Corrective Action Plans

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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
Tuerk House, Inc. acknowledges the finding related to procurement and suspension and debarment requirements and recognizes the need for strengthened internal controls to ensure continued compliance with Uniform Guidance and the Organization's procurement policies. To address this repeat finding, Tu...
Tuerk House, Inc. acknowledges the finding related to procurement and suspension and debarment requirements and recognizes the need for strengthened internal controls to ensure continued compliance with Uniform Guidance and the Organization's procurement policies. To address this repeat finding, Tuerk House is taking the following corrective actions: ·Updating the procurement policy to explicitly include steps for verifying all vendors against the federal government's System for Award Management (SAM) exclusion list prior to engaging in any procurement activity funded by federal awards. ·Implementing a procurement checklist and documentation protocol to ensure proper procedures are followed for purchases exceeding $10,000, including competitive bidding, price or rate quotations, and appropriate justification for vendor selection. ·Conducting mandatory training for finance and program staff on updated procurement procedures, including documentation and vendor vetting protocols. ·Establishing a centralized record-keeping system to retain documentation related to procurement, vendor selection, and debarment checks in accordance with 2 CFR Part 200 and 2 CFR 180. The Organization is committed to full compliance and will ensure that all future procurements charged to federal awards meet the applicable requirements. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditu...
Tuerk House, Inc. recognizes the importance of maintaining compliance with federal grant requirements related to allowable costs and documentation standards. The Organization acknowledges the deficiencies identified in the areas of time and effort reporting and supporting documentation for expenditures charged to grant programs. To address this finding, Tuerk House is taking the following corrective actions: ·Implementing a formal time and effort certification process that requires employees to certify actual time worked on federal grant activities on a regular basis, rather than relying on budgeted allocations. ·Developing a standardized cost allocation methodology that aligns with actual grant activity and is supported by verifiable documentation. ·Requiring that all expenditures charged to federal awards be supported by complete and accurate source documentation, including vendor invoices, timesheets, and approvals. ·Establishing a document retention policy consistent with 2 CFR § 200.334 to ensure all supporting records are retained for the required period and readily accessible for audit or review. Training sessions for program and finance staff will be conducted to ensure consistent understanding and application of these updated policies and procedures. Organization Contact Person Responsible for Corrective Action – Joseph Koehler, Director of Finance Anticipated Completion Date – June 30, 2025
View Audit 361681 Questioned Costs: $1
Plan: • Ensure all applications are saved in files on the computer and paper copies if needed for backup. • Work for Success manager and VP will work with DCF to determine clear eligibility qualifications. It will be determined whether or not 18-24 year olds involved in the juvenile or foster care ...
Plan: • Ensure all applications are saved in files on the computer and paper copies if needed for backup. • Work for Success manager and VP will work with DCF to determine clear eligibility qualifications. It will be determined whether or not 18-24 year olds involved in the juvenile or foster care system are eligible. • Proper documentation showing that a participant does qualify will be obtained and kept in the file with the application. • Staff will ensure the participant and staff working with participant completing the application sign off on the application. Management will then review and sign off on the application and note appropriate funding stream. • If a change appears to be made on an application the staff member shall note the change on the appropriate application and initial the change. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
Plan: • Implement a policy to ensure appropriate review process and documentation for each application is obtained. • Implement internal control that management signs off on all applications, verifying that appropriate documentation is present and noting what funding the applicant qualifies for. ...
Plan: • Implement a policy to ensure appropriate review process and documentation for each application is obtained. • Implement internal control that management signs off on all applications, verifying that appropriate documentation is present and noting what funding the applicant qualifies for. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
Plan: • Implementing new work flows around grants being awarded. Ensuring all grants are tracked in a single location with identifications within the spreadsheet to track federal awards. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO will review ...
Plan: • Implementing new work flows around grants being awarded. Ensuring all grants are tracked in a single location with identifications within the spreadsheet to track federal awards. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO will review staffs entries on the spreadsheet to ensure necessary data/information for each grant is being kept, in order to have a SEFA prepared for each audit.
Plan: • CEO and CFO will analyze the needs for additional staffing in the accounting department to ensure appropriate help is available to ensure needed processes and procedures can be completed monthly/annually for all tasks to be complete. Implementation Date: Beginning of Fiscal Year 26- July 1...
Plan: • CEO and CFO will analyze the needs for additional staffing in the accounting department to ensure appropriate help is available to ensure needed processes and procedures can be completed monthly/annually for all tasks to be complete. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Des Martens CEO and Shelby Turner CFO.
Plan: • Revenue streams will be analyzed, identifying type of grant transaction to determine the appropriate recording of revenue. • When grants are obtained efforts will be made to ensure if the funds are federal, state or other. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Res...
Plan: • Revenue streams will be analyzed, identifying type of grant transaction to determine the appropriate recording of revenue. • When grants are obtained efforts will be made to ensure if the funds are federal, state or other. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO, will have overall responsibility and will perform the validation and review of the grant types and appropriate entries for the funds based on the information staff are able to obtain on the grant.
Plan: • The accounting team will implement processes to review and reconcile the cash and investment account quarterly. • The depreciation schedule will be maintained more accurately each month. Additional training will be provided to AP Clerk whom enters assets into the module. • Prepaid expense...
Plan: • The accounting team will implement processes to review and reconcile the cash and investment account quarterly. • The depreciation schedule will be maintained more accurately each month. Additional training will be provided to AP Clerk whom enters assets into the module. • Prepaid expenses will be reconciled monthly by AP Clerk and reviewed quarterly by the CFO. • Accrued payroll liabilities will be adjusted to supporting documentation at the end of each fiscal year. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Shelby Turner CFO, will have overall responsibility and will perform the validation and review of these reconciliations.
Starting during Fiscal Year 2024, the County Finance Department has been preparing and analyzing quarterly draft Single Audit expenditures and other trial balance amounts with participation from grant fiscal staff throughout the County to improve the reporting of expenditures at year-end. There are...
Starting during Fiscal Year 2024, the County Finance Department has been preparing and analyzing quarterly draft Single Audit expenditures and other trial balance amounts with participation from grant fiscal staff throughout the County to improve the reporting of expenditures at year-end. There are also a variety of other initiatives to improve financial reporting and other grant-related processes. An interorganizational Grants Workgroup has been started to have periodic meetings to work on root causes that affect the accounting of grant expenditures. For example, this work group is addressing topics such as expenditure reconciliations, timely recording of grant receivables and revenues throughout the fiscal year to facilitate expenditure analysis at year-end, timely recording of County match and the identification of County match-funded versus grantor-funded (Single Audit reportable) expenditures, and the development of accounting-system reports. County Finance management (Merrie Allen and Ajay Gajjar) will continue to work with the Grants Workgroup and develop improvements that will improve the reporting of grant expenditures.
Please accept this letter as my response for our audit finding. The inter-program amount of $106,589.00 reported at the end ofFY2024 between the Public Housing and Housing Choice Voucher (HCV) programs occurred because of lack of funding from HUD. Our HAP funding has also been declining and we are n...
Please accept this letter as my response for our audit finding. The inter-program amount of $106,589.00 reported at the end ofFY2024 between the Public Housing and Housing Choice Voucher (HCV) programs occurred because of lack of funding from HUD. Our HAP funding has also been declining and we are not receiving enough funding to cover the expenses for our program. Currently, we are working with our Field Representative, Wilma Henry and Finance Management, Lin Wang to release our reserves to resolve this issue.
View Audit 361639 Questioned Costs: $1
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