Corrective Action Plans

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Finding 572058 (2023-004)
Significant Deficiency 2023
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develo...
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develop written policies requiring cash disbursements to follow a clear, tiered approval process based on the amount. For example: • Up to a set threshold: Department manager approval • Above threshold: Department manager plus finance director/CFO approval • High-value disbursements: Additional executive or board-level approval. Requiring supporting documents (invoices, contracts, purchase orders) for every disbursement. Approvers must verify accuracy and completeness before authorizing payment. If there are any questions regarding this plan, please e-mail Yumiko Molden at ymolden@waikikihealth.org. Sincerely, Yumiko Molden CFO
Finding 572057 (2023-003)
Significant Deficiency 2023
Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directl...
Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.
Finding 2023-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Cindy Sharp, Deputy Finance Director Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will...
Finding 2023-004 Late Reporting and Noncompliance with Reporting Requirements Name of Contact Person: Cindy Sharp, Deputy Finance Director Corrective Action Plan: Management will carefully review report deadlines and ensure that submission of reports is made before they are due. Management will also carefully review reporting requirements and ensure that requirements are adhered to. This includes the following programs: US Department of the Interior, US Department of the Treasury Federal Payment in Lieu of Taxes (PILT) and Coronavirus State and Local Fiscal Recovery Funds. Proposed Completion Date: Fiscal year 2024.
Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing ...
Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing Number 19.510 and 93.567 Criteria: The Code of Federal Regulations (CFR) Section 200.510(b) states in part, “The auditee must also prepare a schedule of federal expenditures for the period covered by the auditee’s consolidated financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Also, in accordance with CFR Section 200.302(b) - Financial Management, the auditees financial management system must provide 1) identification of all federal awards received and expended; 2) accurate, current, and complete disclosure of the financial results of each federal award or program; 3) records that identify adequately the source and application of funds for federally‐funded activities; 4) effective control over, and accountability for, all funds, property, and other assets; 5) comparison of expenditures with budget amounts for each Federal award; 6) written procedures to implement the requirements of section 200.305 and; 7) written procedures for determining the allowability of costs in accordance with Subpart E and the terms and conditions of the Federal award. Recipients of federal awards must submit accurate, complete and timely financial and performance reports. The Organization should have internal controls designed to ensure compliance with those provisions. The Organization should retain sufficient documentation such as invoice and allocation support for expenditures to retain documentation for audit purposes. Condition: During detail testing of expenditures, it was noted that the Organization did not maintain adequate documentation to support how certain costs were allocated to the federal program. Several transactions lacked sufficient detail, such as invoice or expense reimbursement form. Several expenditures selected for testing did not obtain sufficient approval by an individual at the Organization. It was noted that quarterly reports provided to the federal program were not reviewed by an individual at the Organization prior to submission to ensure accurate report of expenditures. Cause: The Organization does not have an adequate system in place to ensure quarterly reports have sufficient supporting documentation, proper approval/review, and accurate reporting prior to submission. Responsibilities for expenditure tracking were not clearly assigned, and there was no formal review process in place. The Organization is not following their Document Retention Policy. Effect: The effect of this condition increases the possibility that quarterly financial reports are misstated or inaccurate and increase the risk of noncompliance with federal requirements. The effect of this condition also increases the risk that expenditures are unallowable per the grant, federal regulations, or cost principles due to the insufficient support of proper approval retained. Questioned costs: None Repeat Finding: Yes - 2022-004 Recommendation: Policies and procedures should be in place to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved and reviewed. A formal review process should be established to ensure compliance. The Organization should following the Document Retention Policy that was put in place and required by law. Management Response: There is no disagreement with the audit finding. Management has taken steps to address these deficiencies in fiscal year 2025 including but not limited to: the implementation of a new accounting system that includes document retention and review/sign off logs, the engagement of a third-party CPA firm to provide client advisory and accounting services and the review and updating of accounting policies and procedures for best practices. Responsible Person for Corrective Action Plan: Marc Hall, Director of Operations Implementation Date for Corrective Action Plan: Fiscal year 2025
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
View Audit 362889 Questioned Costs: $1
GLRC is currently experiencing a delay in completion of their required audit which is causing us to miss filing to the single audit clearinghouse by June 30, 2025. We will be out of compliance for the 2024 audit but will be cathing up for meeting the June 2026 deadline for the 2025 audit. GLRC will ...
GLRC is currently experiencing a delay in completion of their required audit which is causing us to miss filing to the single audit clearinghouse by June 30, 2025. We will be out of compliance for the 2024 audit but will be cathing up for meeting the June 2026 deadline for the 2025 audit. GLRC will be engaging a new audit firm for the upcoming fiscal year. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: GLRC expects to be caught up for June 30, 2026
Finding Summary: The District was required to have their first single audit for the year ending June 30, 2023. They did not submit its audited financial statements and federal program data to the Federal Audit Clearinghouse by the due date of March 31, 2024. Responsible Individuals: Peter McElroy, D...
Finding Summary: The District was required to have their first single audit for the year ending June 30, 2023. They did not submit its audited financial statements and federal program data to the Federal Audit Clearinghouse by the due date of March 31, 2024. Responsible Individuals: Peter McElroy, Director. Corrective Action Plan: The District has experienced significant turnover in management positions. They have recently employed a new Director. As a result, the District will have more timely filings going forward, if required.
Finding 571810 (2023-001)
Significant Deficiency 2023
Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate t...
Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate that the policies and procedures will be completed and approved by June 30, 2026. Contact Person: Julie Hebert, Finance Director
Finding 571807 (2023-002)
Significant Deficiency 2023
Correction Action Plan – Finding 2023-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: The Treasurer/Collect...
Correction Action Plan – Finding 2023-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: The Treasurer/Collector’s office has taken over most of the school’s payroll in FY25 and is working with our new School Business Manager to correct all of the timesheet inadequacies. We anticipate that all major inefficiencies within school payroll will be eradicated by December 31, 2025. The Town is also shifting to a new payroll system which will properly report time and attendance. Contact Person: Julie Hebert, Finance Director; Janet Jannell, Treasurer/Collector; Kaitlyn Shelar, School Business Manager
Finding 571806 (2023-007)
Significant Deficiency 2023
The annual budget for fiscal year 2023-2024 was submitted late due to a computer crash. The computer had to be repaired so the report could not be completed until the computer was repaired and returned. All reports will be initialed and dated to show independent review and will be timely submitted f...
The annual budget for fiscal year 2023-2024 was submitted late due to a computer crash. The computer had to be repaired so the report could not be completed until the computer was repaired and returned. All reports will be initialed and dated to show independent review and will be timely submitted from now on.
Finding 571785 (2023-003)
Significant Deficiency 2023
We will develop a checklist to ensure all documentation and eligibility requirements are met. We will review monthly with the teams to validate all documentation. During this review we will also make sure that all program directors are trained on the proper documentation and eligibility requirements...
We will develop a checklist to ensure all documentation and eligibility requirements are met. We will review monthly with the teams to validate all documentation. During this review we will also make sure that all program directors are trained on the proper documentation and eligibility requirements. Reasonable completion date: 06/30/25 Responsible Party: Erin Lasiter, VP Programs/Operations
Management’s Response/Corrective Action Plan (Unaudited): Management agrees to address the finding. Management will implement procedures to obtain certification from vendors stating their organization is not suspended, debarred, or otherwise excluded from participating in federal assistance programs...
Management’s Response/Corrective Action Plan (Unaudited): Management agrees to address the finding. Management will implement procedures to obtain certification from vendors stating their organization is not suspended, debarred, or otherwise excluded from participating in federal assistance programs. The Organization will also retain supporting documentation for review. Planned Completion Date: June 2025 Contact Person Responsible for Correction Action: Adam Courtney
Management’s Response/Corrective Action Plan (Unaudited): Management agrees with the findings and implemented corrective action after the 2022 Audit. The Organization has designated a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports p...
Management’s Response/Corrective Action Plan (Unaudited): Management agrees with the findings and implemented corrective action after the 2022 Audit. The Organization has designated a knowledgeable person separate from the preparer of the reports to review all expenditures that go into the reports prior to submission and will retain documentation of such review. Planned Completion Date: April 2024 Contact Person Responsible for Correction Action: Adam Courtney
Management’s Response/Corrective Action Plan (Unaudited): Management agrees to address the finding in its capital asset tracking schedule. The Organization and its outsourced accountant have discussed the finding and will implement procedures on tracking capital assets funded with federal grants. Th...
Management’s Response/Corrective Action Plan (Unaudited): Management agrees to address the finding in its capital asset tracking schedule. The Organization and its outsourced accountant have discussed the finding and will implement procedures on tracking capital assets funded with federal grants. This tracking will be incorporated to the current capital asset tracking schedule. Planned Completion Date: June 2025 Contact Person Responsible for Correction Action: Adam Courtney
Finding 2023-005: Restricted Net Assets Restatement - Recommendation: We recommend implementing enhanced controls to ensure all donor and grant agreements are reviewed for restrictions upon receipt and at year-end. Restricted net asset balances should be reconciled regularly to ensure accurate finan...
Finding 2023-005: Restricted Net Assets Restatement - Recommendation: We recommend implementing enhanced controls to ensure all donor and grant agreements are reviewed for restrictions upon receipt and at year-end. Restricted net asset balances should be reconciled regularly to ensure accurate financial reporting. Management’s Response: We agree with the recommendation. Management will implement enhanced controls to ensure all donor and grant agreements are reviewed for restrictions both upon receipt and as part of the year-end close process. In addition, restricted net asset balances will be reviewed and reconciled on a regular basis to ensure accurate classification and financial reporting in accordance with donor intent and applicable accounting standards.
Finding 2023-004: Late Submission of the Single Audit Reporting Package to the Federal Audit Clearinghouse - Recommendation: We recommend the Organization implement procedures to ensure the accounting records and information pertaining to the audit process are finalized and made available to the aud...
Finding 2023-004: Late Submission of the Single Audit Reporting Package to the Federal Audit Clearinghouse - Recommendation: We recommend the Organization implement procedures to ensure the accounting records and information pertaining to the audit process are finalized and made available to the auditors to allow adequate time to complete the audit prior to the statutory deadline. Management’s Response: We agree with the recommendation. Management will implement procedures to ensure accounting records and supporting documentation are finalized in a timely manner and made available to the auditors early in the audit process. This includes establishing internal deadlines for closing the books, preparing audit schedules, and coordinating with relevant departments to allow sufficient time for audit completion prior to the statutory deadline.
Finding 2023-003: Overstatement of Gross Revenue and Contractual Allowances in the General Ledger - Recommendation: We recommend the Organization improve its reconciliation procedures between the PSR reports, billing system, and general ledger to ensure both gross revenue and contractual allowances ...
Finding 2023-003: Overstatement of Gross Revenue and Contractual Allowances in the General Ledger - Recommendation: We recommend the Organization improve its reconciliation procedures between the PSR reports, billing system, and general ledger to ensure both gross revenue and contractual allowances are accurately reported. Management’s Response: We agree with the recommendation. Management will enhance reconciliation procedures between the PSR reports, billing system, and general ledger to ensure gross revenue and contractual allowances are accurately recorded. This will include regular reconciliation schedules, improved documentation of adjustments, and coordination between finance and program staff to ensure consistency and accuracy in financial reporting.
Finding 2023-002: Federal Expenditures Reported Under Incorrect Assistance Listing Number (ALN) - Recommendation: We recommend the Organization establish a formal review process for SEFA preparation to ensure expenditures are accurately reported under the correct ALNs. Management’s Response: We agre...
Finding 2023-002: Federal Expenditures Reported Under Incorrect Assistance Listing Number (ALN) - Recommendation: We recommend the Organization establish a formal review process for SEFA preparation to ensure expenditures are accurately reported under the correct ALNs. Management’s Response: We agree with the recommendation. Management will establish a formal review process for the preparation of the SEFA to ensure federal expenditures are accurately reported under the correct Assistance Listing Numbers (ALNs). This process will include a detailed review of grant agreements, coordination with program staff, and reconciliation to the general ledger to help ensure accuracy and compliance with federal reporting requirements.
Finding 2023-001: Year-End Close and Review - Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any large outstanding items, and reviewing details of account balances...
Finding 2023-001: Year-End Close and Review - Recommendation: We recommend the Organization perform a thorough year-end close and review by reviewing current balances compared to the prior year, reviewing bank reconciliations for any large outstanding items, and reviewing details of account balances, as necessary, prior to providing the trial balance for audit. Management’s Response: We agree with the recommendation and recognize the importance of a thorough year-end close and review process. Management will implement procedures to compare current year account balances to the prior year, ensure all bank reconciliations are completed and reviewed for significant outstanding items, and analyze account details as needed. These steps will be incorporated into our year-end closing checklist to help ensure the accuracy and completeness of the trial balance prior to submission for audit.
Management recruited a new Chief Financial Officer who started in January 2024. Management is fully committed to making any necessary changes to its financial reporting policies and procedures to comply with independent auditing of financial statements being completed in accordance with Federal and ...
Management recruited a new Chief Financial Officer who started in January 2024. Management is fully committed to making any necessary changes to its financial reporting policies and procedures to comply with independent auditing of financial statements being completed in accordance with Federal and State Regulations, as well as with commonly accepted industry standards.
Finding 571681 (2023-003)
Significant Deficiency 2023
FINDING 2023-003 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Procurement – Suspension and D...
FINDING 2023-003 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Procurement – Suspension and Debarment Audit Findings: Significant Deficiency, Noncompliance Condition: The City of Bloomington could not provide documentation to support that vendors procured under CSLFRF funding were not suspended or debarred. Context: In a sample of five vendors with aggregate disbursements for FY2023 above the $25,000 covered transaction threshold, Crowe noted for each selection that the City had not completed a check for suspension and debarment nor had had they obtained a contract clause from the vendor/service provider certifying that they were not suspended and/or debarred. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and has formulated a procurement policy specific to federal awards to ensure all necessary requirements are met moving forward, which includes checking whether a vendor is suspended and/or debarred prior to entering into a contract with said vendor. Responsible party and timeline for completion: The City’s Controller will oversee the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.
Finding 571680 (2023-002)
Significant Deficiency 2023
FINDING 2023-002 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Sign...
FINDING 2023-002 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficiency Condition: City of Bloomington completed quarterly reporting in a timely manner substantiated by the City’s expenditure detail. However, management could not differentiate between subrecipients and standard vendor purchases. Context: During our testing procedures over CSLFRF reporting, we noted that segregation of duties is not present in the Federal reporting process. The Deputy Controller prepared and submitted the reports without a secondary review taking place. As a result, the City did not report expenditures for the grant that were consistent with the expenditures reported on the SEFA and could not properly identify subrecipient expenditures. Views of Responsible Officials and Planned Corrective Actions: Management will develop an internal controls process to ensure that there’s segregation of duties within the reporting process for federal programs. Responsible party and timeline for completion: The City’s Controller will oversee the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.
Finding 2023-001 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Subrecipient Monitoring Audit ...
Finding 2023-001 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Subrecipient Monitoring Audit Findings: Material Weakness, Noncompliance Condition: The City of Bloomington was unable to identify subrecipients of CSLFRF funding for the purposes of financial reporting and compliance with requirements under 2 CFR 200.332. The City could not distinguish between a subrecipient and a general vendor. Management misreported subrecipient activity on the SEFA, failed to include required contractual language for subrecipient awards in executed agreements, and did not perform monitoring procedures over the subrecipients management identified during audit testing procedures. Context: The 10 subrecipients represent approximately 18%, $1,025,070, of the total award expenditures of $5,590,828, in 2023. The condition reported was prevalent for each subrecipient participating in the award. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will draft a policy and develop an internal controls process regarding subawards and the monitoring of subrecipients to ensure the compliance requirements are met. Responsible party and timeline for completion: The City’s Controller will be responsible for overseeing the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.
Condition: Single Audit Report should have been submitted the earlier of 30 days after receipt of the auditor’s report or 9 months after the end of the Organization’s year end. Criteria: Uniform Guidance requires organizations that expend $750,000 and greater of federal funds to conduct a Single Au...
Condition: Single Audit Report should have been submitted the earlier of 30 days after receipt of the auditor’s report or 9 months after the end of the Organization’s year end. Criteria: Uniform Guidance requires organizations that expend $750,000 and greater of federal funds to conduct a Single Audit and submit the data collection form to the Federal Audit Clearinghouse no later than nine months after year end. Cause: The Organization expended federal funds over $750,000 requiring a Single Audit to be performed. Because of the misunderstanding in the filing requirement and due to shortage of staff, the Organization failed to meet the Uniform Guidance requirement of submitting the Single Audit report nine months after year end. Effect: The Organization's Single Audit report was not submitted timely resulting in noncompliance with requirements under the Uniform Guidance (2 CFR Part 200). Furthermore, missing the deadline can lead to an organization being considered "high risk" in the following year and subject to additional testing, potentially incurring extra audit expenses. Recommendation: The Organization should implement policies and procedures that would guide personnel to prepare timely for the Single Audit, conduct the audit earlier in the year, and submit the report no later than nine months after year end. Views of Responsible Officials and Planned Corrective Actions: Given that the Organization’s accounting team is relatively small, consisting of only three staff members, the Organization has determined that initiating the audit in July-no later than August- will be the most feasible approach moving forward. This timing aligns with the fiscal year calendars of the majority of their funding partners, which will provide the Organization with an extended period to dedicate their full attention to the audit process as the new fiscal year begins. Name of Contact Person Responsible for Corrective Plan: Denise Villamil, Executive Director Anticipated Completion Date: June 30, 2025
The District will work with the Auditors to get the District caught up and ensure audits are submitted on time. There were no prior year findings in the Schedule of Findings and Questioned Costs in our audit for the year ended June 30, 2021.
The District will work with the Auditors to get the District caught up and ensure audits are submitted on time. There were no prior year findings in the Schedule of Findings and Questioned Costs in our audit for the year ended June 30, 2021.
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