Corrective Action Plans

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Management?s View and Corrective Action PlanThe following is Novant Health?s response to the audit of Federal programs in accordance with the Uniform Guidance for year ending December 31, 2022.2022-001: First tier subawards were not reported on the Federal Funding Accountability and Transparency Act...
Management?s View and Corrective Action PlanThe following is Novant Health?s response to the audit of Federal programs in accordance with the Uniform Guidance for year ending December 31, 2022.2022-001: First tier subawards were not reported on the Federal Funding Accountability and Transparency Act Subaward Reporting System (?FSRS?)Cluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: Coordinated Services and Access to Research for Women, Infants, Children, and Youth (?Ryan White Part D Program?)Award #: 7 H12HA45378-01-00; 2 H12HA45378-02-00Assistance Listing #: 93.153Award Year: Fiscal year 2022Pass-through entity: N/AManagement understands the importance of reporting the first tier subaward to Duke University within the FSRS. Novant Health receives a Federal Notice of Award (NOA) from HRSA that outlines a summary of the Federal Award financial information and specific grant terms, including reporting requirements. The NOA indicates relevant reports and submission guidelines with the expected submission web portal sites.Corrective Action Plan and Anticipated Completion DateNovant Health management?s corrective action plan includes:? Creation of a contract summarization control? Review of contract summarization by Grant/Program Manager prior to contract start, to ensure relevant requirements are known and included? Creation of a contract requirement timeline by Grant/Program Manager, to ensure all contract requirements are executed in accordance with the contract specifications and establish the individual(s) who are responsible for completionIn order to capture a summary of all reporting requirements, the program manager created a timeline for all reporting requirements, both grant and fiscal year. This summary report was created on September 26, 2023. The timeline will be reviewed as part of the agenda within the program?s monthly meetings, beginning October 10, 2023. This will establish an internal review of all reporting requirements. At the time of the first tier subaward reporting to FSRS system, the expected timeline for reporting requirements was not part of the Monthly Program Meeting.Additionally, Novant Health will report the subaward to Duke in FSRS by October 15, 2023. The program manager will provide an email of completed submission to the Grants Director and team. At the beginning of each NOA budget period, the program manager will provide a fiscal update to the Grants team to ensure compliance with all applicable reporting requirements.For follow-up questions and information, please contact Randy Brantley, Novant Health Grants Director at rlbrantley@novanthealth.org.Sincerely,Randy BrantleyGrants Directorrlbrantley@novanthealth.org
FINDING 2022-002Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ens...
FINDING 2022-002Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensurereporting compliance requirements are met. The corporation will assure one individual is completing the reports andanother is verify the reports.Anticipated Date of Completion: March 2023
FINDING 2022-001Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ens...
FINDING 2022-001Contact Person Responsible for Corrective Action: Allison Pund and Melissa BoeglinContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensurecompliance with the Allowable Costs/Cost Principles compliance requirement. The Corporation will do so by maintainingadequate time records, to insure the proper amount was charged to the Federal Awards.Anticipated Date of Completion: March 2023
View Audit 312295 Questioned Costs: $1
FINDING 2022-004Contact Person Responsible for Corrective Action: Timothy LaGrangeContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois and the DSP Exceptional Child?s Co-op have created a systemof internal c...
FINDING 2022-004Contact Person Responsible for Corrective Action: Timothy LaGrangeContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois and the DSP Exceptional Child?s Co-op have created a systemof internal controls that will ensure reporting compliance requirements are met. The Co-op has developed a shared file foreach of their staff that is participating gin the requirements for the proportionate share. This will be a detailed list of datesand duties that were applied to the proportionate share of each member school corporation. This list will be printed andattached to the grant records and can also be provided to each member corporation if requested.Anticipated Date of Completion: May 2023
FINDING 2022-003Contact Person Responsible for Corrective Action: Allison Pund and Ora Lee CottonContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensu...
FINDING 2022-003Contact Person Responsible for Corrective Action: Allison Pund and Ora Lee CottonContact Phone Number: 812-683-3971Views of Responsible Official: We concur to the finding.Description of Corrective Action Plan: Southwest Dubois will develop a system of internal controls that will ensurereporting compliance requirements are met. The corporation will assure one individual is completing the claims/reportsand another is verify the reports.Anticipated Completion Date: March 2023
Finding 421301 (2022-101)
Significant Deficiency 2022
Improve the Timeliness and Accuracy of Financial and Programmatic Reports21.023, 21.027 Emergency Rental Assistance Program, Coronavirus State and Local Fiscal Recovery FundsName of contact person: Connie DeKemper, Finance DirectorAnticipated completion date: 6/30/2023The Finance Department has corr...
Improve the Timeliness and Accuracy of Financial and Programmatic Reports21.023, 21.027 Emergency Rental Assistance Program, Coronavirus State and Local Fiscal Recovery FundsName of contact person: Connie DeKemper, Finance DirectorAnticipated completion date: 6/30/2023The Finance Department has corrected the issue of late reporting by working with the subrecipient and developing processes to accurately and timely report on the requirements of the grant. The US Treasury has developed an extension request process to allow for the collection of additional data due to changing requirements. The Finance Department has submitted its closeout data accurately and timely for the Emergency Rental Assistance Program correcting any reporting errors.Improve the Timeliness and Accuracy of Financial and Programmatic Reports93.224, 93.527 Health Center Program ClusterName of contact person: Tracy Pytlakowski, Community Health Center of Yavapai Finance ManagerAnticipated completion date: 4/17/2023The Community Health Center of Yavapai has corrected the late reporting of its federal funding by ensuring that reports are prepared as soon as possible so that unforeseen staffing absences do not affect the ability to meet timely reporting requirements. The quarterly report that was submitted late is no longer required by the grantor.
Finding 421297 (2022-102)
Significant Deficiency 2022
Improve the Timeliness of Filing the Annual Audit17.258, 17.259, 17.278, 20.205, 21.023, 21.027, 93.224, 93.527, 93.268 Workforce Investment Opportunities Act (WIOA) Cluster, Highway Planning and Construction, Emergency Rental Assistance Program, Coronavirus State and Local Fiscal Recovery Funds, He...
Improve the Timeliness of Filing the Annual Audit17.258, 17.259, 17.278, 20.205, 21.023, 21.027, 93.224, 93.527, 93.268 Workforce Investment Opportunities Act (WIOA) Cluster, Highway Planning and Construction, Emergency Rental Assistance Program, Coronavirus State and Local Fiscal Recovery Funds, Health Center Program Cluster, Immunization Cooperative AgreementsName of contact person: Connie DeKemper, Finance DirectorCompletion date: 06/30/2023The County?s Single Audit reporting package for the fiscal year ended June 30, 2022 was not submitted to the Federal Audit Clearinghouse by the required deadline of March 31, 2023. The Finance Department has had significant turnover in the past 24 months. Due to this turnover, the prior year financial statements were delayed. This has contributed to the delay in the current year financial statement submission. The Finance Department continues to train staff and document the processes and procedures for accurate and timely submission of the financial statements.
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: Management will implement controls and procedures to ensure that the required Excess Cost Computation Form is completed each year.Proposed Completion Date: Immediately
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: Management will implement controls and procedures to ensure that the required Excess Cost Computation Form is completed each year.Proposed Completion Date: Immediately
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: The Board will implement controls to ensure that management fully understands all program requirements pertaining to grant funding received by the district to ensure that available grant funding is maximized for th...
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: The Board will implement controls to ensure that management fully understands all program requirements pertaining to grant funding received by the district to ensure that available grant funding is maximized for the benefit of the district.Proposed Completion Date: Immediately
View Audit 312291 Questioned Costs: $1
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: Budget Managers will monitor Program Report Code expenditures on a monthly basis for compliance with the 10% federal requirement. Amendments will be submitted through the BUD system, as necessary, to ensure complia...
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: Budget Managers will monitor Program Report Code expenditures on a monthly basis for compliance with the 10% federal requirement. Amendments will be submitted through the BUD system, as necessary, to ensure compliance with the 10% requirement.Proposed Completion Date: Immediately
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: Monthly reconciliations will be completed by the 15th day of the following month. A report showing completion of the reconciliations will be provided to the Superintendent by the end of the following month. The res...
Name of Contact Person: Victoria Blue, Interim Finance OfficerCorrective Action Plan: Monthly reconciliations will be completed by the 15th day of the following month. A report showing completion of the reconciliations will be provided to the Superintendent by the end of the following month. The results of the reconciliations will be evident in the monthly Trial Balance.Proposed Completion Date: Immediately
Finding Number: 2022-004Prior Year Finding: NoFederal Agency: U.S. Department of EducationFederal Program: COVID-19 - Elementary and Secondary Schools EmergencyRelief Fund (ESSER)Assistance Listing: 84.425C, D, U, WPass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber a...
Finding Number: 2022-004Prior Year Finding: NoFederal Agency: U.S. Department of EducationFederal Program: COVID-19 - Elementary and Secondary Schools EmergencyRelief Fund (ESSER)Assistance Listing: 84.425C, D, U, WPass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:201787-01 (3/13/20 ? 9/30/22)Compliance Requirement: Allowable Costs/Cost PrinciplesType of Finding Significant Deficiency in Internal Control over Compliance,Other MattersRecommendation:We recommend that the Board review its policies and procedures to verify that controls are inplace to ensure expenditures are not reimbursed under more than one Federal Program.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding: ESSER funds will no longer be used for Food and NutritionServices.Name(s) of the contact person(s) responsible for corrective action: BCPS grant managers,and Fiscal Services staff.Planned completion date for corrective action plan: For immediate implementation andongoing
View Audit 312282 Questioned Costs: $1
Finding Number: 2022-003Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryFederal Program: Special Education ClusterAssistance Listing: 84.027, 84.173Pass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211021-03 (10/1/20 ? 9/30/22)Compliance ...
Finding Number: 2022-003Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryFederal Program: Special Education ClusterAssistance Listing: 84.027, 84.173Pass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211021-03 (10/1/20 ? 9/30/22)Compliance Requirement: Suspension and DebarmentType of Finding Significant Deficiency in Internal Control over ComplianceRecommendation:We recommend that the Board enhance its procedures and internal controls to ensure that itretains documentation of procurement suspension/debarment status verifications for its vendorsand that this documentation is available for audit purposes.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding: The SAM.gov federal website to verify that a vendor isnot suspended or debarred was checked and the documentation was provided. However, theSAM.gov site does show a date when checked. We will provide updated training to Grant staff toensure the date from their computer screen is included when the screenshot of SAM.gov ischecked.Name(s) of the contact person(s) responsible for corrective action: BCPS grant managersand grant accountants/fiscal staff.Planned completion date for corrective action plan: For immediate implementation andongoing
Finding Number: 2022-002Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryFederal Program: Special Education ClusterAssistance Listing: 84.027, 84.173Pass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211021-03 (10/1/20 ? 9/30/22)220391-02 (...
Finding Number: 2022-002Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryFederal Program: Special Education ClusterAssistance Listing: 84.027, 84.173Pass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211021-03 (10/1/20 ? 9/30/22)220391-02 (7/1/21 ? 9/30/23)221324-01 (7/1/21 ? 9/30/23)Compliance Requirement: ProcurementType of Finding Significant Deficiency in Internal Control over Compliance,Other MattersRecommendation:We recommend that the Board ensures that documentation of Procurement's decisions on anypurchases that are excluded from the requirements noted in the Procurement Policy are retainedfor audit purposes.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding.Action taken in response to finding This finding was a result of only one vendor being availableat the time. The Office of Purchasing and Grants staff will comply with the requirement forobtaining quotes and document any exceptions if two quotes cannot obtained.Name(s) of the contact person(s) responsible for corrective action: BCPS Office ofPurchasing staff, grant accountants/fiscal staff.Planned completion date for corrective action plan: For immediate implementation andongoing.
Finding Number: 2022-001Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryU.S. Department of EducationFederal Program: COVID-19 -Coronavirus State and Local Fiscal Recovery FundsCOVID-19 - Education Stabilization FundSupporting Effective Instruction State Grants (formerlyImproving Tea...
Finding Number: 2022-001Prior Year Finding: NoFederal Agency: U.S. Department of TreasuryU.S. Department of EducationFederal Program: COVID-19 -Coronavirus State and Local Fiscal Recovery FundsCOVID-19 - Education Stabilization FundSupporting Effective Instruction State Grants (formerlyImproving Teacher Quality State Grants)Assistance Listing: 21.019, 84.425C and DPass-Through Entity: Maryland State Department of EducationPass-Through AwardNumber and Period:211838-01 (3/3/21 ? 12/31/24) 211815-01 (3/3/21 ? 12/31/24)211875-01 (3/3/21 ? 12/31/24) 201873-01 (3/13/20 ? 9/30/22)201787-01 (3/13/20 ? 9/30/22) 202233-01 (3/13/20 ? 9/30/22)191360-01 (7/1/18 ? 9/30/21) 201067-01 (7/1/19 ? 9/30/21)210781-01 (7/1/20 ? 6/30/22) 221052-01 (7/1/21 ? 6/30/23)Compliance Requirement: ReportingType of Finding Significant Deficiency in Internal Control over Compliance, OtherMattersRecommendation:We recommend that the Board review its policies and procedures to ensure that ReimbursementRequests and the detail & accompanying reconciliations used to prepare it are retained for auditpurposes.Explanation of disagreement with audit finding: There is no disagreement with the auditfinding. Action taken in response to finding: Procedures to ensure that the documentation to supportthe monthly submission of the Financial Status Report have been modified accordingly.Name(s) of the contact person(s) responsible for corrective action: BCPS grant accountants;Accounting Manager.Planned completion date for corrective action plan: For immediate implementation andongoing.
FINDING 2022-006Contact Person Responsible for Corrective Action: Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment will be made. TheDirector of Bus...
FINDING 2022-006Contact Person Responsible for Corrective Action: Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment will be made. TheDirector of Business will conduct and internal audit of capital assets records. New staff will also be trained on trackingcapital assets transitions and completing the necessary documentation for future capital assets transaction. There is aconstruction project that will result in capital assets being added.Anticipated Completion Date: June 2023
FINDING 2022-005Contact Person Responsible for Corrective Action: Robin Popejoy/Kim DeVaneyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment have been made.As th...
FINDING 2022-005Contact Person Responsible for Corrective Action: Robin Popejoy/Kim DeVaneyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment have been made.As this finding is in review of ESSER funding, it should be noted that most all guidance and direction for these grantscame after they were issued. All financial transactions related to grants will have board oversight and approval.Anticipated Completion Date: February 2023
View Audit 312279 Questioned Costs: $1
FINDING 2022-007Contact Person Responsible for Corrective Action: Robin Popejoy/Kim DeVaneyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment have been made.As th...
FINDING 2022-007Contact Person Responsible for Corrective Action: Robin Popejoy/Kim DeVaneyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustment have been made.As this finding is in review of ESSER funding, it should be noted that most all guidance and direction for these grantscame after they were issued. As ESSER reports and reimbursements are completed the supporting documents will bekept with reports. Prior to submission, reports completed and documentation compiled by the Grant Specialist will bereviewed by the Director of Business.Anticipated Completion Date: February 2023INDIANA STATE
FINDING 2022-004Contact Person Responsible for Corrective Action: Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustments have beenmade. To cover oversig...
FINDING 2022-004Contact Person Responsible for Corrective Action: Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustments have beenmade. To cover oversight of the School Food Service Accounts, at the close of the month the Director of Business willsend Director of Food Service reports to approve all activity of School Food Service Accounts.Anticipated Completion Date: February 2023
FINDING 2022-003Contact Person Responsible for Corrective Action: Kim DeVaney/Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustments have beenmade. To p...
FINDING 2022-003Contact Person Responsible for Corrective Action: Kim DeVaney/Robin PopejoyContact Phone Number: 317.758.4172Views of Responsible Official: We concur with the finding.Description of Corrective Action Plan: Those procedures and errors were discussed and adjustments have beenmade. To prevent errors the Payroll Specialist will make sure the employee timesheets that was signed off by the Directormatches with the hours they were approved to work when hired.Anticipated Completion Date: February 2023
Finding 2022-003 - Allowable Activities or Unallowed, Allowable Costs/Cost Principles and CashManagementMaterial Weakness in Internal Control over Compliance and Material Noncompliancefinding Summary: During the audit, the appropriate documentation for grant expenditures to supportthe drawdown from ...
Finding 2022-003 - Allowable Activities or Unallowed, Allowable Costs/Cost Principles and CashManagementMaterial Weakness in Internal Control over Compliance and Material Noncompliancefinding Summary: During the audit, the appropriate documentation for grant expenditures to supportthe drawdown from grant funding was not readily provided. In addition, the process to ensure thatgrant expenditures are allowable and reconciled was not clearly communicated to appropriate partiescausing expenditures to be inappropriately claimed in the wrong fiscal year.Responsible Individual: Chief Financial OfficerCorrective Action Plan; We have designated a member of management to participate in monthly,quarterly, or annual reconciliations as proposed by the auditors. The existing controls will be clearlycommunicated to ensure that program expenditures are made prior to requesting reimbursement offunds.Anticipated Completion Date: Ongoing
View Audit 312271 Questioned Costs: $1
Finding 2022-002 - Procurement, Suspension and DebarmentMaterial Weakness in Internal Control over ComplianceFinding Summary: As part of the audit, Eide Bailly LLP identified that the formally documented policy didnot include many of the necessary procurement provisions. Provisions include a consist...
Finding 2022-002 - Procurement, Suspension and DebarmentMaterial Weakness in Internal Control over ComplianceFinding Summary: As part of the audit, Eide Bailly LLP identified that the formally documented policy didnot include many of the necessary procurement provisions. Provisions include a consistent control in placeto check applicable vendors for potential suspension and/or debarment for covered transactions. Inaddition, current controls are to be documented to provide for a proper audit trail.Responsible lndividual(s): Chief Financial OfficerCorrective Action Plan: The policy has been updated to include all federal requirements regardingprocurement controls and suspension and debarment controls as proposed by the auditors. Managementwill retain documentation to support that the control process was followed.Anticipated Completion Date: Ongoing
Recommendation: We recommend that the College ensure its policies and procedures over procurement are being enforced to ensure reasonable prices and rates. Specifically, the College should consider training employees that regulations do apply when a single vendor is being used for a good or service...
Recommendation: We recommend that the College ensure its policies and procedures over procurement are being enforced to ensure reasonable prices and rates. Specifically, the College should consider training employees that regulations do apply when a single vendor is being used for a good or service, yet the charges are split amongst various funding sources.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action in Response to Finding: The College will implement training and procedural changes during the grant budgeting process and in the post-award process to ensure documentation of reasonable prices and rates to include training related to handling vendors who may be used across multiple funding sources.Name of the contact person responsible for corrective action: Tess Powers, Director of Faculty Research Support (719) 389-6318Planned completion date for corrective action plan: May 1, 2023
Recommendation: We recommend that the College increase the time and effort certification process to be more timely and implement a review process over the time and effort certification process.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action in R...
Recommendation: We recommend that the College increase the time and effort certification process to be more timely and implement a review process over the time and effort certification process.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action in Response to Finding: The College will implement the change to conduct the time and effort certification process semi-annually and to add an additional review by the Department Chair or Program Director, or in cases in which the PI is chair, the Dean of the Faculty.Name of the contact person responsible for corrective action: Tess Powers, Director of Faculty Research Support (719) 389-6318Planned completion date for corrective action plan: May 1, 2023
Recommendation: For any reports required by federal grants or programs, the College should establish procedures that include ensuring an audit trail remains for information reported. Those who review after prepared should trace back to such information.Explanation of disagreement with audit finding:...
Recommendation: For any reports required by federal grants or programs, the College should establish procedures that include ensuring an audit trail remains for information reported. Those who review after prepared should trace back to such information.Explanation of disagreement with audit finding: There is no disagreement with the audit finding.Action in Response to Finding: The reporting for COVID-19 funds was disbursed prior to the audit of previous years. For possible future funds, all numbers will have background data saved to explain.Name of the contact person responsible for corrective action: Shannon Amundson, Director of Financial Aid (719) 389-6651.Planned completion date for corrective action plan: Ongoing for the current fiscal year.
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