reconciled to the disbursement ledger.
All future federal expenditures will be reconciled to the disbursement ledger.
Planned Corrective Action: The Town will adopt policies pertaining to federal awards, specifically ARPA, that have been effective and useful in other municipalities. Using established policies from other municipalities will expedite bringing Southampton into compliance. The new policies will esta...
Planned Corrective Action: The Town will adopt policies pertaining to federal awards, specifically ARPA, that have been effective and useful in other municipalities. Using established policies from other municipalities will expedite bringing Southampton into compliance. The new policies will establish controls setting responsibilities and deadlines for timely and accurate submissions. With ARPA funding moving towards an expiration date, these policies will be important to finalize and close-out any awards.
Finding 2022-02: The Project has not received any PRAC receipts in 2022 and 2021 or subsequent to the year end. Recommendation: Management needs to work with HUD to process monthly PRAC submission receipts. Action Taken: Management is working with Darletta Baugh, HUD’s project manager regarding...
Finding 2022-02: The Project has not received any PRAC receipts in 2022 and 2021 or subsequent to the year end. Recommendation: Management needs to work with HUD to process monthly PRAC submission receipts. Action Taken: Management is working with Darletta Baugh, HUD’s project manager regarding the non-receipt of the PRAC monthly submission. In addition, Management has delegated the oversight of the PRAC process.
Finding 2022-01: The monthly deposits to the Replacement Reserve totaling $12,000 were not made in 2022 as the project assumed HUD would grant a waiver. Recommendation: Deposit past due Replacement Reserve amounts if HUD approval of suspension of monthly deposits is not received. Action Taken:...
Finding 2022-01: The monthly deposits to the Replacement Reserve totaling $12,000 were not made in 2022 as the project assumed HUD would grant a waiver. Recommendation: Deposit past due Replacement Reserve amounts if HUD approval of suspension of monthly deposits is not received. Action Taken: Management funded required Replacement Reserve funding in February 2023.
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