Corrective Action Plans

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The Government concurs with the finding. OTAG established a centralized SF-270 tracking log and implemented reconciliation procedures to ensure completeness and accuracy of cash drawdowns prior to submission.
The Government concurs with the finding. OTAG established a centralized SF-270 tracking log and implemented reconciliation procedures to ensure completeness and accuracy of cash drawdowns prior to submission.
The Government concurs with the finding. OTAG implemented enhanced payroll controls including a dual manual and electronic timesheet system, verification of pay rates against NOPA forms, and separation controls to discontinue benefit charges upon employee separation or retirement.
The Government concurs with the finding. OTAG implemented enhanced payroll controls including a dual manual and electronic timesheet system, verification of pay rates against NOPA forms, and separation controls to discontinue benefit charges upon employee separation or retirement.
The Department of Health will create an internal control procedure to indicate proper review and approval of the SF-425 excel print out from the electronic USDA FPRS System.
The Department of Health will create an internal control procedure to indicate proper review and approval of the SF-425 excel print out from the electronic USDA FPRS System.
The Department of Health concurs with the Auditor’s findings and recommendations. To ensure that the WIC program is included in all processes and receive all documents and correspondence relating to WIC Special Funding as a secondary oversight of the transactions.
The Department of Health concurs with the Auditor’s findings and recommendations. To ensure that the WIC program is included in all processes and receive all documents and correspondence relating to WIC Special Funding as a secondary oversight of the transactions.
DOH revised drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted internally or externally.
DOH revised drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted internally or externally.
The Department of Health (DOH) concurs with the auditor’s findings and recommendations. The DOH will work closely with DPP to improve their internal controls to ensure adherence to federal regulations relating to the procurement of goods and services. DOH will encourage DPP to review current records...
The Department of Health (DOH) concurs with the auditor’s findings and recommendations. The DOH will work closely with DPP to improve their internal controls to ensure adherence to federal regulations relating to the procurement of goods and services. DOH will encourage DPP to review current records retention policies. To address this, there will be timely coordination and communication with DPP and the Department of Health for the handling and managing of procurement tasks.
The Department of Health concurs with the auditor’s findings and recommendations. To address this, DOH revised drawdown Standard Operating Procedures (SOPs) for Fiscal Year 2025 to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted at c...
The Department of Health concurs with the auditor’s findings and recommendations. To address this, DOH revised drawdown Standard Operating Procedures (SOPs) for Fiscal Year 2025 to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted at certification level of certification. DOH have also incorporated this updated procedure into Federal Grants update trainings and made it accessible to all staff on Business Process Improvement SharePoint site.
VIDE acknowledges the audit finding regarding the Child Nutrition Cluster Period of Performance and concurs with the recommendation. We recognize that while the cost was incurred during the valid period, the liquidation payment occurred 18 days past the allowable deadline. To prevent recurrence, VID...
VIDE acknowledges the audit finding regarding the Child Nutrition Cluster Period of Performance and concurs with the recommendation. We recognize that while the cost was incurred during the valid period, the liquidation payment occurred 18 days past the allowable deadline. To prevent recurrence, VIDE will enforce strict protocols for grant closeout and liquidation. To achieve this, VIDE will establish an internal hard stop deadline for invoice submission, requiring that all invoices for expiring grants be submitted to the Fiscal Office no later than 45 days prior to the federal liquidation deadline to provide a necessary buffer to resolve vendor disputes and process payments before the federal cutoff. Additionally, the State Director of Special Nutrition Programs will implement a scheduled notification system to issue closeout alerts to relevant program staff and fiscal support personnel at 90, 60, and 30 days prior to the liquidation deadline, which will trigger the immediate review of open encumbrances and the expediting of pending invoices to ensure the internal hard stop deadline is met. Furthermore, for any valid expenditures remaining unpaid within 30 days of the liquidation deadline, the Fiscal Office will generate a priority payment list and transmit it to the Department of Finance with a high-priority flag to ensure these specific vouchers are processed before the grant period closes. Finally, the Federal Grants Director and the Deputy Commissioner of Fiscal and Administrative Services will review the Grant Expiration Report monthly to identify grants approaching their liquidation deadline and ensure the internal cut-off dates are being adhered to.
VIDE acknowledges the audit finding regarding the Child Nutrition Cluster payroll and concurs with the recommendation. Because this is a recurring finding from prior year 2022-023, VIDE will develop and institute stricter fiscal controls to address the root causes of documentation and allocation dis...
VIDE acknowledges the audit finding regarding the Child Nutrition Cluster payroll and concurs with the recommendation. Because this is a recurring finding from prior year 2022-023, VIDE will develop and institute stricter fiscal controls to address the root causes of documentation and allocation discrepancies for this program. To prevent discrepancies including unapproved project codes and pay rate mismatches between NOPAs and payroll registers, the Fiscal Team will take the lead in preparing and maintaining the official staffing list for federally funded personnel within this program, an effort that involves reviewing the grant application for all positions and informing HR of required action entries. Furthermore, VIDE will implement a control where the Budget Team and the Deputy Commissioner of Fiscal and Administrative Services will review and approve every personnel action in the ERP prior to the NOPA being executed to match the action against the approved grant application or staffing list and ensure the project code and pay rate are accurate before the payroll cycle begins. To address the unavailability of timesheets, the program will implement a strict reconciliation protocol wherein the Program Director or designee will verify that the payroll register aligns with approved timesheets prior to performing the drawdown and posting. These timesheets will then be digitally archived in a centralized SharePoint repository organized by pay period to ensure that time and effort documentation is securely retained and immediately available for audit review. To support these new protocols, mandatory training will be conducted for relevant staff and supervisors on these new timesheet procedures, federal time and effort requirements, and the new NOPA reconciliation workflow. Finally, the Office of Fiscal and Administrative Services will conduct monthly spot checks of the SharePoint repository and ERP logs to measure the effectiveness of these controls.
The Program has drafted a Standard Operating Procedures and Procedures (SOPP) document to outline the EBT Reconciliation process, once the internal review is completed, it will be submitted to the cognizant agency for approval. Additionally, onboarding a Director of Support Services will provide the...
The Program has drafted a Standard Operating Procedures and Procedures (SOPP) document to outline the EBT Reconciliation process, once the internal review is completed, it will be submitted to the cognizant agency for approval. Additionally, onboarding a Director of Support Services will provide the required compliance and oversight for the EBT card security.
While the ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a ...
While the ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Director of Audit and Compliance has been onboarded. Once the audit team is developed, support and compliance monitoring will be provided to ensure compliance.
The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts reconcile payroll, and ...
The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts reconcile payroll, and a workflow ensures accurate NOPA listings for payroll purposes. Additionally, in order to ensure that Notices of Personnel Actions are updated on a timely basis, ensuring that salaries are charged to the respective account, DHS has implemented the following process: Provisional Payroll Codes are requested (1) Provisional Payroll Codes are requested prior to the close of the Fiscal Year by the Department of Finance through the Office of Management and Budget through the established process.(2)Once the codes are received, the Division of Human Resources will update the most current Personnel Distribution Sheets to reflect active employees. (3) The sheets will be submitted to Fiscal for certification by the CFO. (4) NOPA's are updated with the provisional codes.
Implement procedures to ensure supervisors’ approval of all federally funded timecards by a set deadline. HR will run a “missing timecard report” each pay cycle to ensure time cards are properly completed. Will conduct annual training on federal compliance requirements.
Implement procedures to ensure supervisors’ approval of all federally funded timecards by a set deadline. HR will run a “missing timecard report” each pay cycle to ensure time cards are properly completed. Will conduct annual training on federal compliance requirements.
The AAIHB missed the filing deadline for the FY 2023 Federal Financial Reports for seven different reports due during the 2023 FY. The AAIHB has filed the FY 2023 Federal Financial Reports as of the date this report is dated. The AAIHB will review and revise its internal review processes to ensure f...
The AAIHB missed the filing deadline for the FY 2023 Federal Financial Reports for seven different reports due during the 2023 FY. The AAIHB has filed the FY 2023 Federal Financial Reports as of the date this report is dated. The AAIHB will review and revise its internal review processes to ensure future Federal Financial Reports are completed and filed in a timely manner. Corrective action plan timeline is to submit FY 2024 and FY 2025 Federal Financial Reports within the required timeline. Designation of Employee Position Responsible for Meeting Deadline Executive Director and Finance Officer
We acknowledge that the purchase of gift cards was not an allowable expense under federal grant guidelines. During the COVID-19 pandemic, our staff were tasked with responding to urgent and overwhelming public health demands, particularly as the New Mexico Department of Health became overextended. T...
We acknowledge that the purchase of gift cards was not an allowable expense under federal grant guidelines. During the COVID-19 pandemic, our staff were tasked with responding to urgent and overwhelming public health demands, particularly as the New Mexico Department of Health became overextended. To recognize staff who went above and beyond to ensure timely case reporting and investigations for tribal communities, gift cards were used as a form of appreciation. Moving forward, we will ensure full compliance with federal grant requirements. Specifically: 1. We will adhere strictly to the cost principles and allowability guidance outlined in federal regulations and the terms of each Notice of Award. 2. In instances where the allowability of an expense is unclear, we will proactively seek guidance and written approval from our Federal Grant Management Officer before incurring the cost. 3. We will provide refresher training to program and fiscal staff on allowable costs under federal awards to prevent recurrence of similar findings. These corrective actions will ensure future expenditures are fully compliant with federal guidelines and that staff recognition practices remain appropriate, allowable, and consistent with award terms. • Immediate (Already in Effect): Ceased use of gift cards and other unallowable incentives. • Within 30 Days: Finance and program leadership will review current grant guidance and distribute a written summary of allowable/unallowable costs to all program managers. • Within 60 Days: Refresher training on federal cost principles (2 CFR 200) and Notice of Award guidance will be provided to all program and fiscal staff. • Ongoing: When ambiguity exists regarding allowable costs, staff will consult with the Federal Grant Management Officer prior to obligating or expending funds. Designation of Employee Position Responsible for Meeting Deadline Program Managers/Directors, Finance Officer, and Accounting Manager.
The AAIHB has missed the filing deadline for the FY 2023 Data Collection Form. The AAIHB will file the FY 2023 Data Collection Form within 30 days. The AAIHB will review and revise its internal review processes to ensure future Data Collection Forms are completed and filed in a timely manner. Correc...
The AAIHB has missed the filing deadline for the FY 2023 Data Collection Form. The AAIHB will file the FY 2023 Data Collection Form within 30 days. The AAIHB will review and revise its internal review processes to ensure future Data Collection Forms are completed and filed in a timely manner. Corrective action plan timeline is to submit FY 2024 audit and data collection forms within 30 days. Executive Director and Finance Officer
FINDING 2023-005 – Allowable Costs: Significant Deficiency over Internal Controls over Compliance Condition/context – In a sample of 25 payroll disbursements and 25 non-payroll disbursements, it was found that time and effort for 11 salaried employees were not supported by documentation for the allo...
FINDING 2023-005 – Allowable Costs: Significant Deficiency over Internal Controls over Compliance Condition/context – In a sample of 25 payroll disbursements and 25 non-payroll disbursements, it was found that time and effort for 11 salaried employees were not supported by documentation for the allocation. The sample of non-payroll disbursements had 4 transactions without the documented methodology or support for the allocation between programs. Corrective Action Plan: • Implemented a formal time and effort reporting process (Allocation Method) for all employees whose salaries are charged to more than one funding source, in compliance with federal requirements. • Developing and enforcing a standardized cost allocation methodology for shared non-payroll expenses, ensuring documentation is retained for all allocation decisions. • Training program and finance staff on allowability and allocation requirements under 2 CFR Part 200. • Periodically reviewing cost allocations to ensure continued reasonableness and compliance with applicable grant terms. • Policy and Procedures updated/Staff Training on new Timesheet processes Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: Corrected: September 2025
FINDING 2023-004 – Cash Management: Significant Deficiency over Internal Controls over Compliance Condition/context – The Organization draws down funds based on a profit and loss report to signify the excess expenses incurred over the grant revenue. The Organization identifies themselves as on the r...
FINDING 2023-004 – Cash Management: Significant Deficiency over Internal Controls over Compliance Condition/context – The Organization draws down funds based on a profit and loss report to signify the excess expenses incurred over the grant revenue. The Organization identifies themselves as on the reimbursement method. The request for reimbursements are not reviewed to ensure amounts have been paid with the Organization’s funds prior to the reimbursement request because certain expense codes do not relate to expenses paid but rather expenses incurred. Additionally, the frequency of draws during mid-months creates potential for errors when the reporting period has not been reconciled and therefore coded expenses are subject to change. Corrective Action Plan: Policy & Procedure adjustments within Cash Management: • Reimbursement requests will be based solely on expenditures that have been paid using the Organization’s funds. • Financial reports used to prepare draw requests are reconciled to ensure expense coding accuracy. • Expense codes distinguish clearly between paid and accrued expenditures. • Mid-month draws are avoided or subject to additional reconciliation controls prior to submission. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: December 31, 2026
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months
Fusion’s Procurement Coordinator and Accounts Payable began reviewing in 2024 websites for vendors that are debarred from doing business using Federal Funding http://www.sam.gov/ and State/City Funding https://egov.maryland.gov/BusinessExpress/EntitySearch. Fusion has moved to implementing the scree...
Fusion’s Procurement Coordinator and Accounts Payable began reviewing in 2024 websites for vendors that are debarred from doing business using Federal Funding http://www.sam.gov/ and State/City Funding https://egov.maryland.gov/BusinessExpress/EntitySearch. Fusion has moved to implementing the screening of all payment requests using this method. Planned Implementation Date of Corrective Action Plan – Parts of plan implemented as of January 1, 2024. The plan will be fully implemented by January 1, 2025.
Although Fusion reviews all backup submitted to funders for reimbursement, where our process has fallen short is in the corrections to the finance reports internally to match what is submitted in real time. In 2024 Fusion added additional staff review to invoice submission and financial reports. Thi...
Although Fusion reviews all backup submitted to funders for reimbursement, where our process has fallen short is in the corrections to the finance reports internally to match what is submitted in real time. In 2024 Fusion added additional staff review to invoice submission and financial reports. This will be fully corrected with the new finance system going online in Q1 of 2025 and additional process added by our AR staff reviewing expenses when invoices are submitted to ensure accuracy.
We also added a Procurement Coordinator as of May 9, 2023. We have overhauled our Procurement Policies and implemented changes to be in compliance beginning January 1, 2024. This process is documented as we obtain the various quotes from vendors over dollar amount thresholds and have implemented a b...
We also added a Procurement Coordinator as of May 9, 2023. We have overhauled our Procurement Policies and implemented changes to be in compliance beginning January 1, 2024. This process is documented as we obtain the various quotes from vendors over dollar amount thresholds and have implemented a bidding process for contracts over a larger threshold. Documentation of such is maintained in the vendor files. Additionally, the purchasing coordinator attends partner engagement coordinator meetings regularly to discuss purchases that are subject to increased scrutiny in order to improve cross departmental communication. A standardized bid evaluation policies and procedures document will be created to give clear direction to internal stakeholders. A comprehensive training course will also be created and made available to all parties involved in the bid evaluation process.
Fusion added a Payroll Coordinator to our staff who has improved the payroll process and is in the process of streamlining how payroll gets allocated in our finance system. HR now approves all payroll before it is submitted. Fusion is also working to implement a new Payroll system in 2025 that will ...
Fusion added a Payroll Coordinator to our staff who has improved the payroll process and is in the process of streamlining how payroll gets allocated in our finance system. HR now approves all payroll before it is submitted. Fusion is also working to implement a new Payroll system in 2025 that will further streamline this process.
We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system...
We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system. The creation and implementation of a google submission for disbursements has added the necessary review and approval of all expenses. Additional Partner Engagement Coordinator review of requests and backup documentation has been implemented for weekly approval of disbursements.
Personnel Responsible for Corrective Action: Jim Keeney, CFO, Eljana Kaziaj, Controller, Ro White, Grant Manager Anticipated Completion Date: Completed. Corrective Action Plan: Management acknowledges the recommendation and will implement the policy and procedure for timely federal grant reports. Th...
Personnel Responsible for Corrective Action: Jim Keeney, CFO, Eljana Kaziaj, Controller, Ro White, Grant Manager Anticipated Completion Date: Completed. Corrective Action Plan: Management acknowledges the recommendation and will implement the policy and procedure for timely federal grant reports. The additional accounting resources will now ensure proper oversight of the process. Reports will be timely and reviewed/approved by the CFO.
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