Corrective Action Plans

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Finding Number: 2022-005 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: All quarterly DHS reports will be reviewed and signed following completion. Documentation for all will be mai...
Finding Number: 2022-005 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: All quarterly DHS reports will be reviewed and signed following completion. Documentation for all will be maintained. Anticipated Completion Date: 12/31/2022
Finding Number: 2022-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Crystal Zaviska Corrective Action Planned: Implement semi-annual trainings including asset verifications, timelines, and income verifications. Anti...
Finding Number: 2022-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Crystal Zaviska Corrective Action Planned: Implement semi-annual trainings including asset verifications, timelines, and income verifications. Anticipated Completion Date: 12/31/2023
Finding 392162 (2022-003)
Material Weakness 2022
Forth
OR
Material Weakness 2022-003 Finding - Cash Management (Invoices) – Material Weakness in Internal Control over Compliance. Reporting (Federal Form 425 & FSRS) – Material Non-Compliance and Weakness in Internal Control over Compliance. Condition / Context: It was noted during the audit that there wer...
Material Weakness 2022-003 Finding - Cash Management (Invoices) – Material Weakness in Internal Control over Compliance. Reporting (Federal Form 425 & FSRS) – Material Non-Compliance and Weakness in Internal Control over Compliance. Condition / Context: It was noted during the audit that there were insufficient internal controls over invoices submitted for cost reimbursement related to federal grants as invoices were created and approved by one individual. While the internal controls were insufficient, our sample of invoices did not contain errors or undocumented amounts. It was noted during the audit that there were insufficient internal controls over required federal financial reports as federal financial reports were created and approved by the one individual. While the internal controls were insufficient, our sample of federal financial reports did not contain errors or undocumented amounts. It was also noted that there were three first-tier subawards entered into during 2022 greater than $30,000 that were not reported to the Federal Funding Accountability and Transparency Act Subaward Reporting System. Recommendation: The Organization should establish written policies and procedures regarding federal financial reporting and invoicing for cost-reimbursement related to federal grants which include proper segregation of duties. Additionally, the Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Action Taken: We agree with the auditor’s comments, and the following actions have been or will be taken to improve the situation. We hired a Senior Finance Manager in late 2022 and an Accounting Associate in early 2023 to allow for further segregation of duties. Effective 2023, the Senior Finance Manager prepares the invoices and financial reports related to federal grants for review and approval by the Director of Finance and Operations. Additionally, there are now static financial reports and supporting documentation to substantiate each billing invoice. We will update the financial policies and procedures to reflect these enhanced internal controls over reporting and invoicing by March 2024. Policies and procedures will be revised as needed to ensure the guide is current. Responsible Official: Gina Avalos-Limardo, Director of Finance & Operations Planned Completion Date: March 31, 2024
Finding 392161 (2022-002)
Material Weakness 2022
Forth
OR
Findings – Federal Award Material Weakness 2022-002 Finding - Subrecipient Monitoring –Material Non-Compliance and Weakness in Internal Control Over Compliance. Condition / Context: Forth passed through $75,170 in funding to subrecipients under Assistance Listing 81.086. During our audit, we noted...
Findings – Federal Award Material Weakness 2022-002 Finding - Subrecipient Monitoring –Material Non-Compliance and Weakness in Internal Control Over Compliance. Condition / Context: Forth passed through $75,170 in funding to subrecipients under Assistance Listing 81.086. During our audit, we noted that Forth did not have documented written procedures or controls in place to ensure compliance with the U.S. Office of Management and Budget’s Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) subrecipient monitoring requirements. Per review of subaward contracts, required federal contract information was not clearly identified. Further, subrecipients were not evaluated for risk of non-compliance, were not monitored, and there were no procedures in place to ensure the accountability of for-profit subrecipients. Recommendation: The Organization should establish written policies and procedures regarding the contracting and monitoring of subrecipients that are in line with Uniform Guidance requirements, as well as establish organizational controls to ensure that such policies and procedures are being followed. Action Taken: We agree with the auditor’s comments, and as soon as we were made aware of the deficiency in early 2024, we began to implement the following action steps to improve the situation. We will create and document the policies and procedures for effective monitoring of subrecipients of federal funds by February 2024. To ensure such policies are being followed, we will monitor all subrecipients of federal funds by May 2024. Policies and procedures will be revised as needed to ensure the guide is current. We will designate a responsible staff person in 2024 to manage the subrecipient monitoring process and provide routine training on this process so staff understand their responsibilities. Responsible Official: Gina Avalos-Limardo, Director of Finance & Operations Planned Completion Date: May 1, 2024
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will establish a debt service fund in accordance with the letter of conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward and will obtain required insurance coverage as noted in the Letter of Conditions. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Q2 of 2023
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit findi...
Material Weakness in Internal Control and Compliance Recommendation: The Organization should review the Letter of Conditions and loan agreement to ensure all requirements are being met on an annual basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review policies and procedures to ensure compliance is met going forward including providing required financial information the USDA. Name(s) of the contact person(s) responsible for corrective action: Lori Guenther, CFO Planned completion date for corrective action plan: Has been implemented.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Aberdeen School District No. 5 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regul...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Aberdeen School District No. 5 September 1, 2021 through August 31, 2022 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of District contact person: Elyssa Louderback, Fiscal Consultant 216 N. G Street, Aberdeen, WA 98520, (360)538-2007 Corrective action the auditee plans to take in response to the finding: The district will issue an RFP annually, with an option to extend the contract. The district will keep records of the cost analysis each time a need is identified and a provider is hired to fill that need. Additionally at the beginning of the year, the district will do a cost analysis based on the responses of the RFP per vendor with the services they are to be contracted. A staff member will also attend Procurement Boot camp training in compliance with OMB Uniform Grant Guidance. Anticipated date to complete the corrective action: July 2023
The Association will implement procedures to ensure that all federal funds received are identified as such to ensure that the Association maintains compliance with applicable federal requirements including required audit submission due dates. The Association will also update its financial policies a...
The Association will implement procedures to ensure that all federal funds received are identified as such to ensure that the Association maintains compliance with applicable federal requirements including required audit submission due dates. The Association will also update its financial policies and procedures to include these new procedures and have the updated financial policies and procedures reviewed and approved by the board of directors. Persons Responsible Executive Director and Accountant Date of Implementation of Recommendation December 2023
Finding 392119 (2022-003)
Material Weakness 2022
The county added information to the Payment Request Form to ensure that sub recipients are aware of possible single audit requirements, active SAM registry and UEI.
The county added information to the Payment Request Form to ensure that sub recipients are aware of possible single audit requirements, active SAM registry and UEI.
Finding 392118 (2022-002)
Material Weakness 2022
The county added information to the Payment Request Form to make sub recipients aware that their organization along with any respective Contractors need an active UEI and must be registered in SAM.
The county added information to the Payment Request Form to make sub recipients aware that their organization along with any respective Contractors need an active UEI and must be registered in SAM.
The District continues to review internal controls and will make changes where appropriate.
The District continues to review internal controls and will make changes where appropriate.
Finding 392094 (2022-002)
Significant Deficiency 2022
Since the ERAP grant was a new COVID-related grant that was fast-tracked by the Government to provide immediate assistance in the midst of the pandemic, neither the Grantor, nor the Grantee, provided clear templates for reporting to the Organization as a Subgrantee. This forced the organization to c...
Since the ERAP grant was a new COVID-related grant that was fast-tracked by the Government to provide immediate assistance in the midst of the pandemic, neither the Grantor, nor the Grantee, provided clear templates for reporting to the Organization as a Subgrantee. This forced the organization to create its own templates, in which the unprotected spreadsheet formulas became corrupt, and were not consistent from month to month--largely due to changing interpretations of requirements for what could be claimed as a reimbursement. It is noted, that neither the organization, nor the primary Grantee caught the spreadsheet miscalculations -- in order to reconcile the accounts in a timely manner. The Organization made a change in Executive Directors a month after the Grant closed (April 2022), and a week before the fiscal year end (June 28, 2022). As part of understanding the process of grant reimbursements in the past, the current Executive Director created a Financial Reimbursement Policy for submitting grant reimbursements going forward into FY23. With this change, the Organization has stronger controls in place to catch any errors in financial reporting. This policy was reviewed by the Board of Directors in October 2022, to ensure procedures are in place in which non-protected spreadsheet formulas are double checked for accuracy, all receipts are reviewed and entered by at least two persons, and reimbursements are reconciled with corresponding requests in cooperation with a third-party accountant. In addition, due to work slowdowns that occurred during the COVID crisis, it created a long time lapse in waiting for reimbursement deposits from requests through the Grantee and Grantor. In many cases, reimbursements were not deposited until months after the request. Unfortunately, at the time, there was no mechanism in place to track these expenses for reconciliation. This too has been corrected in the new Reimbursement Policy change that includes a new grant reimbursement tracker in place going forward. While current Management recognizes the above failure to reconcile these discrepancies at the time, in review, the miscalculations on the submitted spreadsheets actually underestimate the expenses incurred compared to what was requested for reimbursement. Over the course of the grant the Organization actually under invoiced for its expenses. Since the grant was closed, the new Director, did not find these discrepancies until the audit and the organization understands this loss cannot be recouped.
View Audit 302227 Questioned Costs: $1
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable ...
US Department of Housing and Urban Development Federal Financial Assistance Listing #14.157 Supportive Housing for the Elderly (Section 202) Finding Summary: As a result of management transition, supporting documentation for expense transactions and tenant eligibility were destroyed and were unable to be recreated. The organization was lacking appropriate internal controls to ensure records were retained for the required period of time. Responsible Individual: Dawn Helmowski, Finance Director Corrective Action Plan: Subsequent to the audit period under review, the affiliated entity of Luther Social Services of North Dakota has been replaced with Beyond Shelter, Inc. Upon this change, the new LSS Jamestown Housing, Inc. Board of Directors, implemented a Document Retention and Destruction Policy that includes retention or required documents for the required time periods that will ensure documents are retained. This policy was put into place on April 19, 2023. Anticipated Completion Date: April 2023
Finding 392054 (2022-002)
Significant Deficiency 2022
We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure...
We will utilize new software to automate the preparation and compilation of audit reports and compliance reports, streamlining the entire process and reducing the likelihood of delays. We will establish a centralized document management system with robust retention protocols. This system will ensure that all relevant documents and information required for the reports are readily accessible and properly maintained, minimizing delays caused by searching for necessary materials. We will institute a schedule for regular reviews and monitoring of the reporting process. This will involve conducting periodic assessments to identify any bottlenecks or potential issues that could lead to delays, allowing for proactive intervention and resolution. By implementing these measures, we aim to mitigate the risk of late filing of the audit report, thereby enhancing compliance with regulatory requirements and ensuring timely and accurate reporting.
To fortify our internal controls over financial reporting, we will introduce new software to streamline data management and reporting processes, ensuring both accuracy and efficiency. Concurrently, we will refine our internal workflows, introducing comprehensive procedural guides to standardize oper...
To fortify our internal controls over financial reporting, we will introduce new software to streamline data management and reporting processes, ensuring both accuracy and efficiency. Concurrently, we will refine our internal workflows, introducing comprehensive procedural guides to standardize operations and enhance transparency across all departments. Additionally, we'll implement a centralized repository for document storage with stringent retention policies to uphold organized and accessible record-keeping. Finally, we commit to conducting regular, rigorous reviews of financial information by designated personnel, enabling timely identification and resolution of any discrepancies, thereby reinforcing our control environment and safeguarding the integrity of our financial reporting system.
The Organization has established internal guidelines for identifying future Single Audit requirements and for contracting with an independent audit firm when required. Additionally, as evidenced by the filing of this report, the Organization has hired an independent audit firm to perform the audit f...
The Organization has established internal guidelines for identifying future Single Audit requirements and for contracting with an independent audit firm when required. Additionally, as evidenced by the filing of this report, the Organization has hired an independent audit firm to perform the audit for each of the years ended June 30, 2022, 2021 and 2020.
March 27, 2024 2022-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Control: The Consortium did not provide documentation of eligibility for each participant selected for testing. Planned Corrective Action: We agree with the finding. The consortium recognizes the impor...
March 27, 2024 2022-002: Material Weakness in Internal Control/Material Noncompliance- Eligibility Control: The Consortium did not provide documentation of eligibility for each participant selected for testing. Planned Corrective Action: We agree with the finding. The consortium recognizes the importance of having support documentation for all eligibility determinations. During COVID-19 staff were allowed to work from home, as a result two staff were not following document saving protocol and saved vital documentation on their local drive (desktop). Upon the transition back into the office, those individuals did not follow protocol and ensure all files were backed up/saved to the networked database. Once of the individuals no longer worked for MWSE and the other employee as well as their manager both were made aware of the issue. After further conversations with the manager, management was assured this will not happen again. A process for spot checking and compliance sign-off by managers has been implemented to work to ensure this issue does not arise again. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: Completed January, 2024 Respectfully, Shamar Herron
March 27, 2024 2022-003: Significant Deficiency in Internal Control / Immaterial Noncompliance – Cash Management (repeat comment) Condition: 1) The Consortium requested funds in advance of when the related disbursements were made, 2) the basis for the advances (requests) were not supported by approp...
March 27, 2024 2022-003: Significant Deficiency in Internal Control / Immaterial Noncompliance – Cash Management (repeat comment) Condition: 1) The Consortium requested funds in advance of when the related disbursements were made, 2) the basis for the advances (requests) were not supported by appropriate documentation, and 3) authorization for requesting funds in advance not obtained. Corrective Action: We agree with the finding. The Consortium has carefully reviewed our policies and procedures and have made the necessary changes to ensure that cash draws are based on expenditures already incurred and they are supported by transactions recorded in the books and records of the Consortium. We believe the updated procedures will result in the reduction over time and ultimately the complete elimination of this issue. Contact Person: Shamar Herron: Sherron@mwse.org Anticipated Completion Date: December 2024 Respectfully, Shamar Herron
March 27, 2024 2022-005: Significant Deficiency in Internal Control / Immaterial Noncompliance – Reporting Condition: Quarterly reports for WIOA Cluster and Employment Services Cluster and Temporary Assistance for Needy Families Cluster, and final close out reports selected for WIOA Cluster, were su...
March 27, 2024 2022-005: Significant Deficiency in Internal Control / Immaterial Noncompliance – Reporting Condition: Quarterly reports for WIOA Cluster and Employment Services Cluster and Temporary Assistance for Needy Families Cluster, and final close out reports selected for WIOA Cluster, were submitted after the deadline. Planned Corrective Action: We agree with the finding. With new closeout procedures in place, this finding will be addressed over the next several reporting periods. We do not anticipate this issue in our 2024 Single Audit when several cycles of closeouts have been completed. Anticipated Completion Date: June 30, 2025 Contact Person: Shamar Herron: Sherron@mwse.org Respectfully, Shamar Herron
March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) ar...
March 27, 2024 2022-004: Significant Deficiency in Internal Control / Immaterial Noncompliance – Activities Allowed/Allowable Cost (repeat Finding) Condition: Allocations of non-direct charged wage time (i.e., paid time off, bereavement, jury duty, holiday, medical paid time off, medical waivers) are managed through a labor allocation whereby amounts of non-direct charged wage time are charged to various programs incorrectly. Corrective Action: We agree with the finding. We have addressed this issue with management within the consortium to properly allocate non-direct wage time. This includes the current (March of 2024) procurement of a sufficient payroll and time keeping software to assist in the remediation of this finding. Contact Person: Shamar Herron: Sherron@mwse.org Completion Date: August 2025, procurement will be completed and system implemented. Respectfully, Shamar Herron
Management concurs with this finding. As noted in the response to Subrecipient Monitoring – Improper Communication to Subrecipient, Subrecipient vs. contractor differentiation has been an area of continued improvement. Management believes recent efforts to properly differentiate between subrecipient...
Management concurs with this finding. As noted in the response to Subrecipient Monitoring – Improper Communication to Subrecipient, Subrecipient vs. contractor differentiation has been an area of continued improvement. Management believes recent efforts to properly differentiate between subrecipients and contractors has resulted in accurate determinations. However, documentation, ongoing monitoring, and communication are areas for further improvement. To that end, Management has implemented a new subrecipient/contractor determination form that includes both documentation of the determination and a checklist for ongoing compliance and monitoring for both subrecipients and contractors. This form requires that a subrecipient monitoring plan be put in place which will address compliance with all applicable federal award conditions including Single Audits. Management believes implementation of this form/process will reduce the risk of further noncompliance.
Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.
Management concurs with this finding. Management is reviewing and revising its procurement policies to comply with state and local laws, the standards of the CFR, as well as reflect current operating procedures.
Management concurs with this finding. Management has focused its attention on both the determination and designation of key personnel within a contract as well as the ongoing compliance of key personnel designations. Management has implemented control provisions to highlight and approve future key p...
Management concurs with this finding. Management has focused its attention on both the determination and designation of key personnel within a contract as well as the ongoing compliance of key personnel designations. Management has implemented control provisions to highlight and approve future key personnel designations within future contracts. Further, a semi-annual review process will be undertaken to review and document ongoing contractual compliance which will include reference to and consideration of key personnel designations.
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be revie...
Recommendation: We recommend LSI design controls to ensure an adequate review process is in place for all drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Requests for reimbursements will be reviewed and approved by management prior to submission. Name(s) of the contact person(s) responsible for corrective action: Roni Knief Planned completion date for corrective action plan: 12/31/2023
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