Corrective Action Plans

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Finding 573971 (2023-010)
Significant Deficiency 2023
Management’s Response and Corrective Action Plan: The City implemented a grant management policy specific to verification of contractor suspension, debarment, or pending debarment in accordance with the provisions of 2 CFR Part 180. The policy provides staff with three option for compliance – perfor...
Management’s Response and Corrective Action Plan: The City implemented a grant management policy specific to verification of contractor suspension, debarment, or pending debarment in accordance with the provisions of 2 CFR Part 180. The policy provides staff with three option for compliance – perform a search and verification through Sam.gov, request a contractor certification upon award, and including a clause in the bid documents and final contract whereas the contractor’s signature affirms compliance. The latter is the preferred method, however the circumstances specific to each grant may be varied. The policy provides flexibility while ensuring compliance. The policy is currently in effect.
Management’s Response and Corrective Action Plan: Grant review is included within the month-end close procedure referenced in the response to 2023-001. The procedure includes defined roles and responsibilities by position.
Management’s Response and Corrective Action Plan: Grant review is included within the month-end close procedure referenced in the response to 2023-001. The procedure includes defined roles and responsibilities by position.
Management’s Response and Corrective Action Plan: The City has implemented a procedure requiring the project manager to prepare required finance-based grant reports in conjunction with the finance director. The finance director must approve the required grant report before the project manager is au...
Management’s Response and Corrective Action Plan: The City has implemented a procedure requiring the project manager to prepare required finance-based grant reports in conjunction with the finance director. The finance director must approve the required grant report before the project manager is authorized to submit. The procedure includes timelines and authorizations requiring all grants to be entered into the City’s financial management software suite to ensure complete and timely project monitoring. All users have access to the financial software and have real-time access to all data.
Management will make arrangements to have their records inspected quicker after year-end to ensure the timely completion of an andut. Additionally, follow-up procedures will be executed to ensure all parties have received the required information to complete audit procedures prior to deadline.
Management will make arrangements to have their records inspected quicker after year-end to ensure the timely completion of an andut. Additionally, follow-up procedures will be executed to ensure all parties have received the required information to complete audit procedures prior to deadline.
While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP was recently developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility f...
While BREC currently does not have any federal expenses identified as unallowable costs applicable to this finding, a written SOP was recently developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. Anticipated completion date: November 1, 2024 Responsible contact person: Don Johnson, Cheif Finance Officer
Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Pr...
Type of Finding: Significant Deficiency in Internal Control over Compliance 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with reporting requirements. During our testing, we noted the Town did not have submit the Project and Expenditure report, that was due by April 30, 2023. Recommendation: CLA recommends the Town implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of their grant agreements. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Taken in Response to Finding: Management will implement procedures to ensure compliance with all requirements under which the Town if obligated to comply as part of our grant agreements. Name(s) of Contact Person(s) responsible for Corrective Active Plan: Kevin Gervais Jr. Planned completion date for corrective action plan: July 2025
The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The...
The Federal Programs Director and the Business Manager have been attending the Monthly Federal Programs Virtual Trainings as well as the Fiscal Tech Office Hours offered by the PDE Division of Federal Programs. Both have been very informative and have offered us the opportunity to ask questions. The Federal Program Director attended The Pennsylvania Association of Federal Program Coordinators annual conference in 2024 and 2025 and will attend yearly in the future. We are also in contact with our Regional Coordinator, Emily Johnson who has been able to assist as needed.
BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. BHI has also engaged an audit firm to perform it...
BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. BHI has also engaged an audit firm to perform its federally-required federal financial statement and single audits each year. This reminder and timeline has been put on the BHI shared calendar so that this task is not missed in the future.
BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. Furthermore, BHI has implemented procedures to ...
BHI has engaged a professional research administration consulting firm to provide guidance on federal grants management activities, compliance requirements and policy and procedure development. BHI meets monthly with the grants management consultant. Furthermore, BHI has implemented procedures to ensure adequate internal control over financial processes. For one, all the invoicing on all grant and contract accounts are done monthly. The BHI admin/program manager prepares all invoices on a monthly basis which are then reviewed by Chief Operating Officer and finally approved by the Principal Investigator. All financial transactions are recorded in QuickBooks so that bank and credit card accounts can be reconciled monthly. And lastly, an automated solution has been implemented to keep all bill payment and approvals strictly separate.
Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls with federal wage rate requirements. Name, address, and telephone of City contact person: Nancy Reddick, Clerk-Treasurer, 149 Hodgden St S, Tenino, WA 98589, (360) 264-2368. Corrective action the auditee p...
Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls with federal wage rate requirements. Name, address, and telephone of City contact person: Nancy Reddick, Clerk-Treasurer, 149 Hodgden St S, Tenino, WA 98589, (360) 264-2368. Corrective action the auditee plans to take in response to the finding: The City will include the required wage rate provisions in future contracts and will require weekly certified payroll reports prior to paying the contractor for the appropriate periods. Anticipated date to complete the corrective action: Immediately
Corrective Action Plan Financial Statement Finding: 2023-008 Identification of Federal Awards and Preparation of a Complete and Accurate Schedule of Expenditures of Federal Awards (SEFA) Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee’s ...
Corrective Action Plan Financial Statement Finding: 2023-008 Identification of Federal Awards and Preparation of a Complete and Accurate Schedule of Expenditures of Federal Awards (SEFA) Criteria: The Uniform Guidance requires the auditee to prepare a SEFA for the period covered by the auditee’s financial statement. It is the responsibility of the auditee's management to design and implement internal controls that provide reasonable assurance over the completeness and accuracy of the SEFA. The SEFA is the basis for the auditor’s identification of major programs. Cause/Condition: The City does not have a method to accurately track the related expenditures for reporting. The City's initial SEFA provided for the audit was incomplete and contained inaccurate program expenditure amounts. In particular, there were multiple federal programs that were materially misstated; including the following major federal program for the year under audit: 1. ALN 14.228 Community Development Block Grants/State's Program and Non-Entitlement Grants in Hawaii In addition, there were multiple federal programs that were not identified on the initial SEFA for the year under audit: 1. ALN 20.600 / 20.616 Highway Safety Cluster 2. ALN 66.818 Brownfield Multipurpose, Assessment, Revolving Loan Fund, and Cleanup Cooperative Agreements 3. ALN 66.458 Capitalization Grants for Clean Water State Revolving Funds 4. ALN 93.568 Low-Income Home Energy Assistance 5. ALN 97.039 (COVID-19) Disaster Grants - Public Assistance (Presidentially Declared Disasters) Effect: A Uniform Guidance compliance audit is based on the premise that management must comply with federal statutes, regulations and the terms and conditions of the federal awards it receives. Without identifying the funds as federal, the auditee may not have complied with those requirements. In addition, there is increased risk regarding the accurate reporting of grant expenditures and noncompliance with policies and procedures surrounding the recording of federal awards. Recommendation: We recommend the City develop and implement procedures to ensure that information related to all federal awards is accumulated to assist in the preparation of the SEFA. In addition, we recommend management of the City verify the completeness and accuracy of the amounts reported on the SEFA. Response: The City agrees with the finding. Corrective Action Plan: The City will include tracking of federal awards in the Capital Project tracking process. Capital projects will be reflected in a separate budget alongside the operational budget beginning in FY 2026. Anticipated Completed Date: July 31, 2025 for the tracking process; December 20, 2025 for the budget. Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance
Corrective Action Plan Financial Statement Finding: 2023-007 Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, ...
Corrective Action Plan Financial Statement Finding: 2023-007 Noncompliance with Uniform Guidance Late Filing of Single Audit Reporting Package Criteria: Under the Single Audit Act of 1996 and Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), §200.512, Report Submission, the Single audit reporting package is required to be filed within the earlier of 30 calendar days after receipt of the auditors' report, or 9 months after the end of the audit period. Cause/Condition: Staffing shortages caused the delays in financial reporting. This deadline was not met on a timely basis for the year ended December 31, 2023. Effect: As a result, the entity is not incompliance with §200.512 of the Uniform Guidance. Recommendation: We recommend the requirements of §200.512 of the Uniform guidance be adhered to by striving to have all information required for the audit available on a timely basis. This will help to ensure timely audit report issuance and compliance with the filing deadline. Response: The City is still facing staffing shortages and is working to get the subsequent financial statements completed. It is expected the 2024 reporting package will be filed on time. Corrective Action Plan: The City has hired a full complement of staff in the Finance department, and anticipates timely filings going forward. Anticipated Completed Date: September 30, 2025. Responsible Contact Person: Elizabeth Greenwood, Director of Administration & Finance
We have reviewed the deficiencies and have included our responses to each below. 1. Finding # 2023-001 –Late filing of Financial and Audit. Reports had not been filed within nine months after the fiscal year end of Jun. 30, 2023, which should have been by Mar. 31, 2024. Management Response: Flore...
We have reviewed the deficiencies and have included our responses to each below. 1. Finding # 2023-001 –Late filing of Financial and Audit. Reports had not been filed within nine months after the fiscal year end of Jun. 30, 2023, which should have been by Mar. 31, 2024. Management Response: Florence Carlton School District 15-6 has historically filed audit reports in a timely manner to the respective agencies. The district experienced multiple key changes in financial management positions within a short period, which slowed down the audit process. Florence Carlton has filed our audit reports and data collection forms with the state, federal, and credit agencies, but this process also lacked training. Internal control procedures have been outlined and implemented for the future, including the Schedule of Federal Awards, and will continue to be implemented moving forward. The lack of Standard Working Instructions (SWI) contributes to the lack of consistency, compliance, and training. I have developed SWIs with Visual (photos or videos) directions for each step in all areas of a broad base of responsibility of the clerk position.
Finding 573743 (2023-016)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervis...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-016 Inaccurate Resource Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. Transfer of Asset policy and procedures will be reviewed with applicable caseworkers. TOA evaluation and clear documentation of Transfers and Resolutions must be documented. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. May 1, 2024 Section III - Federal Award Findings and Question Costs (continued) 141
Finding 573742 (2023-015)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-015 Inadequate Request for Information Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) April 11, 2024 Cases will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what cases should contain and the importance of complete and accurate record keeping. All cases will include online verifications ran timely, documented resources, income and make certain those amounts agree to information input into NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed by the caseworker and the results of those actions. Information must be updated at every application/recertification and change in circumstance adhering to Medicaid Policy. Templates have been updated to address request for information, income verifications, reasonable compatibility and to include electronic resources are ran with verification of date ran. CW must address all Household income and have clear documentation of request or findings. Training targeted to address error trend of Documentation of Vehicles and Rebuttals. Training targeted to address error trend of evaluation of 1/3 reduction. Information requested from OST to properly enter 1/3 reduction in NCFAST obtained. Training targeted for applicable staff to address Transfer of Asset requirements and how to address and clearly document transfers. Help Desk tickets should be submitted timely if information or functionality is not working properly. All avenues available to caseworker must be exhausted before requesting information from client, unless information provided and information obtained is questionable. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. 140
Finding 573741 (2023-014)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Super...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-014 Inaccurate Information Entry Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor Section III - Federal Award Findings and Question Costs (continued) A refresher training will be held to review errors. Files will be reviewed internally to ensure proper documentation is in place for eligibility. Workers will be retrained on what files should contain and the importance of complete and accurate record keeping. All files include accurate household members, online verifications, documented sources and verifications of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. An updated template has been put in place for applications and recertification to address household members, tax filing status, electronic checks/verifications and documentation that is needed to accurately approve/deny/continue or terminate benefits. Caseworkers will need to review Determinations to ensure all eligibility is calculated accurately. All active cases regardless of program in NCFAST are to be reviewed to ensure we have the correct information. Weekly Communications and Changes will be reviewed weekly at Unit Meeting to address any changes and NCFAST issues that may require a Help Desk Ticket. We will continue to train on this issue, and it will also be addressed in new worker Trainings. Training in the learning gateway is also available. May 1, 2024 139
Finding 573740 (2023-013)
Significant Deficiency 2023
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 20...
CASWELL COUNTY 144 Court Square, Yanceyville, NC 27379 www.caswellcountync.gov 336/694-4193 Corrective Action Plan For the Year Ended June 30, 2023 Finding: 2023-012 Late Submission of Data Collection Form Name of contact person: Corrective Action: Proposed Completion Date: December 2025 Finding: 2023-013 IV-D Non-Cooperation Name of contact person: Corrective Action: Proposed Completion Date: Heather Starr Thomas, Medicaid Supervisor At the time the determinations under audit were completed this was a requirement. However, under current policy referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). Please see Administrative Letter 13/23 Due to CCU referrals are not being enforced for cooperation with the Child Support Enforcement Agency (IV-D). 5/1/2024 Caseworkers will adhere to Continuous Coverage Unwinding (CCU) Period Policy. As noted in the response to Findings 2023-001 and 2023-006, County finance staff is diligently working to improve the timeliness of transaction processing and anticipates timely completion of the FY25 audit which will resolve this finding. Melissa Miller, Interim Finance Officer Section III - Federal Award Findings and Question Costs 138
Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Res...
Finding 2023-002 U.S. Department of Housing and Urban Development – CFDA #14.850 Public and Indian Housing Eligibility Significant Deficiency in Internal Control over Compliance Finding Summary: For 5 participant files, the recertification / move-in checklists were not signed by Authority staff. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: In addition to accounting, we also had newer staff members in the compliance department after a leadership transition with the department manager. We have conducted thorough training and discussions to help identify solutions moving forward. We will establish internal controls to ensure that all recertification/move-in checklists are signed by Authority Staff. We will work with the department manager to ensure that the control processes are being followed. Anticipated Completion Date: January 2024
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Nonco...
U.S. Department of Housing and Urban Development – CFDA #14.871 Section 8 Housing Choice Vouchers Activities Allowed or Unallowed, Allowable Costs and Cost Principles, Eligibility, Special Test and Provisions Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Finding Summary: The Authority was not able to locate 1 of the 61 participant files selected for audit testing. Responsible Individual: Steven Trujillo, Executive Director Corrective Action Plan: During 2023, the Housing Choice Voucher Department moved physical locations from the 10th Floor of 1414 Santa Fe to 201 S Victoria. Also, during this time, all of the historical paper files were being scanned for digital storage. During this time, paperwork for one of the participants re-certification and inspection were misplaced and not able to be located during audit fieldwork. We do not anticipate this issue in the future since there will not be another office move, and all recertification paperwork moving forward is being scanned and attached in our software Anticipate Completion Date: January 2024
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The Authority has determined the cost of eliminating the deficiencies would exceed its benefit.
The village is currently reviewing the Federal Requirement for reporting and how the village will be able to track and handle this reporting in the future. In regard to monthly reporting the village has a population of approximately 1500 residents and received approximately $50,000 SLFRF funds. Wel...
The village is currently reviewing the Federal Requirement for reporting and how the village will be able to track and handle this reporting in the future. In regard to monthly reporting the village has a population of approximately 1500 residents and received approximately $50,000 SLFRF funds. Well below the quarterly requirements and were only required to file yearly per the guidelines listed by the U.S. Department of Treasury’s own reporting guidelines. See below chart. Please take note that the Village has reported each year since 2022 as required. A copy of the yearly reports are available if needed.
In regard to the village not having a written policy in place for the requirements outlined in the Code of Federal Regulations regarding the villages received Coronavirus funding, as previously stated the village does not routinely receive federal funds and was not aware at the time of having such a...
In regard to the village not having a written policy in place for the requirements outlined in the Code of Federal Regulations regarding the villages received Coronavirus funding, as previously stated the village does not routinely receive federal funds and was not aware at the time of having such a policy. The village is currently working with the village solicitor to rectify this issue. A new policy will be implemented to resolve this issue. – Mayor M. Shane Patrone
As stated in the finding (2023-005) the Village was unaware of the monies being Federal Monies as they were received from a State of Ohio distribution, and after a discussion with the auditors the Village prepared the required reports. The village, being a small municipality, does not receive feder...
As stated in the finding (2023-005) the Village was unaware of the monies being Federal Monies as they were received from a State of Ohio distribution, and after a discussion with the auditors the Village prepared the required reports. The village, being a small municipality, does not receive federal funds routinely and I believe the Coronavirus funds will not be something the village anticipates receiving in the future. – Mayor M. Shane Patrone
Finding 573711 (2023-011)
Significant Deficiency 2023
The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the third-party admini...
The Board of County Commissioners, with the cooperation and participation of all elected officials, reviews, develops and implements policies and procedures to create a strong internal control environment. The Board of County Commissioners will work with all elected officials, the third-party administrator, and federal, state and local partners to develop policies, procedures, and internal controls designed to accurately track grants, including the application process, verification, oversight, and reporting of grant requirements. To assist in this process, the Board of County Commissioners engaged a third-party administrator to oversee the grant process, including application, eligibility, review, requirements, contracting, recipient tracking and oversight, and documentation and reporting. The Board of County Commissioners will work with the third-party administrator to ensure proper grant administration.
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