Corrective Action Plans

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Finding 2023-004 Noncompliance-Reporting Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: The report for the year ende...
Finding 2023-004 Noncompliance-Reporting Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: The report for the year ended December 31, 2022, was not filed within the required report submission period. Actions Planned in Response to the Finding: Prior to 2022, the Organization barely had the infrastructure to fully run a non-profit organization. The state legislature has been kind to provide funding to build the infrastructure within the organization. The learning curve has been steep but senior management staff and Board members in understanding the federal requirements. With adequate resources, the Organization is on track to accelerate the submission of future audit reports henceforth. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: July 15, 2025
Finding 2023-003 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U.S. Department of Health and Human Services Minnesota Department of Human Services Condition: The sys...
Finding 2023-003 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U.S. Department of Health and Human Services Minnesota Department of Human Services Condition: The system used for processing transactions does not include documentation that transactions have been reviewed for compliance with OMB regulations, before they are charged to a federal grant. Actions Planned in Response to the Finding: With the hiring of a full-time staff accountant within the next 2 weeks, the organization will engage in the design, documentation, and implementation of a system of internal control measures that meet the requirement of OMB Uniform Guidance. The in-house accountant will obtain additional training in Uniform Guidance and federal grant management so that a system of internal control over compliance can be installed. Specifically, the new in-house accountant will ensure that transactions have been reviewed for compliance with OMB regulations before they are charged a federal grant. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025
View Audit 344524 Questioned Costs: $1
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Emplo...
Finding 2023-002 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Employee time sheets do not identify the hours charged to each federal grant, and do not identify hours worked by employees on non-federal grants. Actions Planned in Response to the Finding: The timeline for hiring an in-house accountant is very compressed. The in-house accountant will undergo various training on Uniform Guidance and federal grant management. These training programs will help the organization to create a system of time and effort reporting that will meet the Standards for Documentation of Personnel Expenses included in OMB Uniform Guidance. Specifically, time sheets will be redesigned to ensure that employees record hours charged to each federal grant, any other projects, and administrative time. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: June 30, 2025
View Audit 344524 Questioned Costs: $1
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minn...
To: U.S. Department of Health and Human Services-Passed through Minnesota Department of Human Services RE: Single Audit Corrective Action Plan (CAP) for the fiscal year ended December 31, 2023 Name and address of independent accounting firm: BWK Rogers PC 431 South Seventh Street, Suite 2424 Minneapolis, MN 55415 African American Child Wellness Institute submits the following corrective action plan for the year ended December 31, 2023. Please contact Akinyele Akinsanya at 763-522-0100. Finding 2023-001 Noncompliance-Allowable Costs/Costs Principles Material Weakness ALN 93.958 Block Grants for Community Mental Health Services Pass-through Entity Identification Number GRK 213195 U. S. Department of Health and Human Services Minnesota Department of Human Services Condition: Expenses charged to the federal grant cannot be traced into the Organization’s general ledger. Invoices submitted to the pass-through agency for reimbursement also cannot be traced into the general ledger. Actions Planned in Response to the Finding: It is clear to management that the Organization needs to boost its accounting team to fulfil effective reporting that could easily be traced into the organization’s general ledger. As a result, the organization will recruit and hire a full-time accountant to work with the current team. Further steps may be required including replacing the organization’s current accounting software that will identify and record expenditure specific to each cost centers for each federal grant. The in-house accountant will also be required to obtain additional training in Uniform Guidance and federal grant management and create a system of financial reporting to record expenditure directly to each federal grant award. Official Responsible for Ensuring the CAP: Chief Operating Officer Planned Completion Date for the CAP: March 15, 2025
View Audit 344524 Questioned Costs: $1
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee R...
Finding 2023-004 - Accounting for Grants, Schedule of Expenditures of Federal Awards, and Fiscal Management (Material Weakness) CFDA Title and Number 84.425 Education Stabilization Fund Name of Federal Agency: U.S. Department of Education Criteria: CFR Part 200.508, CFR Part 200.510, Auditee Responsibilities state that the auditee must prepare the Schedule of Expenditures of Federal Awards, which must list individual Federal awards by Federal Agency, including the total Federal awards expended, name of the pass-through entity, CFDA number, and total amount provided to subrecipients. The information contained in the Schedule of Expenditures of Federal Awards should be derived from and relate directly to the underlying accounting and other records used to prepare the financial statements. Condition: The Schedule of Expenditures of Federal Awards (SEFA) was presented for audit with values that were not reconciled with the general ledger. Cause: The District relied on individuals with insufficient training or support to prepare the SEFA and ensure that it was reconciled with general ledger amounts. District management did not have sufficient training or monitoring policies to recognize and correct the deficiency. Effect or Potential Effect: Errors in recording and reporting of revenues and expenditures of federal awards may not be detected and/or corrected. Because the Auditee’s SEFA that was presented for audit was completed incorrectly, and not reconciled to the general ledger, the SEFA was materially misstated, prior to auditors’ correction recommendations. Questioned Cost: No Context: Lack of adequate controls over the Schedule of Expenditures of Federal Awards and related accounting resulted in the following: • SEFA was originally presented for auditors with incorrect information. • Inadequate reconciliation between federal expenditures reported on the GL and the SEFA was presented. Repeat of a Prior-Year Finding: No Recommendation: We recommend that the District establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Internal controls should be designed to prevent, detect, or correct errors in a timely manner by performing periodic reconciliations of the SEFA information to the general ledger throughout the fiscal year. The District should provide appropriate training to staff who are assigned to prepare and review the SEFA. District’s Response: The District acknowledges the deficiencies. Corrective Action Plan: The District will establish policies and procedures to ensure that all Federal awards are identified and reported accurately on future SEFAs. Planned Implementation Date: November 1, 2024 Responsible Person: District Business Manager
Recommendation – We recommend that management revise policies to ensure proper vendor compliance in the future. Views of Responsible Officials and Planned Corrective Actions – Procurement Policy was updated and documentation will be maintained to support vendor verification in the future.
Recommendation – We recommend that management revise policies to ensure proper vendor compliance in the future. Views of Responsible Officials and Planned Corrective Actions – Procurement Policy was updated and documentation will be maintained to support vendor verification in the future.
Recommendation – We recommend that management ensure that all grant reporting is tracked to ensure future compliance. Views of Responsible Officials and Planned Corrective Actions – Reporting requirements will be tracked to support requirements in the future.
Recommendation – We recommend that management ensure that all grant reporting is tracked to ensure future compliance. Views of Responsible Officials and Planned Corrective Actions – Reporting requirements will be tracked to support requirements in the future.
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor be...
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.
View Audit 344486 Questioned Costs: $1
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and ...
Recommendation – We recommend that management ensure that supporting reports are current and accurate for expenses charged to federal programs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Reports will be reviewed and retained to support expenses in the future.
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor be...
Recommendation – We recommend that management ensure that non-payroll costs charged to the program are allowable costs to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – All non-payroll costs are reviewed by a supervisor before being approved. This supervisor review includes which programs are being charged along with other internal coding. Management has emphasized the requirements for supervisors to review invoices to verify programs are being properly charged along with other internal coding.
View Audit 344486 Questioned Costs: $1
Recommendation – We recommend that management ensure that supporting documentation for expenses charged to federal programs be maintained to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Expense documentation will be main...
Recommendation – We recommend that management ensure that supporting documentation for expenses charged to federal programs be maintained to ensure future compliance with applicable federal cost rules. Views of Responsible Officials and Planned Corrective Actions – Expense documentation will be maintained to support expenses in the future.
View Audit 344486 Questioned Costs: $1
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure tha...
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure that access to records continues to be available in instances of system migrations.
A detailed Procurement process currently exists; however, due to staff turnover we were unable locate all the procurement documentation requested. We will continue to reinforce our Procurement policy (detailed below as it relates to documentation) and now require all documentation be stored in a Cen...
A detailed Procurement process currently exists; however, due to staff turnover we were unable locate all the procurement documentation requested. We will continue to reinforce our Procurement policy (detailed below as it relates to documentation) and now require all documentation be stored in a Central location for all applicable Finance staff. (1) Mary's Center will establish and maintain procurement records and files. The physical records will be kept in the office of the Chief Executive Officer and/or Finance office and virtual copies will be stored on the Finance shared folder. (2) Mary's Center will document in the procurement files some form of cost or price analysis made in connection with every procurement action. (3) For any contracted service (other than equipment-specific technical support), Mary's Center procurement file will include: Basis for selection of the contractor, Justification for lack of competition when competitive bids or prices are not obtained, and Basis for award cost or price. (4) These records and files will be kept in accordance with Mary's Center's Record Retention and Document Destruction Policy. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
A detailed Procurement process currently exists; however, due to staff turnover we were unable locate all the procurement documentation requested. We will continue to reinforce our Procurement policy (detailed below as it relates to documentation) and now require all documentation be stored in a Cen...
A detailed Procurement process currently exists; however, due to staff turnover we were unable locate all the procurement documentation requested. We will continue to reinforce our Procurement policy (detailed below as it relates to documentation) and now require all documentation be stored in a Central location for all applicable Finance staff. (1) Mary's Center will establish and maintain procurement records and files. The physical records will be kept in the office of the Chief Executive Officer and/or Finance office and virtual copies will be stored on the Finance shared folder. (2) Mary's Center will document in the procurement files some form of cost or price analysis made in connection with every procurement action. (3) For any contracted service (other than equipment-specific technical support), Mary's Center procurement file will include: Basis for selection of the contractor, Justification for lack of competition when competitive bids or prices are not obtained, and Basis for award cost or price. (4) These records and files will be kept in accordance with Mary's Center's Record Retention and Document Destruction Policy. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to s...
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis...
Management acknowledges that the organization operated with provisional rates in 2023 and did not update to actual indirect rates. Management has calculated actual rates for 2023, will update its NICRA for new provisional rates for 2025 and will institute a policy of updated rates on an annual basis including computing actual indirect cost rates at the conclusion of each audit. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management acknowledged several amendments were made to the UDS tables that support the final calculation that was filed. A lack of document retention resulted in the final amended calculation not being saved in a central shared site that would support the amount filed. In future periods, management...
Management acknowledged several amendments were made to the UDS tables that support the final calculation that was filed. A lack of document retention resulted in the final amended calculation not being saved in a central shared site that would support the amount filed. In future periods, management has processes and procedures in place to require reconciliation and tie-out of supporting documentation to final filings which will alleviate this finding. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel t...
Management has assessed that all supporting documentation that was unable to be provided for audit support was related to transactions that occurred on the legacy accounting system. The legacy accounting system did not allow for centralized/shared data storage, and as a result, it caused personnel to store information in different locations. In May 2023, the organization made the transition to the new accounting system where data can easily be centralized/shared. Management has also implemented policies and procedures that require review of documents within the accounting system prior to approval, thus creating internal controls to prevent a lack of supporting documentation for future reporting periods. Anticipated Completion Date: 3/31/2025 Responsible Contact Person: Tony Ricciardella, Interim Chief Financial Officer and Alison Roca, Controller
View Audit 344384 Questioned Costs: $1
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Activities Allowed or Unallowed, Allowable Cost...
Finding 2023-005 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Activities Allowed or Unallowed, Allowable Cost/Cost Principles Material Weakness in Internal Control over Compliance and Noncompliance Finding Summary: Confluence Health claimed and reported expenditures that contained errors based upon the underlying documentation. Context: A nonstatistical sample of 60, supplies, services, and payroll transactions out of a population of approximately 5,215 totaling $5,006,903 were selected for testing. The sample contained errors in two transactions in which the amounts claimed on the Period 5 report were not supported by payroll records. The amounts claimed not supported by payroll records totaled $89,582 out of a total sample value of $2,615,445. Corrective Action Plan: Confluence Health will tract with separate payroll codes for employee working on federal grants that involve inpatient facing care for the next pandemic to allow for accurate tracking of costs. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place on January 15, 2025.
View Audit 344374 Questioned Costs: $1
Finding 2023-004 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: For certain quarters, the am...
Finding 2023-004 Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: For certain quarters, the amounts reported for net patient revenue were based on gross charges. Additionally, amounts did not agree to the supporting documentation provided. Corrective Action Plan: Confluence Health during the next pandemic will confirm reporting requirements before submitting reporting data. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. The 2023 data was reported at net patient revenue as required by the grant. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: Confluence Health selected option ii to calculat...
Department of Health and Human Services Federal Financial Assistance Listing #93.498 COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Applicable Federal Award Number and Year – Period 5 TIN# 910171250 Finding Summary: Confluence Health selected option ii to calculate lost revenue which consists of a comparison of actual results during the period of availability to a budget approved before March 27, 2020, for the entire period of availability. The budget used in the calculation of lost revenue for quarters in 2021, 2022 and 2023 was not approved prior to March 27, 2020. Corrective Action Plan: Confluence Health during the next pandemic will issue a budget for the entire period required by the grant. Confluence developed a Grant Committee to oversee the reporting guidelines before approving grants. This will make the information for reporting requirements clearer to the organization and Financial Reporting Department. Responsible Individual: Eric Caldwell, VP of Finance is responsible for this corrective action plan that was put into place after the audit.
Audit Finding Reference: 2023-013 Management’s Response and Planned Corrective Action: We currently do not have a grant accountant, but a second pair of eyes would make it easier to manage our federal activities fund. Someone to help reconcile and be a second approver on journal entries + adjus...
Audit Finding Reference: 2023-013 Management’s Response and Planned Corrective Action: We currently do not have a grant accountant, but a second pair of eyes would make it easier to manage our federal activities fund. Someone to help reconcile and be a second approver on journal entries + adjusting entries would be a huge source of stability in this area. Management will work with financial support on ensuring our discrepancies are resolved, while we also revamp and complete new grant related procedures – such as monthly reconciliations, timely monthly reporting of expenses/reimbursement, and filing to sure up and make this fund reviewable/auditable. Management has been working to track in an aggregate format – the status of each grant on a live document – which the board has access too so they can see when a grant falls behind. Unfortunately, when management first identified these issues, some grants were behind in reporting to almost a full calendar year, causing issues with getting the fund caught back up to date. Name of Contact Person and Completion Date: Name: Mackenzie Campbell Anticipated Completion Date – 6/30/25
View Audit 344315 Questioned Costs: $1
The audit report was due to be received by the State of New Jersey and the Federal Clearing House no later than September 30, 2024. As a result, the audit was not submitted timely. Recommendation: The School should alert the auditor about new funding received during the year to give ample time to re...
The audit report was due to be received by the State of New Jersey and the Federal Clearing House no later than September 30, 2024. As a result, the audit was not submitted timely. Recommendation: The School should alert the auditor about new funding received during the year to give ample time to research and prepare. Action Taken: The administrator will monitor the School’s funding that they receive throughout the year and will alert the auditor as soon as they receive funding from a new program. As such, the required corrective actions have been implemented. Implementation Date: Corrective Action Plan has been implemented as of January 7, 2025. Person Responsible for Implementation: Yehuda Neuwirth, the Administrator, is the responsible party for implementation of the CAP. Telephone Number: 908-770-6708.
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a...
Management’s Response (Unaudited) – The Community Development staff is in the process of preparing all outstanding FFATA reports and is developing a compliance checklist to ensure that these reports are filed timely. Corrective Action Plan (Unaudited) – The Community Development staff will create a checklist to ensure that these reports are filed timely once the agreements with the subrecipients have been approved.
Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management ...
Construction projects for A+ Arts were facilitated by the management company with approval from the Board of Directors. Although the likelihood of additional construction projects being done in the future using Federal dollars since ESSER funds are no longer available is very remote, the management company is aware of the prevailing wage and certified payroll requirement and will make sure any future projects adhere to these requirements.
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