Corrective Action Plans

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The Organization concurs with the finding and has begun implementing corrective action to address the identified issues, including enhancing internal controls and strengthening review procedures to ensure more accurate and timely financial reporting going forward.
The Organization concurs with the finding and has begun implementing corrective action to address the identified issues, including enhancing internal controls and strengthening review procedures to ensure more accurate and timely financial reporting going forward.
View Audit 370000 Questioned Costs: $1
2024-002 Noncompliance: Activities Allowed/Unallowed; Allowable Costs/Activities; Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by s...
2024-002 Noncompliance: Activities Allowed/Unallowed; Allowable Costs/Activities; Reporting A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management concurs. Large fiber installation project still in process at year-end. Subsequent reconciliations have been completed. Controls and other project processes have been improved to ensure more timely reconciliation of material charge-outs to the timing of the installation of material. Anticipated completion date: Completed Contact information for this finding: Amanda Burnett, Chief Financial Officer, 573-471-5821
View Audit 369998 Questioned Costs: $1
2024-001 Material Weakness in Internal Control A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management...
2024-001 Material Weakness in Internal Control A. Comments on Findings and Recommendations: We concur with the auditor’s findings and recommendations regarding reporting of project expenses and unidentified errors in project reconciliations completed by staff. B. Actions Taken or Planned: Management concurs. Large fiber installation project still in process at year-end. Subsequent reconciliations have been completed. Controls and other project processes have been improved to ensure more timely reconciliation of material charge-outs to the timing of the installation of material. Anticipated completion date: Completed Contact information for this finding: Amanda Burnett, Chief Financial Officer, 573-471-5821
Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management's Corrective Actions: During 2025, Hamilton County Area Neighborhood Development, Inc. (HAND) hired a con...
Condition: An effective internal control system was not in place to ensure compliance with requirements related to the grant agreement and the Cash Management compliance requirements. Management's Corrective Actions: During 2025, Hamilton County Area Neighborhood Development, Inc. (HAND) hired a controller to assist with the preparation of the parent company and subsidiaries financials while instituting improved internal control policies. As such, HAND with the assistance of its controller will establish effective internal control systems to ensure the compliance with the requirements for grant agreements and cash management compliance requirements
Recommendation: We recommend that the Organization implement a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by requiring every employee that works on a federal grant to charge their time to a spe...
Recommendation: We recommend that the Organization implement a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by requiring every employee that works on a federal grant to charge their time to a specific grant charge code regardless of position. We recommend the Organization adopt a written policy and implement a system of internal controls to review and true-up grant wages to actual to ensure accuracy, allowability, and proper allocation of federal and non-federal time. There is no disagreement with the audit finding. Action taken in response to finding: We have updated both our time reporting policy in Chapter 1 and added time allocation to the Allowable Costs section of Chapter 2 Financial Policies of our Fiscal Program Management Policy Manual. Copies of both additions are attached. We updated the staff of these changes at our April 16, 2025 Team Meeting, the agenda of the meetingis attached. We have also included payroll summaries and timesheets to show we are allocatingtime accurately. Name(s) of the contact person(s) responsible for corrective action: Tracey Hunter Planned completion date for corrective action plan: 4/16/2025
View Audit 369990 Questioned Costs: $1
2024-002 Procurement Documentation Retention Corrective Action Plan The Center for Black Excellence and Culture Inc will obtain procurement documentation for all vendors and keep for our records electronically in our shared google drive folders. We will have the board review and approve a criteria f...
2024-002 Procurement Documentation Retention Corrective Action Plan The Center for Black Excellence and Culture Inc will obtain procurement documentation for all vendors and keep for our records electronically in our shared google drive folders. We will have the board review and approve a criteria for RFP evaluation and a procurement policy. Person(s) Responsible: Jason Fields, Chief Operations Officer Timing for Implementation: No later than December 31, 2025
2024-001 Accounting Policies and Financial Review Corrective Action Plan The Center for Black Excellence and Culture Inc has drafted an accounting policies and procedures document that will be reviewed and approved by the Board of Directors by December 31, 2025. Person(s) Responsible: Janine Stephen...
2024-001 Accounting Policies and Financial Review Corrective Action Plan The Center for Black Excellence and Culture Inc has drafted an accounting policies and procedures document that will be reviewed and approved by the Board of Directors by December 31, 2025. Person(s) Responsible: Janine Stephens Hale, Chief Administrative Officer Timing for Implementation: No later than December 31, 2025.
Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grant...
Program Name - STOP Violence Grant- Victim Services CFDA Number - 16.588 Pass-through Entity - Michigan Department of Health and Human Service Condition and Description - For 4 out of 20 samples tested, during our testing of participant eligibility under the STOP Violence against Women Formula Grants, the Organization was unable to provide enrollment forms or supporting documentation. These forms are necessary to verify that participants met the program's eligibility criteria. YWCA Response- The YWCA Victim Services acknowledges this finding and has implemented the following corrective action plan to ensure compliance. Corrective Action Plan - Procedures exist to ensure all clients are enrolled and eligible for services under the STOP grant. In addition to documentation in the Apricot system, an additional legal screening process and intake forms are used to determine eligibility and complete client enrollment within a Victim Services application called MyCase. During the audit, documentation for the four identified cases from MyCase was erroneously excluded, causing the finding. As a subsequent event, the documentation for intake and eligibility for the four identified cases was provided to the external auditors. This process will continue, and future audits will include client documentation for both systems. Additionally, Enforcement of enrollment procedures within Apricot, and oversight from department Directors, has been made a priority. Time Frame for Correction -Appropriate procedures were in place during the full audit year of 2024 and will continue into future years. Corrective action related to documentation within the Apricot system was implemented in August 2025. Individuals Responsible - Jessica Glynn, Vice President of Victim Services and Kellie Swikoski, Grant Manager.
View Audit 369986 Questioned Costs: $1
Program Name - Temporary Assistance for Needy Families (TANF); Services for Trafficking Victims; Violence Against Women Formula Grants CFDA Number- 93.558 16.320, 16.588 Finding Type - Significant Deficiency and Noncompliance Condition and Description - During our procedures, we noted, the Agency di...
Program Name - Temporary Assistance for Needy Families (TANF); Services for Trafficking Victims; Violence Against Women Formula Grants CFDA Number- 93.558 16.320, 16.588 Finding Type - Significant Deficiency and Noncompliance Condition and Description - During our procedures, we noted, the Agency did not properly allocate its employees' leave hours for employees working on multiple activities. For 13 out of 20 samples selected for testing, Controls were not in place to ensure that leave time was proportionately distributed based on actual time worked on each activity. YWCA Response - The YWCA Victim Services acknowledges this finding and has implemented the following corrective action plan to ensure compliance. Corrective Action Plan - No employee leave hours are to be billed to the TANF grant. The cost of employee leave will be borne by non-governmental grants for all Victim Service staff. Time Frame for Correction - Corrective action was implemented in April 2025. Individuals Responsible- Marcy Dix, Director of Grant management with oversight from Jodi Breithart, CMA, MAcc, Vice President of Finance.
View Audit 369986 Questioned Costs: $1
Views of Responsible Officials: The delay resulted primarily from turnover within the grants management team and the concurrent implementation of a new subaward monitoring system during the reporting period. These factors temporarily affected the timely completion and review of FFATA submissions. To...
Views of Responsible Officials: The delay resulted primarily from turnover within the grants management team and the concurrent implementation of a new subaward monitoring system during the reporting period. These factors temporarily affected the timely completion and review of FFATA submissions. To address the issue and prevent recurrence, HI has taken the following corrective actions: 1. Process Strengthening: Internal grants management procedures have been updated to include a detailed FFATA reporting checklist and a pre-submission timeline that allows for earlier internal review. 2. Staff Training: All grants and compliance staff received refresher training in February 2025 on FFATA reporting requirements and internal deadlines. 3. Oversight and Monitoring: The Director of Grants and Compliance will review FFATA submissions monthly to ensure adherence to Federal reporting deadlines. HI is committed to maintaining full compliance with Federal requirements and will continue to monitor the effectiveness of these corrective measures throughout the current fiscal year.Anticipated Completion Date: February 2025 (with ongoing monthly monitoring throughout the current fiscal year). Responsible Official: Hannah Guedenet, U.S. Executive Director.
The task of completing program reports will be immediately assigned to the senior accountant. The senior accountant name and email address will be added to communications with the funder so that he receives notices. Once completed the senior accountant will provide to the CFO who will review and sub...
The task of completing program reports will be immediately assigned to the senior accountant. The senior accountant name and email address will be added to communications with the funder so that he receives notices. Once completed the senior accountant will provide to the CFO who will review and submit it.
View of Responsible Officials and Planned Corrective Action Plan: Going forward, all Adoption Subsidy case files will include Criminal Background Checks and Statewide Central Registry (SCR) clearances, in accordance with the updated OCFS-4401. Each Adoption Subsidy determination will be reviewed by ...
View of Responsible Officials and Planned Corrective Action Plan: Going forward, all Adoption Subsidy case files will include Criminal Background Checks and Statewide Central Registry (SCR) clearances, in accordance with the updated OCFS-4401. Each Adoption Subsidy determination will be reviewed by the Senior Caseworker in charge of the FAHD Unit and subsequently verified by a Services Eligibility Unit Social Services Specialist to ensure that all required documentation is included prior to case opening.
2024-006 - Failure to Maintain Standards for Documentation of Personnel Expenses Auditor Description of Condition and Effect: During our testing of Allowable Costs, for all 12 disbursements tested we noted that the hourly rate charged under the grant was higher than the actual hourly rate noted in p...
2024-006 - Failure to Maintain Standards for Documentation of Personnel Expenses Auditor Description of Condition and Effect: During our testing of Allowable Costs, for all 12 disbursements tested we noted that the hourly rate charged under the grant was higher than the actual hourly rate noted in personnel files. As a result of this condition, the Organization did not fully comply with the Uniform Guidance by not charging the proper hourly rate to the grant. Auditor Recommendation: We recommend that the Organization use actual rates per approved compensation records when charging costs to the grants. Corrective Action: Management has established procedures to enhance and improve the controls related to payroll charges under the grant to ensure that the proper pay rate is charged. Responsible Person: Michael Young & Dora Gonzales Anticipated Completion Date: December 2025
2024-005 - Procurement, Suspension and Debarment Auditor Description of Condition and Effect: During Procurement, Suspension and Debarment testing, the Organization could not provide evidence that they determined whether vendors are suspended or debarred. Certain vendors could be used that are consi...
2024-005 - Procurement, Suspension and Debarment Auditor Description of Condition and Effect: During Procurement, Suspension and Debarment testing, the Organization could not provide evidence that they determined whether vendors are suspended or debarred. Certain vendors could be used that are considered suspended or debarred by the federal government resulting in noncompliance. Auditor Recommendation: We recommend that the Organization adhere to the policy over suspension and debarment review to ensure they are contracting with vendors that are allowable. Corrective Action: While the Organization has controls in place to ensure vendors are not suspended or debarred, management will ensure to have this process documented going forward. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025
2024-004 - Subrecipient Monitoring Activities Auditor Description of Condition and Effect: During subrecipient monitoring testing, the ALN number and award number were not included in the four subrecipient agreements subjected to testing. Additionally, the Organization does not have a policies/proce...
2024-004 - Subrecipient Monitoring Activities Auditor Description of Condition and Effect: During subrecipient monitoring testing, the ALN number and award number were not included in the four subrecipient agreements subjected to testing. Additionally, the Organization does not have a policies/procedure in place to evaluate and address subrecipient's fraud risk and risk of noncompliance. Auditor Recommendation: We recommend that the Organization adopt additional policies and procedures related to subrecipient monitoring to ensure compliance with Uniform Guidance. Corrective Action: The Organization will implement stronger control in place to ensure that subrecipient disclosure requirements are included in the subrecipient agreements. In addition, the Organization will put in place a formal policy to address subrecipient fraud risk and risk of noncompliance. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025
2024-003 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Condition and Effect: The Organization did not register or submit any subaward information through the FFATA Subaward Reporting System (“FSRS”) reporting system as required by the Uniform Guidance...
2024-003 - Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Condition and Effect: The Organization did not register or submit any subaward information through the FFATA Subaward Reporting System (“FSRS”) reporting system as required by the Uniform Guidance. The Organization did not follow federal requirements for FFATA reporting through the FSRS and as a result has not completed the appropriate subaward reporting that is required for prime recipients. Auditor Recommendation: We recommend that the Organization establish and implement procedures for FFATA reporting through FSRS and ensure that all key data are reported timely moving forward. Corrective Action: When granting funds as a subaward to a pass-through entity, the Organization will update its records for subawards to include the required information and therefore comply with FFATA reporting requirements for direct awards. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025
2024-002 - Lack of Independent Review and Approval Auditor Description of Condition and Effect: During our testing of Allowable Costs/Cost Principles, of the 12 items tested, we noted all 12 instances where time sheets were missing evidence of review and approval. In addition, there was no evidence ...
2024-002 - Lack of Independent Review and Approval Auditor Description of Condition and Effect: During our testing of Allowable Costs/Cost Principles, of the 12 items tested, we noted all 12 instances where time sheets were missing evidence of review and approval. In addition, there was no evidence of review and approval of the hourly rate or salary for all the employees tested. During Cash Management testing, of the three items tested, all three drawdown requests were missing evidence of review and approval. Finally, during our testing of Reporting, all four of the reports selected for testing lacked evidence of review and approval. The Organization did not comply with the federal requirements as noted per 2 CFR 200.303. Auditor Recommendation: We recommend the Organization adheres to their internal control process of an independent review and approval of transactions, cash management and reporting related to federal grant programs. Corrective Action: While the Organization has controls in place to ensure proper review and approval, Management will ensure to have this process documented going forward. Responsible Person: Dora Gonzales Anticipated Completion Date: December 2025
WWBIC plans to develop and adopt a written Cost Allocation Plan that complies with 2 CFR 200. Ml P's Cost Allocation Module will be implemented for efficiency and automation. WWBIC plans to use a direct method of recording staff time, by requiring staff to allocate time on time sheets by funding sou...
WWBIC plans to develop and adopt a written Cost Allocation Plan that complies with 2 CFR 200. Ml P's Cost Allocation Module will be implemented for efficiency and automation. WWBIC plans to use a direct method of recording staff time, by requiring staff to allocate time on time sheets by funding source. Once payroll postings align with funding sources, direct wages will be used as the allocation base. The 3rd party payroll integration with Paylocity will be implemented to use this method. This project is currently under development with our payroll system, Paylocity and the accounting team.
WWBIC is working with the software developer to have necessary reports available such as interest accrual and maturities calculations as part of the system. Accounting staff will be implementing a new loan tracking coding segment in their general ledger software, ABILA MIP, that will track each loan...
WWBIC is working with the software developer to have necessary reports available such as interest accrual and maturities calculations as part of the system. Accounting staff will be implementing a new loan tracking coding segment in their general ledger software, ABILA MIP, that will track each loan transaction by loan number. This will allow MIP system to be reconciled to the loan software, Ventures monthly using automated reconciliations. Staff in both the accounting and the loan operations areas will be trained to use this coding. Reports that are time sensitive in the loan system will be set to run automatically so that balances can be captured. The accounting staff are now coordinating these processes with WWBIC's loan operations to make sure that the processes capture all activity and reconcile between the two systems.
A comprehensive Fiscal Policies and Procedures Manual will be developed that incorporates all required written procedures under 2 CFR 200 and defines internal controls and implementation processes. Accounting staff, and members of WWBIC's Compliance and Advancement teams, will receive training on th...
A comprehensive Fiscal Policies and Procedures Manual will be developed that incorporates all required written procedures under 2 CFR 200 and defines internal controls and implementation processes. Accounting staff, and members of WWBIC's Compliance and Advancement teams, will receive training on the guidelines and requirements of the Schedule of Expenditures of Federal Awards (SEFA). As Federal and State funding is approved, WWBIC will flag the related accounts during set up to ensure that they are marked to be included in the SEFA. WWBIC will contact our auditors with possible questions before compiling and finalizing the SEFA.
Management is committed to ensuring that we are in compliance with all Head Start regulations required by the Department of Health and Human Services and other regulatory bodies. Management will ensure that the indirect cost calculations complies with all regulations prospectively.
Management is committed to ensuring that we are in compliance with all Head Start regulations required by the Department of Health and Human Services and other regulatory bodies. Management will ensure that the indirect cost calculations complies with all regulations prospectively.
View Audit 369964 Questioned Costs: $1
Management will establish a formal process to review expenditures for items that should be capitalized on a monthly basis and add those capitalized items to the Head Start inventory listing.
Management will establish a formal process to review expenditures for items that should be capitalized on a monthly basis and add those capitalized items to the Head Start inventory listing.
Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management has thoroughly reviewed all the terms and conditions of its grant awards with internal management and externally with...
Management is committed to ensuring we are in compliance with all Head Start Reporting required by the Department of Health and Human Services and other regulatory bodies. Management has thoroughly reviewed all the terms and conditions of its grant awards with internal management and externally with the Department of Health and Human Services and other regulatory bodies to ensure proper completion of subaward reports in FSRS, the SF429 and other required reporting. The above noted issue was discovered during the course of the 2024 audit. Upon discovery of the requirement, Management took the above noted steps to become compliant. The finding repeated in 2024 is solely due to the lack of clarity as to the timing of the reporting. Effective to date, all FSRS and applicable SF429 reports have been filed correctly and timely.
Finding 1157927 (2024-001)
Material Weakness 2024
Federal Award Findings and Questioned Costs – Year ending December 31, 2024 Finding 2024-001 – Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the projec...
Federal Award Findings and Questioned Costs – Year ending December 31, 2024 Finding 2024-001 – Internal control deficiency and noncompliance over activities allowed or unallowed, allowable costs/cost principles, reporting, and special tests and provisions related to amounts reimbursed for the project worksheets. Identification of the federal program: Assistance Listing Number 97.036: • COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) • U.S. Department of Homeland Security • Federal award identification number: o Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers • Federal award year – January 20, 2020 to May 11, 2023 • Pass-through entity – Arizona Department of Emergency and Military Affairs (Arizona DEMA) Condition: During the testing over the expenditures included in the project worksheets, management did not have effective internal controls in place to ensure expenditures reported for reimbursement in the FEMA project worksheets were actual paid expenditures. This resulted in an overstatement of the amount reimbursed by FEMA. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Cause: Management did not have effective internal controls in place over the compliance requirements as stated in the criteria or specific requirement section of the report. Effect or potential effect: Management was reimbursed by FEMA for expenditures that were not based on actual paid expenditures which resulted in an overstatement of the amount reimbursed by FEMA. Without sufficient internal controls, other compliance matters could occur in the future. Questioned costs: $1,406,446 – Assistance Listing Number 97.036 – Federal award identification number – Project number 699651 – CV-727 2020 Q2 PPE and Screening Thermometers Questioned costs were computed by calculating the difference between the expenditures submitted for reimbursement in the FEMA project worksheets and the actual paid expenditures. Context: During the testing over the expenditures included in the project worksheets, the auditors obtained a listing of expenditures submitted for reimbursement to FEMA and selected a sample of 67 for testing the compliance requirements. There was 1 out of 67 selections where the expenditure reported for reimbursement was not based on actual paid expenditure. The sampling was a statistically valid sample. Management performed an analysis of all expenditures submitted to FEMA and determined there were 4 expenditures reported for reimbursement in the FEMA project worksheets that were not based on actual paid expenditures resulting in an overstatement of the amount reimbursed by FEMA in the amount of $1,406,446. Management’s control regarding the review of the project worksheet expenditures did not identify this matter when submitting the project worksheet for reimbursement to FEMA. Identification as a repeat finding, if applicable: No. Recommendation: Management should develop and implement effective internal controls to ensure expenditures reported for reimbursement in the FEMA project worksheets are actual paid expenditures. Management should refund the questioned costs to FEMA and work with FEMA to determine the extent of additional courses of action. Views of responsible officials: Management concurs with the audit finding and has implemented a corrective action plan to address the identified issue. Management has notified Arizona DEMA of the identified expenditures and has begun the process of reimbursing the $1,406,446 to FEMA. For all future FEMA project applications, Management will conduct a comprehensive reconciliation process prior to submission. This process will include a detailed review of invoice documentation and verification of payment to ensure compliance with applicable federal requirements. Responsible Parties: Heather Mahoney, Network Controller Anticipated Date of Completion: September 30, 2025
View Audit 369958 Questioned Costs: $1
In order to provide access to high-quality healthcare regardless of one’s ability to pay, all of HealthCore Clinic’s services under its approved scope are offered on a sliding fee schedule. Patients eligible for HCC’s sliding fee scale have their charges discounted based on their slide level as dete...
In order to provide access to high-quality healthcare regardless of one’s ability to pay, all of HealthCore Clinic’s services under its approved scope are offered on a sliding fee schedule. Patients eligible for HCC’s sliding fee scale have their charges discounted based on their slide level as determined by the sliding fee scale assessment. This audit revealed three errors with HCC’s application of the sliding fee scale resulting in incorrect charges or sliding fee writeoffs. During 2024, HCC engaged Forvis Mazars to conduct a revenue cycle assessment and eClinicalWorks for revenue cycle optimization. The revenue cycle review highlighted areas for improvement and the revenue cycle optimization combed through HCC’s settings and workflows to ensure HCC’s EMR was configured and being used correctly. The revenue cycle optimization project helped HCC further automate its sliding fee scale so the correct amounts are automatically adjusted off of eligible claims. HealthCore Clinic will train all relevant staff on its sliding fee scale and how to correctly address and document additional adjustments and reversals. Additional internal audits will be completed to assess adherence to the sliding fee scale and other financial procedures. Contact Person Responsible, Cedric Toney, Chief Financial Officer Anticipated Completion Date: Implementation of Forvis Revenue Cycle Management will be implemented beginning Q4 of 2025. Additional retraining will be completed 12/31/2025; Additional audits will begin 09/30/24 and will be ongoing.
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