Corrective Action Plans

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Finding 4876 (2022-006)
Material Weakness 2022
Views of Responsible Officials: SAMU had a workshop for procurement practices together with Project Hope back in October/November 2022. The procurement process of Services and (nonrecurring) Goods has been updated in May/June 2023. Therein all the requirements were explained to fulfill the procureme...
Views of Responsible Officials: SAMU had a workshop for procurement practices together with Project Hope back in October/November 2022. The procurement process of Services and (nonrecurring) Goods has been updated in May/June 2023. Therein all the requirements were explained to fulfill the procurement standards established by 2 CFR 200.318. In the meantime, all procurement specialists have been advised to request a minimum of three formal quotes for procurements above $10,000, once those have been received and a proposal with an explanation (via email) of why a certain vendor has been preselected to provide the services and goods in question. With this information, the MD and Finance/Admin head are asked for internal approval and process the procurement of the Services and Goods. The approval is provided by email. An updated procurement policy is in preparation, the procurement process will be discussed again in another workshop in Q1 2024.
Finding 4875 (2022-005)
Significant Deficiency 2022
Views of Responsible Officials: In 2022, narrative program reports were prepared by the management team (inputs were provided by each thematic area/department), the Deputy Director (or her designee) reviewed, and the Managing Director approved and typically sent the narrative reports to United Way v...
Views of Responsible Officials: In 2022, narrative program reports were prepared by the management team (inputs were provided by each thematic area/department), the Deputy Director (or her designee) reviewed, and the Managing Director approved and typically sent the narrative reports to United Way via email (or in some instances, uploaded to the United Way SharePoint directly). In 2022, financial reports were prepared by CBM, reviewed by the Deputy Director (with support from a Coordinator, when possible), and sent to the Managing Director for approval and signature. The signed documents were then uploaded into the United Way SharePoint, and a note was sent to advise that the documents were ready to review. Reimbursements have never been sent to United Way without the approval and signature of the Managing Director. United Way requires that all financial reports reflect Managing Director signature to be reviewed.
Finding 4874 (2022-004)
Material Weakness 2022
Views of Responsible Officials: When SAMU commenced operations at the end of June 2022, the Welcome Respite Project (funded by FEMA) was SAMU's only active project. The HR platform/timekeeping software, Gusto, was implemented prior to the project start date (i.e. employees offer letters and onboardi...
Views of Responsible Officials: When SAMU commenced operations at the end of June 2022, the Welcome Respite Project (funded by FEMA) was SAMU's only active project. The HR platform/timekeeping software, Gusto, was implemented prior to the project start date (i.e. employees offer letters and onboarding materials were sent via the platform). Incoming staff were provided with an overview of how to use Gusto during onboarding, one-on-one meetings with supervisors, and staff meetings. Employee time was remunerated according to the rates authorized. During 2022, staff entered their hours in Gusto and were not engaged in outside, non-project-related activities. In 2022 we had only one project and therefore, some salaried staff were instructed that the completion of a timecard was not needed. However, that changed in 2023 as the new Managing Director requested that all staff, including salaried staff, complete timecards appropriately. Additional project codes were implemented in January 2023 and October 2023. SAMU provided updated guidance on timekeeping and use of project codes during the course of several staff meetings and one-on-one meetings. In 2023, SAMU developed a Gusto training and continues to reinforce timekeeping policies and expectations during meetings. Rate and position changes were and continue to be communicated to staff via official HR letters and stored in program files.
2022-002 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for re...
2022-002 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserve funds, it was not funded in accordance with the budget. Cause: Budgeted transfers were not made before yearend to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted.Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are available and able to be transferred into the reserve account.
VARR agrees with the finding and will continue to enhance our knowledge and understanding of financial reporting, knowing that due to the small size and limited financial resources obtaining a qualified accounting professional either as an employee or an outside consultant to the level of skills, kn...
VARR agrees with the finding and will continue to enhance our knowledge and understanding of financial reporting, knowing that due to the small size and limited financial resources obtaining a qualified accounting professional either as an employee or an outside consultant to the level of skills, knowledge, and experience necessary may be difficult. VARR commenced obtaining this knowledge as the audit progressed and obtained enhanced bookkeeping knowledge necessary to facilitate the posting of these adjustments by November 27, 2023. We expect that our skills, knowledge and experience will improve throughout the remainder of 2023 and beyond. We expect that we will enhance the development of our systems to capture and provide for the seamless integration of this finding by January 31, 2024. This action is in accordance with the requirements of Uniform Guidance 2 CFR §200.511(c).
VARR agrees with the finding and as VARR grows, it will seek opportunities beginning November 27, 2023 to delegate responsibilities to qualified individuals to provide a greater level of segregation of duties that will enhance our internal control. We also believe that our integrity and relationship...
VARR agrees with the finding and as VARR grows, it will seek opportunities beginning November 27, 2023 to delegate responsibilities to qualified individuals to provide a greater level of segregation of duties that will enhance our internal control. We also believe that our integrity and relationship with the Virginia Department of Behavioral Health Development Services and our recovery community centers provide an external layer of control that when tied into our software system known as REC-CAP will alert management when an error occurs. We expect that we will enhance the development of our systems to capture and provide for the seamless integration of this finding by January 31, 2024. This action is in accordance with the requirements of Uniform Guidance 2 CFR §200.511(c).
VARR agrees with the finding and will continue to enhance our knowledge and understanding of financial reporting, knowing that due to the small size and limited financial resources obtaining a qualified accounting professional either as an employee or an outside consultant to the level of skills, kn...
VARR agrees with the finding and will continue to enhance our knowledge and understanding of financial reporting, knowing that due to the small size and limited financial resources obtaining a qualified accounting professional either as an employee or an outside consultant to the level of skills, knowledge and experience necessary may be difficult. Effective November 27, 2023, VARR’s management and executive director is taking remedial steps to become better acquainted with the matters and items contained in its financial statements that may allow VARR to prepare its financial statements in an acceptable manner to its independent auditor by January 31, 2024. This action is in accordance with the requirements of Uniform Guidance 2 CFR §200.511(c).
Finding: The Single audit package was not submitted to the Federal Clearinghouse within the required time period. Corrective Actions Taken or Planned: Rev. Josh Attaway, CFO is responsible for the corrective action. In 2022 the auditors were not able to assign a team to work on the single audit unti...
Finding: The Single audit package was not submitted to the Federal Clearinghouse within the required time period. Corrective Actions Taken or Planned: Rev. Josh Attaway, CFO is responsible for the corrective action. In 2022 the auditors were not able to assign a team to work on the single audit until after the deadline for submission had already passed. In the future, St. Luke's will identify the need for a Single Audit earlier in the year to ensure that a team of auditors is asigned to complete the audit prior to the deadline for submission. In 2023, if a Single Audit is required, it will be complete and submitted by the September 30 deadline.
We continue to look for ways to improve our internal controls.
We continue to look for ways to improve our internal controls.
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
Corrective Action Taken: The entity understands the importance of timely maintenance of the general ledger and has taken steps to document procedures, cross train the accounting team, and hire additional employees to assist with processing transactions.
The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing although this is difficult with a limited number of employees
The District reviews this audit finding internally on an annual basis, identifying control procedures and processes that would leverage movement toward the maximum internal control possible with available staffing although this is difficult with a limited number of employees
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Federal Communications Commission Ass...
FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Federal Communications Commission Assistance Listing Number and Title: COVID-19-32.009-Emergency Connectivity Fund Federal Award Number: ECF202105452 (Year: 2022) Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D210012 (Year: 2021) Questioner Costs: $63,399 Description: A review of expenditures charged to the Emergency Connectivity Fund and Elementary and Secondary School Emergency Relief Fund programs revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were allowable. Corrective Action Plans: The district will contact each Federal Program to determine the appropriate action to take to ensure the funds are appropriately allocated. Moving forward, Finance will review all reimbursements as well as work with other Departments to ensure that expenses are being allocated to the correct program. Estimated Completion Date: June 30, 2023 Contact Person: Betty Corbitt, Finance Director Telephone: 912-699-6009 Email: betty.corbitt@jeff-davis.k12.ga.us
View Audit 6845 Questioned Costs: $1
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Tak...
2022-002 Reporting Recommendation: Our auditors recommend that we review and strengthen current procedures regarding review of reporting by an appropriate level of management prior to submission. As well as that we work with HRSA to take corrective action to rectify this reporting matter. Action Taken: The accounting department had a significant turnover during 2022 which cause reporting errors go unreviewed. Since 2023, the appropriate accounting team has been assembled and proper policies, procedures, authorization, segregation of duties and reviews have been put in place so that going forward this will not be an issue. All reporting is now being reviewed prior to submission so that reporting requirements including proper period and proper information is reported correctly. We have proactively reached out to the PRF Reporting Help Desk to correct the reporting and communicated the noted reporting corrections needed. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organiz...
2022-001 Sliding Fee Discounts Recommendation: Our auditors recommend we review and strengthen the current procedures in place for determining a patient’s financial responsibility for their visit using the sliding fee scale. This should include requiring a knowledgeable representative of the Organizations’ signature approval on the documentation received and the fee calculated and provided to the applicant. All applications should contain support for the individual’s income level or documentation of no income, and the determination of the resulting fee. Action Taken: This finding was repeated in 2022. Since this was a repeat finding, an internal audit was performed on all 2023 approved sliding fee applications to ensure compliance with our policy. Any corrective actions to the 2023 application were address and the facility’s sliding fee scale was modified to reflect proper authorization and proper segregation of duties going forward. Going forward, all sliding fee scale applications are now reviewed and authorized by the Manager of Revenue Cycle. Future auditing procedures have been put in place to review applications and adjusted, if needed, in a timely manner between now and the end of the year. Name(s) of Contact Person(s) Responsible for Corrective Action: John Milligan, CFO, (315) 430-1708. Anticipated Completion Date: October 2023
The College has implemented procedures in which the Manager, Business Operations will work with the Director of Financial Aid to ensure that all HEERF quarterly reports depict accurate data. The Dean, Student Affairs and Enrollment will verify the accuracy of these reports prior to submission.
The College has implemented procedures in which the Manager, Business Operations will work with the Director of Financial Aid to ensure that all HEERF quarterly reports depict accurate data. The Dean, Student Affairs and Enrollment will verify the accuracy of these reports prior to submission.
2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time pe...
2022-003 Compliance Over Reporting Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding which is directly related to the transitions in financial leadership and the need for a more robust finance team. The Center’s full-time permanent CFO was hired in January 2022 who then immediately increased the team by two new members (1.0 FTE Controller hired in July 2022 and 1.0 FTE Staff Accountant hired in January 2023) and overhauled the Center’s financial policies and procedures manual. With the five-member finance team currently in place, we are on track to complete our FY2022-23 audit process by December 31, 2023. It is also relevant to note that San Francisco community health clinics migrated en masse to OCHIN Epic in 2022 with the overarching goal of our safety net hospitals and all community clinics being on the same EHR system to strengthen patient health outcomes for our city. The Center’s go-live date for this was June 2022 and required extensive time from all executive management, with our newly hired CFO being a key leader in this migration. This one-time, significant event had a direct impact on our ability to complete our audit in a timely manner. Proposed Completion Date: June 30, 2023
2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient f...
2022-002 Sliding Fee Discount Determination Name of Contact Persons: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with the recommendation and is taking steps to correct the errors of ensuring all sliding fee patient applications are maintained within the patient files; and, ensuring all patients who apply for the sliding fee scale program receive the correct discount based upon income and family size. During the Center’s HRSA three-day operational site visit in July 2022, the Center made revisions to its Sliding Fee Application form to make space for our eligibility team members to clearly present their mathematical calculations to determine our patients’ annual incomes. This revision contributed to our 100% score that we received after the HRSA operational site visit. In order to further ensure we are in full compliance, the Center has contracted with an external consultant who is aware of HRSA standards and requirements and will thoroughly review current processes, procedures, and systems, and then will provide recommendations to the Center to implement and adopt. The Center will seek additional training and technical assistance to provide specific sliding fee scale training for all employees involved in our Sliding Fee program. Additionally, the Center will continue to implement quarterly audits of all sliding fee scale patients to ensure all sliding fee scale applications are complete and patients receive the correct discount. Proposed Completion Date: October 31, 2023
2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time p...
2022-001 Internal Control Over Financial Close Process Name of Contact Person: Chief Financial Officer: Amber Curley Corrective Action: The Center agrees with this finding and recommendations. The Center went through a change in CFO leadership throughout this fiscal year and our full-time permanent CFO started in January 2022, who then immediately expanded the Center’s finance department and implemented corrective procedures and greatly improved accounting processes and accounting operations, including all balance sheet accounts being reviewed and reconciled in a timely manner. In order to ensure we are fully compliant, two new positions were created and filled – a 1.0 FTE Controller hired in July 2022 and a 1.0 FTE Staff Accountant hired in January 2023. Additionally, our CFO overhauled our financial policies and procedures manual which was approved by the Center’s Board of Directors in July 2022. These policies and procedures were also reviewed by our HRSA consultants during our three-day operational site visit which took place in July 2022. Specific process improvements were made and included more specific segregation of duties, enhanced communication across all departments to address program items around budgetary and resource planning, transactional accuracy, and transparency. Moreover, the five-member finance department is working collaboratively with program management to advise and support the finance department on continued process improvements and maintaining open communication with program staff for effective feedback on program monitoring systems essential to strengthening internal control over financial close and reporting process. Proposed Completion Date: June 30, 2023
Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 The Durham Trinity Corporation d/b/a Mauro Meadow (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, C...
Federal Audit Clearinghouse 1201 East 10th Street Jefferson, Indiana 47132 The Durham Trinity Corporation d/b/a Mauro Meadow (the Project) respectfully submits the following Corrective Action Plan for the year ended December 31, 2022. Hoyt, Filippetti & Malaghan, LLC 1041 Poquonnock Road Groton, Connecticut 06340 Audit Period: Year ended December 31, 2022 The finding from the December 31, 2022 Schedule of Federal Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. 2022-001 RESERVE ACCOUNT FUNDING Criteria: The Project’s reserve account must be fully funded in accordance with the budget as approved by USDA-RD and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserve funds, it was not funded in accordance with the budget. Cause: Budgeted transfers were not made before yearend to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account. If you have any questions regarding this plan, please contact Matthew Scibek at 860-398-5425, or matt@westfordmgt.com.
Finding 4162 (2022-004)
Significant Deficiency 2022
Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly ...
Description: The Township’s IDISC04PR29 Cash on Hand quarterly reports did not agree to the reconciled cash balance in the Community Development Trust bank account. Analysis: Policies and procedures be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Corrective Action: Policies and procedures will be implemented to ensure the CDBG IDISC04PR29 cash on hand quarterly reports are prepared correctly and in agreement with the reconciled cash balances on hand. Implementation Date: Ongoing
Finding 4161 (2022-003)
Significant Deficiency 2022
Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development ...
Description: The Township did not file the Community Development Block Grant program Annual Performance and Evaluation Report within 90 days after the end of the program year. Analysis: The Township implement policies and procedures to ensure all required reporting under the Community Development Block Grant program is completed. Corrective Action: Township is working towards implementing reporting process to meet the 90 day filing deadline for CDGB Annual Performance and Evaluation Report. Implementation Date: Ongoing
Finding 4160 (2022-002)
Significant Deficiency 2022
Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be ch...
Description: Administrative charges to Community Development Block Grant program, are in some instances, not supported by detailed documentation nor are they charged to the correct program year in budgetary records Analysis: All administrative salary and wage and other administrative expenses be charged to the proper program year and be supported by detail documentation Corrective Action: Finance and Planning departments will coordinate to ensure administrative costs are charged to proper program year, and proper supporting documentation is maintained. Implementation Date: Ongoing
Finding 4159 (2022-001)
Significant Deficiency 2022
Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community ...
Description: The Township has excess cash proceeds in its Community Development Block Grant Program as a result of drawing down funds in excess of expenditures incurred. Analysis: The Township’s drawdown policies be enhanced; that only actual supported expenditures be drawn down against Community Development Block Grant award allocations in IDIS. Corrective Action: IDIS drawdowns will be made based on the actual expenditures on the Township’s semi-monthly Bill list. Implementation Date: Ongoing
The Program Manager, alongside the Executive Director, will work on updating the ISC's Government Contracts Management Procedures. It will include detailed written procedures that encompass key areas of federal grants. We will develop a reimbursement policy consistent with federal guidelines for our...
The Program Manager, alongside the Executive Director, will work on updating the ISC's Government Contracts Management Procedures. It will include detailed written procedures that encompass key areas of federal grants. We will develop a reimbursement policy consistent with federal guidelines for our staff and volunteers. We aim to finalize this by 12/31/23. Starting the new year, we will also train all staff and volunteers involved with federal grants to ensure compliance.
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