Corrective Action Plans

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Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The System did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare pro...
Allowable costs related to the program are expenses or losses that were not reimbursed from other sources or that other sources were not obligated to reimburse. The System did not reduce COVID-19 related costs claimed under the PRF program for cost-based reimbursements received from the Medicare program for the COVID-19 related expense. The System will ensure the costs included in all subsequent Provider Relief Fund reporting is reduced for amounts reimbursed by other sources. Status: Completed Name of Responsible Official: Monica Holthaus Chief Financial Officer Community Healthcare Systems NE Kansas 785-889-5036
Finding 401319 (2022-006)
Significant Deficiency 2022
Finding Number: 2022-006 Finding Title: Procurement and Suspension and Debarment Programs: Highway Planning and Construction 20.205 COVID-19 — Coronavirus State and Local Fiscal Recovery Funds 21.027 Name of Contact Person Responsible for Corrective Action: Colleen Robeck, Finance Director ...
Finding Number: 2022-006 Finding Title: Procurement and Suspension and Debarment Programs: Highway Planning and Construction 20.205 COVID-19 — Coronavirus State and Local Fiscal Recovery Funds 21.027 Name of Contact Person Responsible for Corrective Action: Colleen Robeck, Finance Director Corrective Action Planned: McLeod County recognizes the importance of internal controls over Federal funding to be compliant with the Title 2 U.S. Code of Federal Regulations and is working on a procurement policy to address these issues. There are no misuse of funds, issues with allocation, nor concerns with any handling of funds; however, internal controls assist to assure compliance and will be implemented once complete. Anticipated Completion Date: McLeod County is finishing up the procurement policy and will have the State Auditor’s Office review it for compliance before it is taken to the County Board for approval in 2024.
The District will review internal control procedures and implement as current staff allows. The District did hire a 2nd secretary to help with some segregation of duties such as activity cash boxes etc. in FY22.
The District will review internal control procedures and implement as current staff allows. The District did hire a 2nd secretary to help with some segregation of duties such as activity cash boxes etc. in FY22.
Americans for the Arts Corrective Action Plan Cognizant or Oversight Agency for Audit: National Endowment for the Arts Americans for the Arts respectfully submits the following orrective action plan for the year ended December 31, 2022: Name and address of independent public accounting firm: Marc...
Americans for the Arts Corrective Action Plan Cognizant or Oversight Agency for Audit: National Endowment for the Arts Americans for the Arts respectfully submits the following orrective action plan for the year ended December 31, 2022: Name and address of independent public accounting firm: Marcum LLP 1899 L Street NW Suite 850 Washington DC 20036 Audit period: The year ended December 31, 2022. The findings from the 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. ALN #45.024 Finding No. 2022-002: Reporting – Compliance Finding and Material Weakness in Internal Control Over Compliance Recommendation We recommend that management enhance its year end financial close process to include sufficient procedures to adequately prepare for the performance of a Single Audit within the prescribed reporting deadline Management Response A new outsourced accounting team was hired and assumed most accounting duties in early 2023. This new team took over all accounting duties by Dec. 2023. They have streamlined various finance functions and are continuing to improve the close process to ensure the 2023 audit is started and completed in a timely manner. If the National Endowment for the Arts has questions regarding this plan, please call Matt Ryan at 240.357.3420 or mryan@artsusa.org. Sincerely, Matt X. Ryan, CPA, CFE Chief Financial Officer Americans for the Arts
Finding 401269 (2022-003)
Significant Deficiency 2022
Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: ...
Finding 2022-003 Adherence and Application of Financial Policies and Procedures for Vouchering Federal Agency: U.S. Department of Health and Human Services Pass-Through Entity: Illinois Department of Human Services Program Name: Social Services Block Grant Assistance Listing #: 93.667 Questioned Costs: None Corrective Action: We agree with the auditor’s comments and actions stated in the recommendation. The Organization is rewriting its accounting policies and procedures to ensure adherence to the proper procedures for vouchering, which will be completed in fiscal year 2024. In August 2022, the building at 4730 N. Sheridan was sold. During the move some documents were misfiled or otherwise missed place. This made it difficult to find vouchers for the audit. The new accounting system allows Alternatives to save a copy of the vouchers and necessary support within the software. The electronic filing of the backup documentation will prevent misplacement of vouchers in the future. Contact Person: Sonya Cook, Finance Director Anticipated Completion Date: December 15, 2023
Finding 401244 (2022-004)
Significant Deficiency 2022
Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline....
Finding 2022-004 – Reporting (Late Filing) – Significant Deficiency We are implementing policies to address the audit finding 2022-004 as follows: We are continuing to institute processes and procedures to complete timely reconciliations to allow for future filings to be made prior to the deadline. Anticipated completion date: September 30, 2024
Finding 2022-003 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Reporting (Material Weakness) We are implementing policies to address the audit finding 2022-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior ...
Finding 2022-003 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Reporting (Material Weakness) We are implementing policies to address the audit finding 2022-003 as follows: We have implemented a policy to ensure that all future Provider Relief Fund reporting is reviewed prior to filing. Anticipated completion date: September 30, 2024
Finding 2022-002 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Lack of Documentation of Review (Material Weakness) We are implementing policies to address the audit finding 2022-002 as follows: We have implemented a policy to ensure that all expenses are reviewed prior to dis...
Finding 2022-002 – COVID-19 Provider Relief Fund – Assistance Listing Number 93.498 – Lack of Documentation of Review (Material Weakness) We are implementing policies to address the audit finding 2022-002 as follows: We have implemented a policy to ensure that all expenses are reviewed prior to disbursement and that such evidence of approval is documented and retained. Anticipated completion date: September 30, 2024
Noted, the County will work with the departments responsible for administering federal funds to create procedures requiring the review of the System Of Award Management (SAM) for suspended or debarred parties in accordance with Federal Regulation. We agree with the auditor's comments and the county ...
Noted, the County will work with the departments responsible for administering federal funds to create procedures requiring the review of the System Of Award Management (SAM) for suspended or debarred parties in accordance with Federal Regulation. We agree with the auditor's comments and the county recognizes the challenges with staffing, training, onboarding, and managing unforeseen large amounts of federal funds coming into the county during COVID response. The county will be utilizing a contractor to assist in establishing policies, procedures, training, and strategic improvements to allow quick onboarding of staff in policies, procedures and regulations outlined by CRF 200 for future emergency federal funding and routine federal funding. Walla Walla County is committed to the importance of managing federal funding.
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expe...
We appreciate the auditor's assessment, analysis, and recommendations. However, we disagree with the conclusion reached and the finding. The auditor, during oral conversation discussing context, indicated the quantity of program beneficiaries reviewed for eligibility did not reach the auditor's expected quantity for adequate monitoring. As a management team, we assessed risk and determined the level of appropriate monitoring to consist of: 1) financial monitoring through review of reimbursement requests, which contained eligibility information necessary for oversight; 2) execution of regularly scheduled status and reporting meetings wherein we obtained ongoing programmatic data; and 3) review of audit reports, where applicable. We note neither our award agreement nor applicable federal regulations require a specific quantity of files to be reviewed as part of subrecipient monitoring. Accordingly, we do not concur with the presence of a finding. In addition, no instances of ineligible beneficiaries were identified by the auditor such that a material weakness classification does not appear reasonable or appropriate. That being said, we will assess our procedures and add greater clarity to help better tell this story going forward. We will also consider whether testing a specific number of beneficiaries is necessary and may be conducted efficiently.
The audit finding was for the timeframe of the first quarter FYE 9/30/22. lntermountain was aware that it was necessary to have an enterprise-wide electronic time tracking system in place for grant hours worked and by February of 2022 the company had implemented the Ceridian/Day Force Project Tracke...
The audit finding was for the timeframe of the first quarter FYE 9/30/22. lntermountain was aware that it was necessary to have an enterprise-wide electronic time tracking system in place for grant hours worked and by February of 2022 the company had implemented the Ceridian/Day Force Project Tracker platform. This system is an extension of our human resources and payroll platform and allows for actual time worked to be used for accurate grant costing of payroll and benefits.
The District concurs with the recommendation and is in the process of developing processes and implementing controls to ensure timely reporting in the future.
The District concurs with the recommendation and is in the process of developing processes and implementing controls to ensure timely reporting in the future.
The District concurs with the recommendation to adopt a written procurement policy and is in the process of writing the policy.
The District concurs with the recommendation to adopt a written procurement policy and is in the process of writing the policy.
The District concurs with the recommendation to adopt a written conflict of interest policy and is in the process of adopting a policy.
The District concurs with the recommendation to adopt a written conflict of interest policy and is in the process of adopting a policy.
The Asssociation has added additional accounting positions.
The Asssociation has added additional accounting positions.
Suspension and Debarment – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Explanation of disagreement with audit finding: There is no disagreem...
Suspension and Debarment – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare verify that vendors are not suspended or debarred prior to signing contracts or create an approved vendor list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to verify vendors are not suspended or debarred: in progress a. Develop steps in the vendor diligence and procurement process to verify that the vendor is not suspended or debarred. b. Identify role or job that will handle responsibility for following procedure. c. Formalize the process into a written procedure and add to the procurement or other relevant policy. d. Conduct periodic audits to assess adherence to the procedure and train as necessary to ensure compliance.
View Audit 309100 Questioned Costs: $1
Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Acti...
Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare maintain supporting documentation for all reports required to be filed to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create procedure to deposit all supporting files and schedules in a shared and accessible location: in progress a. Develop steps in the UDS process that outlines where working and final supporting schedules will be stored for future access b. Identify role or job that will handle responsibility for following the procedure. c. Formalize the process into a written procedure and add to the UDS Report or other relevant policy. d. After UDS submission, review data folders to check that all relevant supporting schedules and documents have been deposited.
Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagre...
Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend that Promise Healthcare revise its procurement policy to be consistent with the requirements of the Uniform Guidance and follow the stated procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Review Current Procurement Policy: in progress a. Conduct a comprehensive review of Promise Healthcare’s existing procurement policy. b. Identify and revise and discrepancies or non-compliance with the requirements of the Uniform Guidance. c. Integrate industry best practices into revised policy to enhance compliance and efficiency 2. Training and Education: to start a. Provide training sessions for staff authorized to purchase along with relevant personnel on the revised procurement policy and procedures and raise awareness of the requirements of the Uniform Guidance and implications of non-compliance. b. Establish training on documentation standards for procurement activities including requisitions, solicitations, evaluations and contract awards. c. Establish training and procedure for retention of procurement-related documentation 3. Internal Controls and oversight: to start a. Implement mechanisms for monitoring and oversight to ensure compliance with the procurement policy. b. Conduct periodic internal audits to assess adherence to procurement procedures and identify areas for improvement or corrective action
View Audit 309100 Questioned Costs: $1
Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection a...
Special Tests and Provisions – Assistance Listing No. 93.224/93.527 Recommendation: Management should consider increasing the frequency of its self-reviews of patient encounters or expanding its sample sizes in addition to providing additional training for front desk staff regarding the collection and verification of patient information for each patient. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: to start 1. Review current policies and procedures: in progress a. Conduct a comprehensive review of existing procedures for collection and verification of patient information to identify weaknesses, gaps, and areas for improvement. b. Conduct review of current front desk workflow to determine if policies and procedures are followed correctly. c. Enhance policies and procedures as necessary to improve accuracy and consistency of patient information 2. Verification Process: to start a. Review documentation requirements for verifying accuracy of sliding fee information and standardize/improve where necessary. 3. Training and Education: to start a. Review training materials and create/improve where necessary to provide clear instructions and comply with policy and procedure b. Train front desk staff on standardized forms, templates and scripts for collecting information from patients c. Require periodic training and re-training to improve front desk workflow and retention of process to consistently collect and verify information from patients 4. Quality Assurance: to start a. Conduct regular audits and quality assurance checks to monitor the accuracy and integrity of sliding fee information and implementation of sliding fee discount b. Implement corrective actions to address any discrepancies or deficiencies identified during audits or reviews Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: Summer/Fall 2024
Finding 2022-002: Late Audit Reporting: The Organization did not complete and submit its federal single audit of its federal award from National Science Foundation, or their designee, by the due date of June 30, 2023. Name of Contact Person: Charles Xie, Chief Executive Officer email: charles@intof...
Finding 2022-002: Late Audit Reporting: The Organization did not complete and submit its federal single audit of its federal award from National Science Foundation, or their designee, by the due date of June 30, 2023. Name of Contact Person: Charles Xie, Chief Executive Officer email: charles@intofuture.org Corrective Action Plan: The Organization underwent a single audit as required by Uniform Guidance for the year that ended September 30, 2022. The Organization designated an individual at the Organization to implement procedures and monitor the timely filing of the single audit. Part of the reason for the delay was that the Organization had never been subjected to a single audit before, and thus this was the first time they needed to produce supporting documentation. As the Organization was established in June 2020, it was only subject to a regular audit for the year ended September 30, 2021. At that time, the Organization had signed a three-year audit contract with Treeful Damaso Aniceto, Inc. However, when it came the time to audit the year ended September 30, 2022, the audit firm unexpectedly notified the Organization that they no longer performed single audits. As a result, the Organization needed to seek a new audit firm. But many firms that the Organization contacted were already overbooked. It was not until late 2023 that the Organization received quotes from several firms, of which the current auditor was chosen through a process of careful evaluation and comparison. From now on, the Organization will monitor these due dates in future single audits to ensure timely completion. Anticipated Completion Date: Immediately
Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of ...
Criteria: Recipients of federal awards must minimize the time elapsing between the receipt of funds from the U.S. Treasury and disbursement by the Organization set out at 2 CFR section 200.305(b). Audit Recommendation: We recommend that the Organization 1) maintains timely and accurate recording of disbursements in its job‐costing system and 2) regularly request grant funds based on amounts expended as report in the Organization’s job‐costing system. Auditee Response: The Organization is implementing a grant tracking system in addition to its job costing system to better comply with these requirements. Together, these systems will be used to request only the amount attributable to the program for reimbursement. Corrective Action Plan: (1) Records will be kept in a newly developed spend down report for each grant/contract and reviewed with Division Directors and DFO monthly. All transactions are now being logged in QuickBooks with respective grant codes and departments, will not be processed without. (2) Monthly and quarterly invoicing according to each grant / contract agreement will be enforced by the GDCM and DFO in compliance with 2 CFR section 200.305(b). (3) The Organization has enrolled with the Treasury’s Invoice Processing Platform (IPP) to ensure all future Invoicing and payments can be easily tracked to the program/grant. Person Responsible: Matt Poss, Director of Finance Operations Timeline: All expenses and disbursements being coded to proper Grant/Type in QuickBooks Online – January 2023 Treasury Invoice Processing Platform (IPP) Onboarded – April 18th, 2023 Invoicing Timeline Created per collaboration with GDCM and DFO – May 18th, 2023 Revenue Reconciliation and clearing out of uncollectible or overbooked revenue – June 30th, 2023
Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performe...
Criteria: Recipients of federal awards must follow the costs principles set out at 2 CFR section 200.430 to substantiate compensation and other purchases charged to a federal program. “Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: …(iii) reasonable reflect the total activity for which the employee is compensated by the non‐Federal entity” 2 CFR section 200.430(i). The Organization’s processes did not maintain sufficient documentation of the approval of the activity of each employee or the purchase of goods/services. Audit Recommendation: We recommend the Organization ensure it 1) maintains records of each employee’s activity and 2) monitors compliance with the job‐costing system implemented. Auditee Response: The Organization believes the paychecks and purchases identified were approved prior to payment. We will ensure that documentation is downloaded each pay period to ensure such documentation is not lost when a change in servicer is made. Corrective Action Plan: UICSL has implemented a new payroll system Paycom to help account for these Labor Allocation and Grant Codes. Employees are automated to each program and there is a designated reporting function allowing us to review what is assigned. UICSL also now has Directors for each division so there is clearly defined approvers and supervisors for each purchase and transaction. Person Responsible: Matt Poss, Director of Finance Operations Timeline: UICSL transitioned to Paycom in back‐half of 2023 and Leadership was designated and assigned for 2023.
Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: The rev...
Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Period of Performance Finding Summary: The review and approval of the expenditure listing was not retained. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we will implement procedures to retain expenditure listings and other support for federal awards as well as the related review. Anticipated Completion Date: Ongoing
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activitie...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Costs Principles and Reporting Finding Summary: The original expenditure listing which would have included the review of the expenditure listing, was not retained. As a part of the single audit, the Clinic recreated the expenditure listing to support the expenditures reported on the special report submitted to the Department of Health and Human Services for Period 2, however there was no control in place to retain the original documentation of the determination of expenditures and their related review. In addition, there was no retained documentation of the review and approval of the Clinic’s special report submitted to the Department of Health and Human Services for Period 2 TIN #4550559322. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: Management agrees with the finding and has reviewed the operating procedures of Robert C. Byrd Clinic. Furthermore, we will implement procedures to retain expenditure listings and other support for federal awards as well as the related review. Anticipated Completion Date: Ongoing
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Federal Agency Name: Department o...
Federal Agency Name: Department of Health and Human Services Program Name: COVID‐19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 2 TIN#4550559322 Federal Financial Assistance Listing #93.498 Federal Agency Name: Department of Homeland Security Program Name: COVID‐19 Disaster Grants – Public Assistance Federal Financial Assistance Listing #97.036 Compliance Requirement: Preparation of Schedule of Expenditures of Federal Awards Finding Summary: The Clinic does not have an internal control system designed to provide for the preparation of the schedule of expenditures of federal. We requested our auditors, Eide Bailly LLP, to draft the schedule of expenditures of federal awards. Auditor assistance with preparation of the schedule is not unusual as the schedule has unique and specialized requirements and preparation is only required when the Clinic meets a specified threshold of federal expenditures. Responsible Individuals: David Meadows, Interim CFO Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of the schedule of expenditures of federal awards and accompanying notes. We requested that our auditors, Eide Bailly LLP, prepared the schedule of expenditures of federal awards and the accompanying notes to the schedule of expenditures of federal awards as a part of their annual audit. We have designated a member of management to review the drafted schedule of expenditures of federal awards and accompanying notes. Anticipated Completion Date: Ongoing
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