Corrective Action Plans

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Finding 570868 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Internal Controls Over Compliance for Cash Management, Allowable Costs, Procurement, and Conflicts of Interest 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Subsequent to year-end, the City...
Finding 2024-001 Internal Controls Over Compliance for Cash Management, Allowable Costs, Procurement, and Conflicts of Interest 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding Subsequent to year-end, the City addressed this matter by formally adopting written policies meeting the referenced requirements of the Code of Federal Regulations. 3. Official Responsible The City Administrator is the official responsible for ensuring corrective action. 4. Planned Completion Date June 30, 2025. 5. Plan to Monitor Completion The City Council will be monitoring this Corrective Plan.
Identifying Number: 2024-007 Corrective Actions Taken or Planned: Finding: 2024-007 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. This gr...
Identifying Number: 2024-007 Corrective Actions Taken or Planned: Finding: 2024-007 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. This grant has ended as of 6/30/25. In the future if we have fiscal agency services, we will ensure the that the program is being properly reviewed and administered.
Identifying Number: 2024-006 Corrective Actions Taken or Planned: Finding: 2024-006 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. The Cen...
Identifying Number: 2024-006 Corrective Actions Taken or Planned: Finding: 2024-006 Agency: internal Name of contact person and title: Keith Olson, Central Accounting Manager Anticipated completion date: Effective immediately / June 2025 Agency’s response: Concur: We agree with this finding. The Central Accounting team will obtain detailed reporting data and request supporting documentation from subrecipients to reconcile/review expenses annually.
Finding: The data collection form for the year ended June 30, 2024, was filed after the March 31, 2025, deadline, making it a late submission. Corrective Actions Taken or Planned: Envision Unlimited will schedule and complete future external audits in a manner that will allow timely reporting of t...
Finding: The data collection form for the year ended June 30, 2024, was filed after the March 31, 2025, deadline, making it a late submission. Corrective Actions Taken or Planned: Envision Unlimited will schedule and complete future external audits in a manner that will allow timely reporting of the Single Audit. Contact person responsible for corrective action is Dennis James, CFO. The anticipated completion date is June 30, 2025.
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Reporting Finding Summary: No review and approval processes are in place over quarterly progress reports. Corrective Actio...
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Reporting Finding Summary: No review and approval processes are in place over quarterly progress reports. Corrective Action Plan: Management has implemented procedures and control processes to incorporate an independent review and approval over quarterly reporting and retain documentation to support the review was performed. Responsible Individuals: Teena Conrad, SSVF Program Manager, Lysa Allison, Executive Director and Sara VanVlack, Business Manager Anticipated Completion Date: June 2025
Corrective Action Condition Identified: The Organization did not verify whether vendors were suspended or debarred during the year. Cause: The Organization did not have formal procedures in place to ensure vendors were checked against the SAM.gov exclusions list. Corrective Action Taken: The O...
Corrective Action Condition Identified: The Organization did not verify whether vendors were suspended or debarred during the year. Cause: The Organization did not have formal procedures in place to ensure vendors were checked against the SAM.gov exclusions list. Corrective Action Taken: The Organization put a procedure in place that will check vendors against the exclusion list. Anticipated Completion Date: Procedure was put in place in May 2025 Views of Responsible Officials: Management concurs with the finding and has implemented procedures to document vendor eligibility verification via SAM.gov.
Condition: Out of forty payroll transactions tested, we noted two instances where hourly employees did not have their timecard approved by their supervisor. • Corrective Action Plan: o Each supervisor responsible for employees in their area will need to sign off on timecards through Paylocity. o If ...
Condition: Out of forty payroll transactions tested, we noted two instances where hourly employees did not have their timecard approved by their supervisor. • Corrective Action Plan: o Each supervisor responsible for employees in their area will need to sign off on timecards through Paylocity. o If a supervisor is unavailable, the person above them will need to sign off on the timecard. o A corrective action plan will be implemented for repeat offenders. • Responsible Person for Corrective Action Plan: Supervisors, directors, VP of the program, HR and Finance • Implementation Date for Corrective Action Plan: July 1, 2025
View Audit 361760 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Actions Per the Associate Director of Contract Accounting, the Foundation has taken the following steps to strengthen its suspension and debarment compliance process: 1. Completed an annual suspension and debarment review for all applicable vendo...
Views of Responsible Officials and Planned Corrective Actions Per the Associate Director of Contract Accounting, the Foundation has taken the following steps to strengthen its suspension and debarment compliance process: 1. Completed an annual suspension and debarment review for all applicable vendors in February 2025, aligned with the start of most Ryan White Part A contracts, which typically begin on March 1. 2. Updated the Foundation’s policy to require suspension and debarment checks both at initial vendor setup and on an annual basis thereafter. The Foundation has also finalized a Debarment Policy, approved by the Finance Policy Committee, which outlines the procedures for identifying and documenting suspended or debarred vendors. This policy is designed to ensure ongoing compliance with federal regulations. Personnel responsible for implementation: Shibu Sam Position of responsible personnel: National Director of Contracts Date of Implementation: February 2025
Views of Responsible Officials and Planned Corrective Actions The Foundation will ensure that the Contracts Manager assigned to the contract works closely with the Program Staff and the designated contract representative at the granting agency to ensure accurate and timely reporting going forward. ...
Views of Responsible Officials and Planned Corrective Actions The Foundation will ensure that the Contracts Manager assigned to the contract works closely with the Program Staff and the designated contract representative at the granting agency to ensure accurate and timely reporting going forward. Personnel responsible for implementation: Shibu Sam Position of responsible personnel: National Director of Contracts Date of Implementation: August 1, 2025
Views of Responsible Officials and Planned Corrective Actions A. Improved Documentation for Basis of Cost Allocation for Employee Time Charges Per the Associate Director of Contract Accounting, the Foundation reviewed all the invoices on the 1st and 2nd quarters of 2025 and noted that there were no...
Views of Responsible Officials and Planned Corrective Actions A. Improved Documentation for Basis of Cost Allocation for Employee Time Charges Per the Associate Director of Contract Accounting, the Foundation reviewed all the invoices on the 1st and 2nd quarters of 2025 and noted that there were no other adjustments made relating to the invoices within the audit year ended December 31, 2024. To further strengthen internal controls for reimbursement requests, the Foundation will implement the following procedures: 1. Prior to submission of reimbursement requests to the funder, the Contracts Manager for each grant will review the supporting documents and invoice template to ensure only final and fully supported data is invoiced. 2. Continue the practice of reviewing salary costs allocated to each grant in the payroll system, with the percentage charged to the funder to ensure only fully supported costs are billed. B. Improved Documentation of Routinary Reviews of Employee Hours Charged to Grants Per the Associate Director of Contract Accounting, the Foundation has a process to review staff allocated to a grant to ensure that hours and salary costs are allocated correctly at least quarterly, but also additional adjustments and reclasses may be posted at year-end to ensure completeness and that all expenditures are posted in the correct SEFA period as part of the SEFA review process. C. Timecards Lacking Employee and Manager Approvals Per the Associate Director of Contract Accounting, the Foundation has a process in place to ensure that employees and managers approve timecards every pay period and will continue making enhancements to this process to ensure that gaps do not occur subsequently. Personnel responsible for implementation: Shibu Sam Position of responsible personnel: National Director of Contracts Date of Implementation: August 1, 2025
The National Conference of State Historic Preservation Officers respectfully submit the following corrective action plan for the year ended December 31, 2024 Name and address of independent public accounting firm: CBIZ 1899 L Street, NW, Suite 850 Washington, DC 20036 Audit Period: January 01, 2024 ...
The National Conference of State Historic Preservation Officers respectfully submit the following corrective action plan for the year ended December 31, 2024 Name and address of independent public accounting firm: CBIZ 1899 L Street, NW, Suite 850 Washington, DC 20036 Audit Period: January 01, 2024 to December 31, 2024 The findings from the Schedule of Finding for the year ending December 31,2024, are discussed below. The findings are numbered consistently with the number assigned in the schedule. Finding No. 2024-001 Revenue Recognition – Significant Deficiency in Internal Control over Financial Reporting: The finding was that NCSHPO provided a trial balance and SEFA that omitted indirect cost rates on accrued direct expenditures through December 31, 2024. Contacts for Corrective Action: Sharon Smith, Business Manager – email: smith@ncshpo.org – phone: 202-624-5465 Erik Hein, Executive Director – email: hein@ncshpo.org – phone: 202-624-5465 The NCSHPO only recognized the direct costs as revenue for the period ending 12/31/24 not considering that the indirect cost rate should be accrued as revenue also thus causing the SEFA to not balance with the Trial Balance at the end of the year. NCSHPO agreed with CBIZ that the indirect costs should be recognized. The NCSHPO will begin a new internal control procedure to recognize the indirect costs as revenue to include on the SEFA schedule monthly beginning July 1, 2025. The SEFA and the Trial Balance will be reconciled for each job report. When Accounts Receivable (1120-000-0000), Revenue (4700-104-XXXX) and Administration fee/Indirect costs (4420-000-0000) are reconciled, then the SEFA, the Trial balance and the journal entry transaction(s) to recognize revenue will be given to the Executive Director to review and approve to be entered into the General Ledger. Implementation date: 07-01-2025 Finding No. 2024-002 Procurement – Significant Deficiency in Internal Control Over Compliance RE: Federal Award Identification Numbers P17AC00528 and P22AM01146 The finding was that NCSHPO failed to perform the required search of vendors per Title 2 U.S. Code of Federal Regulations (CFR) Part 200 Section 200.213. NCSHPO agreed with CBIZ that we did not do a search for suspension and debarment in SAM for any of the vendors and that it was not included in our Procurement Policy. Contacts for Corrective Action: Sharon Smith, Business Manager – email: smith@ncshpo.org – phone: 202-624-5465 Erik Hein, Executive Director – email: hein@ncshpo.org – phone: 202-624-5465 The NCSHPO updated the Procurement Policy to include a section for Suspension and Debarment. NCSHPO then used SAM to obtain the proper documentation to include in each respective vendor’s file. The NCSHPO will implement the new procedure to do a search in SAM.gov for every vendor it selects to do business with under the Cooperative Agreement and continue to do the search annually. Below is the new policy that is included in NCSHPO’s Procurement Section: Suspension and Debarment: NCSHPO verifies that the vendor or subrecipient with whom NCSHPO intends to do business is not excluded or disqualified in accordance with 2 C.F.R. Part 200, Appendix II (1) and 2 C.F.R. §§ 180.220 and 180.300. Before final selection, the Business Manager or the Special Projects Manager will perform a search on the General Services Administration Excluded Parties List System (EPLS) (http://www.sam.gov). Results of the screenings should be printed and placed in the procurement file. Suspension and debarment checks will be updated annually and will remain documented in the procurement file in line with NCSHPO’s document retention policy. The ED ensures this is completed during inspection and approval of procurement. Implementation date: 04/30/2025
The foundation will establish a vendor file system, create cost allocation templates, and train the accounting team on functional expense reporting.
The foundation will establish a vendor file system, create cost allocation templates, and train the accounting team on functional expense reporting.
The foundation is engaging a professional bookkeeper and implementing new procedures for recording and tracking donations and expenditures.
The foundation is engaging a professional bookkeeper and implementing new procedures for recording and tracking donations and expenditures.
Finding 570730 (2024-002)
Significant Deficiency 2024
2024-002: Complete, accurate and timely financial reporting Management’s Response: As of June 4, 2025, due to the agency’s growth in services and staff, a Human Resource Generalist was hired. With the addition of this new position, our Chief Operating Officer will be focused on complete, accurate an...
2024-002: Complete, accurate and timely financial reporting Management’s Response: As of June 4, 2025, due to the agency’s growth in services and staff, a Human Resource Generalist was hired. With the addition of this new position, our Chief Operating Officer will be focused on complete, accurate and timely financial reporting. Views of Responsible Officials and Corrective Action: See response for finding 2024-002. Anticipated Completion Date: June 4, 2025.
Finding 2024-003: For the year ended March 31, 2024, the Corporation repaid $10,000 to a related entity without HUD approval. Comments on the Finding and Each Recommendation: The related entity should repay $10,000 to the Corporation. The Agent should obtain written approval from HUD prior to making...
Finding 2024-003: For the year ended March 31, 2024, the Corporation repaid $10,000 to a related entity without HUD approval. Comments on the Finding and Each Recommendation: The related entity should repay $10,000 to the Corporation. The Agent should obtain written approval from HUD prior to making any future distributions or payments to related entities. Action(s) taken or planned on the finding: Agreed. The Agent concurs with the finding and agrees with the auditor's recommendation. The related entity repaid the $10,000 to the Corporation on January 2, 2025.
View Audit 361710 Questioned Costs: $1
Finding 2024-002: The Corporation did not furnish HUD a complete annual financial report within ninety (90) days following the end of the fiscal year ended March 31, 2024. Additionally, Form SF-SAC Single Audit Data Collection Form for the year ended March 31, 2024 was not submitted to the federal a...
Finding 2024-002: The Corporation did not furnish HUD a complete annual financial report within ninety (90) days following the end of the fiscal year ended March 31, 2024. Additionally, Form SF-SAC Single Audit Data Collection Form for the year ended March 31, 2024 was not submitted to the federal audit clearinghouse in the required timeframe. Comments on the Finding and Each Recommendation: The Corporation should submit the annual financial statements to HUD and Form SF-SAC Single Audit Data Collection Form for the year ended March 31, 2024 as soon as practical. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. The audited financial statements have been submitted to HUD and the federal clearinghouse. No further action is required.
Finding 2024-001: The Corporation did not make $7,284 of the total required reserve for replacement deposits during the year ended March 31, 2024. Additionally, the Corporation did not make the required reserve for replacements deposits of $6,943, $579, and $382 to correct the underfunded amount for...
Finding 2024-001: The Corporation did not make $7,284 of the total required reserve for replacement deposits during the year ended March 31, 2024. Additionally, the Corporation did not make the required reserve for replacements deposits of $6,943, $579, and $382 to correct the underfunded amount for the years ended March 31, 2023, 2022, and 2021, respectively. Comments on the Finding and Each Recommendation: Management should make all required deposits to the reserve for replacements fund. Management should transfer $15,188 from the operating account to the reserve for replacements fund. Action(s) taken or planned on the finding: Agreed. Management concurs with the finding and the auditor's recommendation. The Corporation made additional deposits totaling $15,188 to the reserve for replacements fund on June 14, 2024 and July 9, 2024.
View Audit 361710 Questioned Costs: $1
We understand the auditor’s need to keep this write up on this year’s audit report. This is the same write up from the year prior because KYEM and FEMA have not yet finished their review of the issues facing Cumberland County with respect to disaster funding and record keeping. We are not only pleas...
We understand the auditor’s need to keep this write up on this year’s audit report. This is the same write up from the year prior because KYEM and FEMA have not yet finished their review of the issues facing Cumberland County with respect to disaster funding and record keeping. We are not only pleased to have made progress on this front, but also extremely appreciative for the guidance and feedback from those reporting agencies. KYEM and FEMA document tracking and reporting is now handled entirely inhouse. Members of the Cumberland County Management Team have responded timely and in full to requests for information and we will continue to do so. The lack of certain systems and processes from years past is no longer a concern of the current administration. It is true that work is still needed to organize and understand some of the work from the last several years, but the Management Team believes that the new process will eliminate most of if not all confusion moving forward on any future disasters.
Condition: The Organization did not comply with the Davis-Bacon prevailing wage requirement. Recommendation: We recommend that grant staff and management review award contracts and related grant guidance and follow documented internal procedures to ensure applicable compliance requirements are ident...
Condition: The Organization did not comply with the Davis-Bacon prevailing wage requirement. Recommendation: We recommend that grant staff and management review award contracts and related grant guidance and follow documented internal procedures to ensure applicable compliance requirements are identified and implemented. Corrective Action Plan: The Director of Finance will prepare a summary document regarding the federal guidelines on procurement in particular highlighting this item of request proposals that follow the Davis-Bacon Act. Contact Person Responsible: Director of Finance Expected Completion date: June 30, 2025
Condition: The Organization did not follow its internal procurement policy or the guidelines for procurement in the Uniform Guidance. The Organization did not solicit the correct number of bids to align with its internal policy, nor did it document the adequacy of the number it did procure to align ...
Condition: The Organization did not follow its internal procurement policy or the guidelines for procurement in the Uniform Guidance. The Organization did not solicit the correct number of bids to align with its internal policy, nor did it document the adequacy of the number it did procure to align with federal guidelines for a small threshold project. The Organization selected a vendor it had worked with previously and did not document criteria for selecting this vendor rather than requesting multiple bids. Recommendation: We recommend the Organization review, update, and follow its procurement policy to ensure compliance with the Uniform Guidance. Corrective Action Plan: The organization will review its existing procurement policy, updating as necessary and will ensure that for future projects, the procurement policy will be carefully followed. Staff involved in projects and procurement will receive training regarding the policies and the federal guidelines for federally funded projects. Contact Person Responsible: Director of Finance Expected Completion date: June 30, 2025
Condition: During our testing of applied sliding fee discounts, twenty-five patient encounters were tested. Of those encounters, we identified two encounters that were charged less than the approved nominal fee due to the nominal fee amount not being updated in the electronic medical record ("EMR") ...
Condition: During our testing of applied sliding fee discounts, twenty-five patient encounters were tested. Of those encounters, we identified two encounters that were charged less than the approved nominal fee due to the nominal fee amount not being updated in the electronic medical record ("EMR") system. Recommendation: The Organization should review internal controls over updates to its sliding fee scale each year to ensure it is properly updated. Corrective Action Plan: The organization has updated fees in the electronic medical record and made sure that those match approved nominal fees and will make sure they are in alignment going forward. Contact Person Responsible: Assistant Director of Finance Expected Completion date: June 30, 2025
Finding 570672 (2024-004)
Significant Deficiency 2024
Finding: Significant Deficiency in Internal Control over Compliance, Suspension and Debarment Recommendation: The Board should adopt a written suspension and debarment policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to...
Finding: Significant Deficiency in Internal Control over Compliance, Suspension and Debarment Recommendation: The Board should adopt a written suspension and debarment policy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Written suspension and debarment policy will be adopted. Responsible Official: Andrea Goering Completion Date: 12/31/25
U.S. Department of Health and Human Services Passed-through the Colorado Department of Human Services FFAL #93.778 Medicaid Cluster Eligibility Significant Deficiency in Internal Control Noncompliance Criteria: The Federal requirement related to processing of an application requires the State to pro...
U.S. Department of Health and Human Services Passed-through the Colorado Department of Human Services FFAL #93.778 Medicaid Cluster Eligibility Significant Deficiency in Internal Control Noncompliance Criteria: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the City and County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. Condition: We tested eligibility determination and controls over this process for sixty case files. We noted the following in our testing: Four instances of non-compliance in which the City and County did not complete the eligibility determination and approve/deny the case within 45 days and no notice of action was sent to the client within the required timeframe. Cause: Due to the City and County’s ineffective monitoring, eligibility determinations were not completed in a timely manner and within the 45-day deadline. Effect: Failure to process applications timely could result in participants that are delayed approval of Medicaid services. Questioned Costs: None to report. Context/Sampling: A nonstatistical sample of 60 participants were selected for eligibility testing. Repeat Finding from Prior Years: Yes. Recommendation: We recommend the County utilize available COGNOS reports to determine which cases are nearing the exceeding processing guidelines. Views of Responsible Officials: Agree
The district acknowledges the finding regarding inadequate internal controls and non-compliance with time-and-effort requirements. We take this concern seriously and are fully committed to addressing them promptly to ensure we are following all applicable federal and state regulations. To do so, the...
The district acknowledges the finding regarding inadequate internal controls and non-compliance with time-and-effort requirements. We take this concern seriously and are fully committed to addressing them promptly to ensure we are following all applicable federal and state regulations. To do so, the district has taken the following steps: 1. Internal Controls: we are reviewing and improving our internal control procedures related to grant documentation and management. 2. Time-and-Effort Reporting: we are ensuring our policies are current and will be training staff to ensure time-and-effort documentation is accurate and up to date in accordance with federal and state guidelines. 3. Monitoring: we are enhancing our monitoring procedures to ensure we have consistent application of our internal controls across departments.
Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has in...
Tuerk House, Inc. acknowledges the finding related to the accuracy of financial and programmatic reporting. We recognize the critical importance of maintaining accurate and supportable reporting for federal awards, particularly in light of this being a repeat finding. In response, Tuerk House has initiated corrective actions to improve internal controls over financial and programmatic reporting. These actions include: ·Establishing a standardized reconciliation process to ensure that all amounts reported in financial reports are tied directly to supporting documentation from the general ledger and other internal financial systems. ·Implementing a dual-review protocol requiring reports to be reviewed and approved by both finance and program staff before submission to funding agencies. · Providing targeted training to relevant personnel on grant reporting requirements, with an emphasis on reporting accuracy, documentation standards, and deadlines. ·Coordinating regular meetings between finance and program departments to align data and ensure consistency between financial and programmatic reporting (e.g., patient counts, service metrics, etc.). ·Developing a reporting calendar to track all reporting requirements and facilitate timely and accurate submissions. We are committed to ensuring accurate and compliant reporting going forward and will monitor implementation closely to prevent recurrence. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
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