Corrective Action Plans

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Type of Finding: Material Weakness; Compliance Requirement: Reporting Finding Summary: The totals submitted on the SLFRF Compliance P&E Annual Report did not match the expenditures incurred by the City. The City passed through funds to three subrecipients during the year to be used for preapproved p...
Type of Finding: Material Weakness; Compliance Requirement: Reporting Finding Summary: The totals submitted on the SLFRF Compliance P&E Annual Report did not match the expenditures incurred by the City. The City passed through funds to three subrecipients during the year to be used for preapproved projects allowed under the award. The City reported funds expended by the subrecipients to date, rather than the funds incurred by the City. Responsible Individuals: Ellen Lorraine McCabe, City Manager Corrective Action Plan: The City has had significant turnover in management positions over the past few years. This was also the first year a single audit was required. New procedures will be implemented to controls surrounding federal programs to ensure accurate reporting. The City inquired about amending the report directly with the Treasury Department and is not required to resubmit the report. No further action is necessary. Anticipated Completion Date: August 29, 2025
Accounting has reviewed all projects and Ordinances related to ARPA and has updated reports and records to fully account for ARPA funding. From the Chief Administrative Officer (CAO) and the department responsible for a specific project that has multiple funding sources, confirmation was obtained on...
Accounting has reviewed all projects and Ordinances related to ARPA and has updated reports and records to fully account for ARPA funding. From the Chief Administrative Officer (CAO) and the department responsible for a specific project that has multiple funding sources, confirmation was obtained on what amounts were obligated ARP funds. This strengthens the controls over the report submission process to ensure the reported amounts are accurate and reconciled properly. Person Responsible: Sheila Faour, CFO Anticipated Completion Date: Immediately
Finding 576085 (2024-011)
Significant Deficiency 2024
The City will strengthen the controls over the vendor debarment and suspension status review during the procurement process with the following steps: (1) the Finance Purchasing Division will communicate with the City Departments receiving federal awards to ensure the contracts are routed through Pur...
The City will strengthen the controls over the vendor debarment and suspension status review during the procurement process with the following steps: (1) the Finance Purchasing Division will communicate with the City Departments receiving federal awards to ensure the contracts are routed through Purchasing for verification of debarment and suspension compliance; (2) the Finance Purchasing Division will run a contract audit report periodically to review the Department contract documents for compliance; and (3) throughout the year, the Finance Department will review the grant expenditures for vendor activity not meeting requirements. Person Responsible: Sheila Faour, CFO Anticipated Completion Date: Immediately
Finding 576083 (2024-003)
Significant Deficiency 2024
2024-003 Policies Condition During inquiry of Church management, it was determined that the Church did not have the required written policies. Recommendation We recommend that the Church’s written policies be updated to properly reflect all requirements. Comments on the Finding The Church is aware o...
2024-003 Policies Condition During inquiry of Church management, it was determined that the Church did not have the required written policies. Recommendation We recommend that the Church’s written policies be updated to properly reflect all requirements. Comments on the Finding The Church is aware of the oversight and has taken steps to address the issue. Action Taken As of the date of this notice, the Church has begun the process of creating the required written policies. All policies will be implemented by the end of the calendar year.
Finding 576082 (2024-004)
Significant Deficiency 2024
DOCUMENTATION OF SUSPENSION AND DEBARMENT Recommendation: It is recommended the County retain documentation related to the applicable federal requirements to ensure compliance with said federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit find...
DOCUMENTATION OF SUSPENSION AND DEBARMENT Recommendation: It is recommended the County retain documentation related to the applicable federal requirements to ensure compliance with said federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will retain documentation related to applicable federal requirements. Name of the contact person responsible for corrective action plan: Denise Snyder, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2025
The Director of Grants and Contracts for Queens Legal Services has spoken to the supervisor for the paralegals responsible for the errors in these cases, who has spoken to the paralegals. The Compliance Officer is working with LSNYC's LegalServer Support IT specialist to see if the platform can be ...
The Director of Grants and Contracts for Queens Legal Services has spoken to the supervisor for the paralegals responsible for the errors in these cases, who has spoken to the paralegals. The Compliance Officer is working with LSNYC's LegalServer Support IT specialist to see if the platform can be customized so that LSC Eligibility Overrides can only be used to go from Yes to No (as is necessary when we have open a duplicate case for a client, since only one case can be LSC eligible), which is the only acceptable way for LSC Eligibility Overrides to work. The Compliance Officer will work with the Citywide Director of Intake to develop written materials that (1) remind intake staff to exclude primary residences from Asset totals, which has always been and will continue to be part of financial eligibility training; (2) remind intake staff that an Asset Override may only be made with the written approval of a supervisor (who will review to make sure that the assets legitimately exceed the asset ceiling) documented in the case file; and (3) explain to intake staff the appropriate use of each of the override fields - income overrides, asset overrides, and LSC Eligibility overrides.
The Compliance Officer met with the Grants and Contracts team from Manhattan Legal Services about the income ineligible case and discussed systems for ensuring that supervisors review the monthly compliance cleanup reports and make the identified corrections as instructed. They will reiterate to al...
The Compliance Officer met with the Grants and Contracts team from Manhattan Legal Services about the income ineligible case and discussed systems for ensuring that supervisors review the monthly compliance cleanup reports and make the identified corrections as instructed. They will reiterate to all staff that the LSC income eligibility category in our case management system, LegalServer, is unrelated to income eligibility criteria for individual contracts and that while LSNYC may represent a client who is not LSC income eligible using funds for which that is permissible, those cases must be marked as LSC income ineligible. The intake paralegal responsible for the erroneous override will get remedial instructions on removing such overrides rather than leaving them in place. Additionally, the Compliance Officer has been meeting with staff in other boroughs who distribute monthly cleanup reports to evaluate their practices for ensuring corrections are made in response to the reports. The Compliance Officer and Citywide Director of Intake Services will continue to train on how the LSC income eligibility criteria are to be applied, and that No should be selected for LSC income eligibility even when a client is income eligible under other funders’ contracts. The Director of Grants and Contracts for Queens Legal Services has spoken to the attorney and supervisor responsible for the incorrect LSC Eligibility Override Note in the asset-ineligible case. The Compliance Officer is working with LSNYC's LegalServer Support IT specialist to see if the platform can be customized so that LSC Eligibility Overrides can only be used to go from Yes to No (as is necessary when we have open a duplicate case for a client, since only one case can be LSC eligible), which is the only acceptable way for LSC Eligibility Overrides to work. The Compliance Officer and the Citywide Director of Intake will continue to train staff on the LSC asset eligibility criteria and stress that although we can accept clients whose assets exceed the LSC asset ceiling, no one should be selected for Asset and LSC eligibility for those cases.
Corrective Action Plan: During the period of the delay WEDI’s management was in regular communication with its U.S. SBA representative. Management was advised to prioritize correcting the system and submitting accurate reports over timeliness. WEDI management has filled the Grants Manager position,...
Corrective Action Plan: During the period of the delay WEDI’s management was in regular communication with its U.S. SBA representative. Management was advised to prioritize correcting the system and submitting accurate reports over timeliness. WEDI management has filled the Grants Manager position, created a workplan schedule forecasting 3 months of grant applications and reporting needs, and developed a system for staff backups in case of absences.
Description of Finding: Sliding fee discounts were given to five of the 40 patients tested that were inconsistent with the Health Center’s sliding fee discount policy. Statement of Concurrence: Shasta Community Health Center (SCHC) management agrees with the finding related to sliding fee discounts...
Description of Finding: Sliding fee discounts were given to five of the 40 patients tested that were inconsistent with the Health Center’s sliding fee discount policy. Statement of Concurrence: Shasta Community Health Center (SCHC) management agrees with the finding related to sliding fee discounts being provided to a small number of patients inconsistent with the Health Center’s sliding fee discount policy. The finding suggests that staff miscalculated which discount these patients would qualify for based on the income documented on the sliding fee forms. This miscalculation caused incorrect sliding fee discounts to be provided. Corrective Action: Miscalculations seem to be the leading cause of the errors noted by the auditors. Ongoing training/internal audits needs to be more robust to ensure staff understand and accurately calculate which discount the patient qualifies for. Center Managers shall review the slide audits to determine which employees are making errors and provide re-training or corrective action as applicable and document/monitor for improvement. In addition, SCHC is in the process of launching a computer-based patient form completion system, which will calculate the slide fee automatically, removing much of the human element, and thereby greatly reducing the likelihood of miscalculation. We will continue to perform audits on the new process to ensure we see an improvement in our administration of the sliding fee discount program. Individual Primarily Responsible for Corrective Action: Chief Operations Officer Projected Completion Date: Center Managers will begin documenting retraining/corrective action taken based on sliding fee audit starting June 2024. SCHC is in the process of creating the electronic forms needed to launch the computer-based registration and income verification. We expect the forms to be ready to go live late Fall, early Winter.
Finding 576074 (2024-006)
Material Weakness 2024
It is recommended that the organization implement a standardized process for documenting the approval of performance reports. This process should include clear guidelines and training for staff to ensure that all reports are reviewed and approved by the designated authority before submission. Additi...
It is recommended that the organization implement a standardized process for documenting the approval of performance reports. This process should include clear guidelines and training for staff to ensure that all reports are reviewed and approved by the designated authority before submission. Additionally, regular audits should be conducted to verify compliance with the documentation requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization is implementing a formalized procedure for the preparation, review, and approval of all performance reports. This will include clear documentation of the review process, designation of responsible approvers, and timelines to ensure timely submission. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025. If the oversight agency has questions regarding this plan, please contact Kristina Valdez, Chief Executive Officer at 484-306-3374.
Finding 576073 (2024-005)
Material Weakness 2024
We recommend that the subrecipient establish and implement procedures to verify the eligibility of parties involved in Federal awards, subawards, and contracts. This should include regular checks against the System for Award Management (SAM) to ensure compliance with suspension and debarment regulat...
We recommend that the subrecipient establish and implement procedures to verify the eligibility of parties involved in Federal awards, subawards, and contracts. This should include regular checks against the System for Award Management (SAM) to ensure compliance with suspension and debarment regulations. Additionally, the subrecipient should maintain documentation to support the review process, including records of SAM checks and any correspondence related to the verification of eligibility. This documentation will provide evidence of compliance and support any future audits or reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization is implementing formal written procedures to verify the eligibility of all contractors and subrecipients prior to entering into any federally funded agreements. This includes mandatory checks against the System for Award Management (SAM.gov) for each party. In addition, the Organization will maintain documentation of all SAM verification checks, including screenshots or download logs, date of the check, name of the party verified, and results. Any correspondence or follow-up related to eligibility will also be retained in the procurement or grant file. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Finding 576072 (2024-004)
Significant Deficiency 2024
We recommend that the subrecipient implement procedures to ensure that written preapproval is obtained from the Federal awarding entity for noncompetitive procurement. Additionally, the procurement process should be documented thoroughly to indicate the circumstances under which noncompetitive procu...
We recommend that the subrecipient implement procedures to ensure that written preapproval is obtained from the Federal awarding entity for noncompetitive procurement. Additionally, the procurement process should be documented thoroughly to indicate the circumstances under which noncompetitive procurement is justified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization is updating its procurement policy to explicitly require written prior approval from the Federal awarding agency for all noncompetitive (sole source) procurements, in accordance with federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Finding 576071 (2024-003)
Material Weakness 2024
We recommend the Organization implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation...
We recommend the Organization implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: During FY 2025 the Organization implemented Clockify, a third-party time reporting system, to track employee hours and to certify personnel costs in accordance with Uniform Guidance. Additionally, a third-party Human Resources consultant was engaged to oversee timesheet management and approval. Prior to this, management utilized a project management platform which offered general oversight for time reporting; however we recognize that it did not meet the federal time certification requirements. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Finding 576070 (2024-002)
Material Weakness 2024
The Organization should review its internal controls and procedures to ensure all supporting documentation for federally funded purchases is retained, and expenditures are appropriately recognized in the correct period. Explanation of disagreement with audit finding: There is no disagreement with th...
The Organization should review its internal controls and procedures to ensure all supporting documentation for federally funded purchases is retained, and expenditures are appropriately recognized in the correct period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization acknowledges the importance of maintaining complete supporting documentation for all federally funded purchases and ensuring expenditures are recorded in the correct accounting period. During fiscal year 2025, a third-party bill payment system, Bill.com, was implemented. The system stores all invoices, payment confirmations, and documentation of the review and approval process for all expenditures. In addition, going forward, we will conduct quarterly internal reviews of federally funded transactions to ensure compliance with documentation and period recognition standards. Findings will be reported to management and corrective action taken as needed. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
FINDING 2024-002 Medical Assistance Program Reporting Finding Subject: Medical Assistance Program Reporting- Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number and Email Address: 317-418-7855, jeb.bardon@...
FINDING 2024-002 Medical Assistance Program Reporting Finding Subject: Medical Assistance Program Reporting- Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Jeb Bardon Contact Phone Number and Email Address: 317-418-7855, jeb.bardon@waynetwp.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The Federal Cost report beginning 2022 will be done by a new firm. The firm is Blue & Co. They are a well-established CPA. The information that is supplied to the CPA firm will be maintained by Wayne Township and will be put in the finished cost report. This is for the financial and other metrics that are needed for the report. The cost report will be reviewed for accuracy by the Township Office. The Ambulance payment adjustment is received about two- and one-half years in arrears. This comment would be repeated until we receive the funds for ambulance activity completed in 2023, which will occur in 2026. The payments received by the Medicaid program will be reviewed by the Township Accounting Specialist. After the person agrees it is then entered into the accounting software and coded to the proper account. Before the Cost report is signed and submitted it will be reviewed by the Township and will ask questions as needed. Anticipated Completion Date: 12/31/25
Finding 576061 (2024-001)
Significant Deficiency 2024
Contact Person (s): Jim McCarthy - jim@waterwatch.org ; Neil Brandt – neil@waterwatch.org Corrective actions planned: The following corrective actions are being immediately implemented for contracts in WaterWatch’s restoration program in order to achieve compliance: 1. Language requiring all contra...
Contact Person (s): Jim McCarthy - jim@waterwatch.org ; Neil Brandt – neil@waterwatch.org Corrective actions planned: The following corrective actions are being immediately implemented for contracts in WaterWatch’s restoration program in order to achieve compliance: 1. Language requiring all contractors to comply with the Build America, Buy America (BABA) Act is added to all new WaterWatch contracts and all current contracts via amendment. 2. Language requiring all contractors to comply with federal suspension and debarment contracting standards is added to all new WaterWatch contracts and all current contracts via amendment. 3. WaterWatch will keep formal documentation of debarment searches for all contractors. 4. WaterWatch will keep formal documentation of contractor procurement process in both Southern Oregon and Portland offices. Anticipated completion date: September 1, 2025
Material weakness in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA adopted a new, updated procurement policy in Oct...
Material weakness in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA adopted a new, updated procurement policy in October 2024. PDA worked with Clark Nuber to develop this policy. Anticipated Completion Date: October of 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors
View Audit 365948 Questioned Costs: $1
Significant deficiency in internal controls over financial reporting of leases in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action ...
Significant deficiency in internal controls over financial reporting of leases in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: Review lease terms at inception of lease(s) and ensure accounted for correctly in the leasing software and general ledger; review all leases again at year end to ensure any changes to said leases were recorded properly. Anticipated Completion Date: End of 2025 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors
Significant deficiency in internal controls over financial reporting of net assets with and without donor restrictions in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following co...
Significant deficiency in internal controls over financial reporting of net assets with and without donor restrictions in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA instituted a monthly review of foundation grant spending to ensure spending is in line with assumptions. By the completion of each fiscal year, PDA will have proper information gathered to release funds from restricted net assets accordingly. Anticipated Completion Date: Implemented in 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors
Finding Number: 2024‐003 Program Name/Assistance Listing Title: Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 21.207 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with th...
Finding Number: 2024‐003 Program Name/Assistance Listing Title: Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 21.207 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated its policies and procedures and implemented the recommendation.
Finding Number: 2024‐002 Program Name/Assistance Listing Title: Housing Voucher Cluster Assistance Listing Number: 14.871 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated...
Finding Number: 2024‐002 Program Name/Assistance Listing Title: Housing Voucher Cluster Assistance Listing Number: 14.871 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated its policies and procedures and implemented the recommendation. Vacancies for certain position are hard to fill in rural Arizona such as the City of Winslow. Due to a vacancy in the PHA, the Director was managing the financials and the day‐to‐day activities for the rental properties onsite as well as doing the required inspections of housing vouchers offsite. The overwhelming responsibilities have been the cause of the aforementioned findings. Moving forward, management acknowledges the need to reassign staff to the PHA when there is a vacancy. The PHA has been fully staffed the latter part of fiscal year 2024 and has implemented the recommendations of the independent auditors during fiscal year 2025.
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Housing Voucher Cluster, Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 14.871, 21.207 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective...
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Housing Voucher Cluster, Coronavirus State and Local Fiscal Recovery Fund Assistance Listing Number: 14.871, 21.207 Contact Person: Daniel Hendrix, Finance Director Anticipated Completion Date: During fiscal year 2025 Planned Corrective Action: The City concurs with the finding and has updated its policies and procedures and implemented the recommendation.
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible C...
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director
Finding Number: 2024-003 Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of th...
Finding Number: 2024-003 Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Peggy Anderson, Chief Executive Officer
Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Furth...
Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from an error in the set up of the automated adjustment calculation within the Electronic Health Record system. Management has identified the error with plans to ensure correction within the system. Further, the Organization will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Peggy Anderson, Chief Executive Officer
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