Corrective Action Plans

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U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to suppo...
U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.
View Audit 372833 Questioned Costs: $1
Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages Management Response Corrective Action:FNCH recognizes the critical importance of establishing robust internal...
Recommendation We recommend that management enhance its internal control structure, including financial close and reporting, to ensure timely filing of future Single Audit reporting packages Management Response Corrective Action:FNCH recognizes the critical importance of establishing robust internal controls to guarantee the timely preparation and accurate submission of reports and records for audit purposes, particularly in alignment with the requirements outlined in 2 CFR 200.512. To effectively implement these internal controls, management will enforce procedures for the timely preparation of all necessary reports and records, including the Schedule of Expenditures of Federal Awards (SEFA). This will not only facilitate smoother audit processes but also ensure adherence to the 2 CFR 200.512. Management will train staff and establish timelines and responsibilities for report preparation and documentation to enhance compliance and streamline overall operations. Expected Outcome: -On-time Single Audit filings in compliance with federal rules. -Clear visibility and accountability for deadlines. -Reduced risk of penalties and funding delays. -Greater confidence from agencies and stakeholders. Due Date of Completion: 3 days following issuance of the audit report Responsible Party(ies): CEO, CFO
Grants are looked at for compliance and ensures proper spending and documentation.
Grants are looked at for compliance and ensures proper spending and documentation.
Finding Reference Number: 2023-004 Description of Finding: The Semi-annual Federal Financial Reports (SF-425) was not submitted timely. Statement of Concurrence or Nonconcurrence: Authority staff agrees to the finding as described. Corrective Action: • An internal grant manager has been appointed to...
Finding Reference Number: 2023-004 Description of Finding: The Semi-annual Federal Financial Reports (SF-425) was not submitted timely. Statement of Concurrence or Nonconcurrence: Authority staff agrees to the finding as described. Corrective Action: • An internal grant manager has been appointed to enable closer financial oversight and we will work closely with engineering and outside consultants to ensure future grant compliance. • Director of Finance has looked into grant management certification courses in order to further educate staff on grant tracking and reporting requirements. • The Authority has since contracted with outside consultants to assist with grant management.
Finding Reference Number: 2023-003 Description of Finding: The Schedule of Expenditures of Federal Awards (SEFA) was not reconciled and complete prior to the beginning of the audit. Statement of Concurrence or Nonconcurrence: The identified issue pertaining to the incomplete SEFA is accurate and cle...
Finding Reference Number: 2023-003 Description of Finding: The Schedule of Expenditures of Federal Awards (SEFA) was not reconciled and complete prior to the beginning of the audit. Statement of Concurrence or Nonconcurrence: The identified issue pertaining to the incomplete SEFA is accurate and clearly defined. Corrective Action: • The Authority has since contracted with a consultant to assist staff with project and budget management of the same project the grant was funding. • Reporting requirements will be completed by the consultant or finance department going forward rather than the engineering manager. • Monthly meetings are held with staff from both accounting, engineering, and the grantor to discuss grant expenditures, invoice submittals and reimbursements, and project updates. • Director of Finance has looked into grant management certification courses in order to further educate staff on grant tracking and reporting requirements.
Finding Reference Number: 2023-002 Description of Finding: The Authority did not complete and submit the February 28, 2023 audited financial statements and single audit by the required deadline of November 30, 2023 or 9 months from fiscal year end. Statement of Concurrence or Nonconcurrence: Authori...
Finding Reference Number: 2023-002 Description of Finding: The Authority did not complete and submit the February 28, 2023 audited financial statements and single audit by the required deadline of November 30, 2023 or 9 months from fiscal year end. Statement of Concurrence or Nonconcurrence: Authority staff agrees the audited financial statement and single audit were significantly delayed. Corrective Action: • Development of audit timeline and “needs” list to be compiled from all staff prior to audit submittal. • Engage with auditors earlier in order to meet required reporting deadlines. • Implementation of month-end closing process rather than waiting for year-end to complete all reconciliations. • Begin contacting vendors for estimates on any potential accruals prior to the end of the fiscal year.
Audit Finding: Finding 2023-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...
Audit Finding: Finding 2023-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately
A standing monthly review meeting has been established between Finance and Engineering to review a list of current grants and the associated activity. This meeting will include discussing any future or proposed grant applications as well. Additionally, Finance and the audit team are meeting to revie...
A standing monthly review meeting has been established between Finance and Engineering to review a list of current grants and the associated activity. This meeting will include discussing any future or proposed grant applications as well. Additionally, Finance and the audit team are meeting to review proper recording of the grants in the general ledger to ensure proper representation in the financial statements.
Finding: 2023-004: Significant Deficiency - Payroll Allocations Description of Finding: Payroll costs were allocated to grant programs using manual spreadsheets rather than an entity-wide time-tracking system, making it difficult to clearly demonstrate the proportional benefit required. This manual ...
Finding: 2023-004: Significant Deficiency - Payroll Allocations Description of Finding: Payroll costs were allocated to grant programs using manual spreadsheets rather than an entity-wide time-tracking system, making it difficult to clearly demonstrate the proportional benefit required. This manual approach increased the risk of allocation inconsistencies and made documentation less robust than needed. Cause: The use of manual spreadsheet-based timekeeping did not provide an auditable system for allocating payroll costs to grants. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian acknowledges the significance of this finding and the potential for misstating staff expense and has taken steps to strengthen its time-tracking and payroll allocation processes. Beginning January 1, 2025, SacAsian implemented a new accounting system that includes electronic timesheets for staff to track their time daily to specific grant activity. Timesheet training has been performed and timesheet completion is required for all employees each day, providing support for hours worked/billed, as well as documentation of the certification and approvals that all staff time entered is accurate and in compliance with contract requirements, and providing proper support for all grant direct labor and indirect costs. Monthly reviews by the Project Directors/Managers, with secondary review by the accounting team are performed, ensuring ongoing compliance with federal requirements. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: January 2025
Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unre...
Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unrestricted. As a result, the ledger detail did not clearly demonstrate the grant claim support without additional reconciliation. Cause: A comprehensive system for allocating and documenting grant-related costs had not yet been implemented. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands and acknowledges the significance of this finding and the potential that it creates for documentation gaps. The Controller and Director of Finance have implemented an ERP system which allows for better cost reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. While the general ledger details do not align, SacAsian did provide full documentation to substantiate the expenses claimed in each billing. Moving forward, all expenditures that have been billed will be reconciled to the general ledger monthly by the Director of Finance, Controller, and external CFO firm to ensure that billings match to expenditure detail and have been correctly allocated. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: October 2025
View Audit 372580 Questioned Costs: $1
Finding: 2023-002: Revised Schedule of Expenditures of Federal Awards (SEFA) Description of Finding: Expenditures reported on the SEFA required revision during the Single Audit due to some inaccuracies, including one omitted program, which occurred because review and reconciliation procedures were n...
Finding: 2023-002: Revised Schedule of Expenditures of Federal Awards (SEFA) Description of Finding: Expenditures reported on the SEFA required revision during the Single Audit due to some inaccuracies, including one omitted program, which occurred because review and reconciliation procedures were not fully sufficient. Cause: The underlying cause was insufficient internal controls over grant documentation review and the accounting of federal award activity. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian acknowledges the significance of this finding and the potential for noncompliance with Uniform Guidance with the grantors and Federal entities, as well as potential increased risk of omitted federal programs and incorrect major program determination. To remediate these issues, SacAsian will strengthen its internal controls over SEFA preparation by implementing a multi-layer review and reconciliation process. SEFA schedules will be prepared by the Director of Finance and reviewed by the newly engaged external CFO firm. Final review will be performed by the President & CEO. SacAsian will implement a more rigorous review of all grant agreements, including pass-through awards, to verify federal components and Assistance Listing Number (ALN) details to ensure all federally funded activity is fully identified and properly reported on the SEFA. The SEFA will be reconciled to the general ledger, federal award agreements, billings submitted, and other supporting documentation. In addition, directors overseeing federal programs will be required to confirm that all federal awards under their purview are completely and accurately reflected. These enhanced controls will be implemented for the 2024 audit and maintained for subsequent audit periods. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: December 2025
Finding: 2023-001: Material Weakness - Untimely Audit Submission in Accordance with 0MB Uniform Guidance Description of Finding: The Sacramento Asian-Pacific Chamber of Commerce (SacAsian) did not submit its December 31, 2023 Single Audit reporting package—including the audited financial statements,...
Finding: 2023-001: Material Weakness - Untimely Audit Submission in Accordance with 0MB Uniform Guidance Description of Finding: The Sacramento Asian-Pacific Chamber of Commerce (SacAsian) did not submit its December 31, 2023 Single Audit reporting package—including the audited financial statements, Data Collection Form, prior-year status, and Corrective Action Plan—to the Federal Audit Clearinghouse by the required deadline. Cause: The submission was delayed because the Single Audit could not be completed on time due to change in audit firm and staffing shortages. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands the seriousness of this deficiency and the need for strict adherence to timely audit submissions per the OMB Uniform Guidance. Additional staff have been hired to assist in accounting processes, including a Controller to review all accounting processes and procedures with the Director of Finance and implement best practice recommendations and stronger month-end closing procedures and schedule. The delay in performing the 2023 audit was caused by a change in auditors. Our previous auditor did not have the capacity to continue our audit engagement due to staff shortages related to COVID. A new audit firm identified and engaged. However, there were delays in beginning the audit, and staffing challenges internally with completing the audit such that deadlines were not met. Additionally, an external finance and accounting firm was hired in September 2025 to provide additional capacity and high-level support to bring our audits current by March 2026. The additional staffing, external expertise, and improved procedures will prevent untimely submissions in future years. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: March 2026
Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps...
Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps to strengthen oversight and ensure future compliance. Knowledgeable personnel are now in place and have been made fully aware of all federal reporting requirements and deadlines. Management is actively developing formalized policies and procedures governing federal reporting, including a centralized compliance calendar, documented workflows, defined roles and responsibilities, and an internal review process prior to submission. These measures will be implemented by the first quarter of 2026.
Management concurs with this finding. The missed submission was caused by inadequate tracking mechanisms and insufficient procedural formalization under prior leadership. New personnel are now assigned responsibility for compliance and reporting, and management has completed a full review of all rep...
Management concurs with this finding. The missed submission was caused by inadequate tracking mechanisms and insufficient procedural formalization under prior leadership. New personnel are now assigned responsibility for compliance and reporting, and management has completed a full review of all reporting obligations across federal awards. Management is in the process of developing standardized grant reporting procedures, enhanced tracking tools, and formal internal review controls to ensure timely and accurate submissions going forward. These procedures will be implemented by the first quarter of 2026.
After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, r...
After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. The Outsourced CFO will ensure that the Organization submits timely single audit data collection and reporting package to the Federal Audit Clearinghouse. 22
The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With...
The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. These changes were necessary to ensure proper U.S. GAAP practices were in place. These updates include accurately accruing accounts payable and accounts receivable, to ensure revenue and expenses are recognized in the proper period. We have also implemented a proper review process of the financial statements and any adjustments that are required to finalize them. The Organization believes it have fully addressed and corrected all procedures that led to this finding.
Notre Dame Health System ceased operation prior to the date of this report. Accordingly, mnagement is unable to take corrective action or implement further internal control improvements related to this finding.
Notre Dame Health System ceased operation prior to the date of this report. Accordingly, mnagement is unable to take corrective action or implement further internal control improvements related to this finding.
View Audit 372473 Questioned Costs: $1
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal ...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal year (FY) 2023. Management has made clearing this backlog its highest priority. The schedule is to complete and file the FY 2023 package by fall 2025 and the FY 2024 package shortly thereafter, at which point CUAHSI expects to return to on-time Federal Audit Clearinghouse filings. Recent upgrades to the accounting system, the hiring of in-house finance staff, and revised closing procedures are designed to streamline and accelerate future audit preparation so that all subsequent audits are filed by the required deadlines. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339) 221-5400 • Email: msabino@cuahsi.org Projected Completion Date: 2026-09-30
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: CUAHSI acknowledges that incomplete documentation was available to show subrecipient-monitoring procedures were followed for FY 2023 wi...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: CUAHSI acknowledges that incomplete documentation was available to show subrecipient-monitoring procedures were followed for FY 2023 within the required timeframe. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI now follows a written Subrecipient Monitoring Policy that specifies the duties of the Director of Finance, Staff Accountant, and Principal Investigator. Monitoring of active subawards began in May 2023. The subaward monitoring process was updated on September 21 2023 and further refined in spring 2024. All subrecipients from FY 2020–2023 have been retroactively certified, and timely reviews were in place for awards from FY 2024 onward. Management performs a mid-year check to confirm that monitoring records are complete, adequate, and securely stored. Name of Contact Person: • Jordan S Read, Chief Executive Officer • Telephone: (339)933-4660 • Email: jread@cuahsi.org Projected Completion Date: NA; is complete
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Vendor status for 2023 recipients was retroactively evaluated by CUAHSI staff and certified by management during calendar year 2024. Re...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Vendor status for 2023 recipients was retroactively evaluated by CUAHSI staff and certified by management during calendar year 2024. Records were organized and filed in a secure, centralized document management system. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI considers this finding closed, as current practices comply with established policies and procedures. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Certain 2023 draws were processed as advances outside grant guidelines, although these draws were properly recorded as advances payable...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Certain 2023 draws were processed as advances outside grant guidelines, although these draws were properly recorded as advances payable in the accounting records. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI considers this finding resolved. A written drawdown procedure is now in place, requiring two-tier preparation and review, and, for working-capital advances, written approval from the prime funder. When the non-compliance was identified, CUAHSI suspended all NSF draws (late March 2023) until new controls were implemented. On 15 June 2023, CUAHSI completed its first draw under the revised policy. Name of Contact Person: • Jordan S Read, Chief Executive Officer • Telephone: (339)933-4660 • Email: jread@cuahsi.org Projected Completion Date: NA; is complete
Implement a tracking system (spreadsheet or database) to monitor completion of home visits and conferences for all enrolled children. Train teachers and family service staff on the requirements and proper documentation procedures for home visits and parent-teacher conferences. Conduct monthly review...
Implement a tracking system (spreadsheet or database) to monitor completion of home visits and conferences for all enrolled children. Train teachers and family service staff on the requirements and proper documentation procedures for home visits and parent-teacher conferences. Conduct monthly reviews to ensure compliance
Confirm the specific reporting periods and deadlines for all DHHS grants, including ARP and CRRSA grants. Ensure semiannual SF-425 reports are submitted within the deadlines outlined in the grant agreements, and annual SF-425 reports for ARP and CRRSA grants Maintain documentation of submission date...
Confirm the specific reporting periods and deadlines for all DHHS grants, including ARP and CRRSA grants. Ensure semiannual SF-425 reports are submitted within the deadlines outlined in the grant agreements, and annual SF-425 reports for ARP and CRRSA grants Maintain documentation of submission dates and retain copies of all reports for audit and compliance purposes. Establish an internal calendar and reminder system to track future SF-425 reporting deadlines to prevent delays.
Finding 2023-005 Assistance Listings: 93.567 & 93.576 Issue: Timely submission of Single Audit We respectfully acknowledge the Single Audit was not submitted timely. We were in a period of growth and building an in-house finance team. Prior to 2024, an outside consulting team performed the accountin...
Finding 2023-005 Assistance Listings: 93.567 & 93.576 Issue: Timely submission of Single Audit We respectfully acknowledge the Single Audit was not submitted timely. We were in a period of growth and building an in-house finance team. Prior to 2024, an outside consulting team performed the accounting function. The basic financial statements were delayed, and this caused the Single Audit for December 31, 2023, reporting deadline to be delayed. Corrective Actions We put in place an internal finance team, a CFO, an Accountant and a Consultant to operate effectively and to meet reporting deadlines. Responsible Official: Renee Carroll, CFO Implementation Date: August 14, 2025
Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review a...
Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review and note interpreter use. 3. File Accountability – Physical files labeled with responsible case manager; cross-checked during audits. 4. Compliance Reviews – Compliance Coordinator conducts quarterly file audits. Responsible Official: Javid Siddiqi, Director of Immigration Services Implementation Date: Completed January 2025; quarterly monitoring ongoing.
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