Corrective Action Plans

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Audit Finding Reference: 2024-003 Improve Internal Controls Over Procurement Planned Corrective Action: The Town will review and revise its procurement procedures to ensure that federal requirements under the Uniform Guidance are followed for all federally funded transactions. For future federally f...
Audit Finding Reference: 2024-003 Improve Internal Controls Over Procurement Planned Corrective Action: The Town will review and revise its procurement procedures to ensure that federal requirements under the Uniform Guidance are followed for all federally funded transactions. For future federally funded contracts, the Town will maintain documentation demonstrating adherence to Uniform Guidance procurement requirements, including appropriate justifications for exemptions. The Town will ensure program staff are trained on the distinction between federal and state procurement requirements. Planned Implementation Date of Corrective Action: February 2, 2026
Audit Finding Reference: 2024-006 Improve Documentation and Controls over Allowable Costs Planned Corrective Action: The Town will implement and enforce procedures to ensure all employees whose salaries or wages are charged to federal grants maintain and retain appropriate time and effort documentat...
Audit Finding Reference: 2024-006 Improve Documentation and Controls over Allowable Costs Planned Corrective Action: The Town will implement and enforce procedures to ensure all employees whose salaries or wages are charged to federal grants maintain and retain appropriate time and effort documentation, including timesheets for hourly staff and semi-annual certifications for salaried staff, in compliance with Uniform Guidance. Management has made staff aware of the Time and Effort reporting requirements associated with Federal grants and will work with grant managers and finance department staff to ensure this requirement is implemented during Fiscal 2026; on or about March 18th.
Audit Finding Reference: 2024-005 Improve Procurement Procedures Planned Corrective Action: The Town will revise its internal controls over procurement to ensure compliance with Uniform Guidance requirements, regardless of state law exemptions. The Town will ensure adequate documentation is retained...
Audit Finding Reference: 2024-005 Improve Procurement Procedures Planned Corrective Action: The Town will revise its internal controls over procurement to ensure compliance with Uniform Guidance requirements, regardless of state law exemptions. The Town will ensure adequate documentation is retained for all federally funded procurements, and that procurement staff and grant managers are trained on the distinction between federal and state procurement requirements. Planned Implementation Date of Corrective Action: Management has made staff aware of the Federal procurement requirements associated with Federal grants and will work with grant managers, finance and procurement department staff to ensure this requirement is implemented in fiscal year 2026; on or about March 18, 2026.
This is a reiteration of Finding 2024-002. Please refer to corrective action plan under Finding 2024-002. Management will review procedures and adopt a system to adequately document and retain approval of disbursements.
This is a reiteration of Finding 2024-002. Please refer to corrective action plan under Finding 2024-002. Management will review procedures and adopt a system to adequately document and retain approval of disbursements.
Finding #2024-002 – Internal Control over Federal Grant Reporting Description of Finding: The City received a significant amount of grant funding during the year ending June 30, 2024, including federal funds that were received in advance. Material audit adjustments were required to record grant rece...
Finding #2024-002 – Internal Control over Federal Grant Reporting Description of Finding: The City received a significant amount of grant funding during the year ending June 30, 2024, including federal funds that were received in advance. Material audit adjustments were required to record grant receivables, an advance from grantors, and the related impact on grant revenue. The grant activity was primarily recorded on the cash basis in the general ledger, which is not consistent with generally accepted accounting principles. Statement of Concurrence or Nonconcurrence: Concurrence Planned Correction Action: The Finance Department has started reviewing active grants on a quarterly basis. A new Planning & Development Director has been hired and is focused on implementing improved grant management through staff reassignment and creation of new grant procedures. Grant administrators are now entering Accounts Receivable for anticipated reimbursements. The Finance Director is building out a SEFA, with supplemental grant information that can be used to track grants from year to year. Staffing shortages have played a critical role in delaying significant progress in this area, however, we have made progress and are confident new staffing approaches will directly address and correct this finding. Anticipated Completion Date: 12/31/2026
The Organization will utilize their outside accounting firm more effectively so they can prepare the financial reports and records on a timely basis for the auditor.
The Organization will utilize their outside accounting firm more effectively so they can prepare the financial reports and records on a timely basis for the auditor.
The City Clerk will ensure that the external auditor is engaged prior to the commencement of financials. All required documentation will be submitted in a timely manner.
The City Clerk will ensure that the external auditor is engaged prior to the commencement of financials. All required documentation will be submitted in a timely manner.
We concur with the recommendation. The City of Angoon has diligently worked to meet the Uniform Guidance requirement of submitting the reporting package within the earlier of 30 days after the receipt of the audit report, or the nine (9) months after the end of the audit period. The Fiscal year endi...
We concur with the recommendation. The City of Angoon has diligently worked to meet the Uniform Guidance requirement of submitting the reporting package within the earlier of 30 days after the receipt of the audit report, or the nine (9) months after the end of the audit period. The Fiscal year ending 06/25/2025 will be submitted timely, as well as all future audits. An external accountant was hired to help train and oversee the city accounting staff which has allowed the accounting records to easily be prepared for future audits.
Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are n...
Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are now required to verify that the patient’s application rating (based on income and family size) aligns with the corresponding Federal Poverty Level (FPL) category and discount level configured within the Epic system. Discounts will not be applied unless this validation is completed. To address inconsistencies identified during the audit period, CAMcare has formalized procedures requiring that all updates to the sliding fee discount schedule, including changes to FPL thresholds or discount percentages, are communicated to registration, financial screening, and billing staff prior to implementation. Additionally, system-level updates within Epic must be validated by designated personnel to ensure that the updated fee schedule is accurately reflected before being used in patient billing. Supervisory review controls have also been strengthened. Financial screening supervisors will perform monthly spot checks of a defined sample of patient accounts to verify that sliding fee discounts have been applied correctly and are supported by complete and accurate patient application data. Any discrepancies identified will be documented, corrected, and escalated for follow-up training or process improvement as necessary. In addition, CAMcare will reinforce staff training on financial screening policies and procedures on a periodic basis and maintain documentation of completed training. Management will monitor compliance through ongoing supervisory review and periodic evaluation of screening and billing accuracy to ensure adherence to established policies. These corrective actions are designed to strengthen internal controls over financial screening and billing processes, ensure accurate application of sliding fee discounts, and reduce the risk of noncompliance in future reporting periods. Anticipated Completion Date: January 1st, 2025, with ongoing monthly monitoring and periodic training. Responsible Contact Persons: Eshan Singh, Vice President of Finance, Analytics & Technology
The Municipality of Comerío made a contract with an auditing firm to work on the reports and submission of the FASS-PH financial report compliance for the years in which the reports were not submitted. Furthermore, instructions were given for the HUD Coordinator to monitor the delivery of reports by...
The Municipality of Comerío made a contract with an auditing firm to work on the reports and submission of the FASS-PH financial report compliance for the years in which the reports were not submitted. Furthermore, instructions were given for the HUD Coordinator to monitor the delivery of reports by the contracted auditing firm and to ensure that the contract for this service is finalized.
Federal awards: 14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants
Federal awards: 14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants
Criteria: Organizations spending more than the minimum threshold in Federal awards must submit an audit reporting package to the Federal Audit Clearinghouse within nine months of the end of the fiscal year per the requirements of the Uniform Guidance.
Criteria: Organizations spending more than the minimum threshold in Federal awards must submit an audit reporting package to the Federal Audit Clearinghouse within nine months of the end of the fiscal year per the requirements of the Uniform Guidance.
Condition: The Organization did not submit the reporting package by the required submission date for the year ended September 30, 2024.
Condition: The Organization did not submit the reporting package by the required submission date for the year ended September 30, 2024.
Management, in conjunction with COTS's outsourced accounting team, has implemented enhanced grant review procedures to ensure all funding agreements are evaluated for federal characteristics when awards are received and again prior to fiscal year-end close. Going forward, COTS's outsourced accountin...
Management, in conjunction with COTS's outsourced accounting team, has implemented enhanced grant review procedures to ensure all funding agreements are evaluated for federal characteristics when awards are received and again prior to fiscal year-end close. Going forward, COTS's outsourced accounting team will maintain a complete grant inventory, document the federal/nonfederal determination for each award, and review all new and existing grant agreements before year-end to confirm whether Single Audit reporting requirements apply. Management believes these procedures will help ensure timely identification of federal awards and timely submission of future audit reporting packages.
2024-002 – All Federal Programs – Compliance – Data Collection Form Finding: For the fiscal year ended September 30, 2023, the Village did not submit the data collection form to the Federal Clearinghouse by the required due date of June 30, 2024, in accordance with the federal requirements. In addit...
2024-002 – All Federal Programs – Compliance – Data Collection Form Finding: For the fiscal year ended September 30, 2023, the Village did not submit the data collection form to the Federal Clearinghouse by the required due date of June 30, 2024, in accordance with the federal requirements. In addition, due to the late issuance of the 2024 fiscal year audit, the submission deadline for FY 2024 of June 30, 2025 has passed and as such, the Village did not meet the submission deadline. Correction Action: The Village will ensure the data collection form for the fiscal year ending September 30, 2025 is submitted at the completion of the audit. Responsible Parties: Village Administrator, Community and Economic Development Coordinator and Accounting Supervisor. Anticipated Completion Date: June 2026
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immedi...
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immediately filed. The Agency will prepare a checklist of required federal reports by the finance department, which will be monitored by the Program Director. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Pr...
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audi...
TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audit process and submit the data collection report within the required time period. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
Corrective Action Plan: Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them informed of the status of required financial reporting. The audit for the year end June 30, 2025 has been expedited and will be issued prior t...
Corrective Action Plan: Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them informed of the status of required financial reporting. The audit for the year end June 30, 2025 has been expedited and will be issued prior to the reporting deadline. To prevent recurrence, management will implement enhanced controls over grant reporting compliance including: •Establishment of a reporting calendar with key deadlines, •Implementation of a standardized checklist to ensure all reporting is completed timely and accurately, and •Periodic management review of reporting status to ensure deadlines are met. Responsible Party - Judy Stein, CFO Estimated Completion - 3/31/2026
Finding # 2024-003 Corrective Action Plan: Subsequent to year-end, management has deposited the required funds into the reserve account to bring the organization into compliance with the USDA loan agreement. To prevent recurrence, management will strengthen its monitoring of debt covenant and reserv...
Finding # 2024-003 Corrective Action Plan: Subsequent to year-end, management has deposited the required funds into the reserve account to bring the organization into compliance with the USDA loan agreement. To prevent recurrence, management will strengthen its monitoring of debt covenant and reserve requirements by implementing the following controls: •Establish a tracking schedule for all loan-related requirements, •Incorporation of reserve funding requirements into the organization’s cash flow planning process, and •Review by appropriate management personnel to ensure timely compliance with all loan agreement provisions. Responsible Party - Judy Stein, CFO Estimated Completion - 3/31/2026
Moving forward, the District will ensure that all supporting documents are retained for reporting elements related to grants. Additionally, the District will add additional review procedures for any reporting items related to grants.
Moving forward, the District will ensure that all supporting documents are retained for reporting elements related to grants. Additionally, the District will add additional review procedures for any reporting items related to grants.
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice a...
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.
2024-004 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants...
2024-004 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Cause: The Village does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of expenditures of federal awards is high. Auditor’s Recommendation: We recommend that the Village works on written policies and procedures over grants and grant expenditures. Management Response: The Village will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance.
Action Taken: We concur with the recommendation, and it was implemented effective March 17, 2026.
Action Taken: We concur with the recommendation, and it was implemented effective March 17, 2026.
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