Corrective Action Plans

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Corrective Action Plan June 26, 2025 U.S. Department of Health and Human Services Health Resources and Services Administration Rocking Horse Community Health Center and Affiliate respectively submits the following corrective action plan for the year ended December 31, 2024. Clark, Schaefer, Hac...
Corrective Action Plan June 26, 2025 U.S. Department of Health and Human Services Health Resources and Services Administration Rocking Horse Community Health Center and Affiliate respectively submits the following corrective action plan for the year ended December 31, 2024. Clark, Schaefer, Hackett & Co. 14 East Main Street, Suite 500 Springfield, OH 45502 Audit period: January 1, 2024 – December 31, 2024 The findings from the June 26, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAM AUDITS Department of Health and Human Services 2024-001 Health Center Cluster Program – ALN # 93.527; Grant No. H2E Significant Deficiency: See Finding 2024-001 Recommendation: Management should strengthen its internal controls over payroll charges to federal awards by ensuring consistent adherence to its time and effort certification policies as well as conduct periodic reviews of payroll documentation to verify compliance with established policies and federal requirements. Action Taken: We concur with the recommendation and will implement formal policies and procedures around obtaining time and effort certifications by June 30, 2025.
View Audit 361604 Questioned Costs: $1
Finding 570574 (2024-003)
Significant Deficiency 2024
YWCA Madison, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 1, 2024 – December 31, 2024 The findi...
YWCA Madison, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Wegner CPAs 2921 Landmark Place Suite 300 Madison, Wisconsin 53713 Audit period: January 1, 2024 – December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINANCIAL STATEMENT FINDINGS SIGNIFICANT DEFICIENCY 2024-001 Recommendation: Management should implement procedures to ensure continuity of key financial controls during periods of personnel transition. This includes assigning interim reviewers, establishing clear handover protocols, and enforcing timely documentation of reviews to maintain financial oversight. Action Taken: Under the leadership of our new fractional CFO and outsourced accounting firm, we have implemented an accounting close and financial reporting management system using ClickUp. Each task impacting key financial controls now has both a designated preparer and reviewer. The system automatically tracks and displays the completion status of each control. Further review of financial schedules is documented through Google Drive approvals. Transitioning from manual to system-driven documentation ensures that, during staffing changes, task reassignments are more visible to all responsible team members. It is important to note that, due to capacity constraints during the transition, immediate reassignment of responsibilities was not feasible. However, once new team members were onboarded, a cumulative review of the period was conducted to ensure the completeness and accuracy of the financial information—ultimately reflected in an unmodified financial audit opinion. MATERIAL WEAKNESS 2024-002 Recommendation: Assign clear responsibility for maintaining and reviewing the monitoring checklist. Management should establish a recurring schedule (e.g., monthly or quarterly) for checklist reviews and ensure the results are documented and retained for accountability and audit purposes. Action Taken: The new fractional CFO, Grants & Compliance Director, and CEO have revised the monitoring checklist to separate financial and compliance controls, as these operate on different schedules. Financial controls have been integrated into the financial management project system in ClickUp. Compliance controls will be maintained within the grant management system and embedded into the grant management and reporting processes. FEDERAL AWARD FINDINGS DEPARTMENT OF TRANSPORTATION STATE OF WISCONSIN DEPARTMENT OF TRANSPORTATION 2024-003 Formula Grants for Rural Areas and Tribal Transit Program — Assistance Listing No. 20.509 Recommendation: Management should conduct a review of depreciation charges for the current and future years to ensure that federally funded assets are excluded from depreciation allocations to federal programs. Action Taken: We have added a new depreciation expense account to distinguish between allowable and non-allowable depreciation expenses in grant expenditure allocations. If there are questions regarding this plan, please call Tania Ibarra, CPA, at 608.347.6747. Sincerely, Geraldine Paredes Vásquez CEO gpvasquez@ywcamadison.org
View Audit 361592 Questioned Costs: $1
Reference Number: 2024-001- Timeliness of Financial Reporting (Material Weakness/Material Noncompliance) Name of Contact Person: Janet Franco, Principal Budget and Financial Analyst or Scott Williams, Director of Finance Corrective Action: The City acknowledges that the financial inform...
Reference Number: 2024-001- Timeliness of Financial Reporting (Material Weakness/Material Noncompliance) Name of Contact Person: Janet Franco, Principal Budget and Financial Analyst or Scott Williams, Director of Finance Corrective Action: The City acknowledges that the financial information and documentation, including the trial balance, was not prepared in a timely manner. This prevented the auditors from completing the audit, and the Single Audit, by March 31, 2025. The implementation of the new financial software system, which went live on July 1, 2023, necessitated almost all of the Finance Department’s staff hours to be allocated to ensuring the software system was accurate in its financial reporting. This allocation of resources prevented the City from producing timely financial information. The Finance Department also had the loss of key staff in the department that added difficulty in providing necessary items in a timely manner. The Finance Department has corrected all of the financial and reporting issues that arose in the Summer and Fall of 2024 and is also working on fully staffing the department to be able to complete reporting in timely manner. The Finance staff has reviewed and updated its procedures for closing the financial records for the 2023-24 fiscal year, and has already begun the process of closing the books for 2024-25. The City fully expects to file the financial audit in a timely manner for the 2024-25 fiscal year. Proposed Completion Date: Fiscal Year ended June 30, 2025.
Corrective Action Plan: The Housing Authority understands that our prior procedure was incorrect and inadequate for capital fund drawdowns. The Finance Director has been instructed on the proper procedure of capital fund drawdowns to first reconcile LOCCS requests to vendor billing to properly reque...
Corrective Action Plan: The Housing Authority understands that our prior procedure was incorrect and inadequate for capital fund drawdowns. The Finance Director has been instructed on the proper procedure of capital fund drawdowns to first reconcile LOCCS requests to vendor billing to properly request and expend funds with the three-day period.
Finding 570553 (2024-004)
Significant Deficiency 2024
Finding 2024-004 Internal Controls Over Compliance for Cash Management, Allowable Costs, Procurement, and Conflicts of Interest 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding The City will adopt the referenc...
Finding 2024-004 Internal Controls Over Compliance for Cash Management, Allowable Costs, Procurement, and Conflicts of Interest 1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Action Planned in Response to Finding The City will adopt the referenced policies in order to comply with Uniform Guidance. 3. Official Responsible Nicole Coler, City Clerk/Treasurer, is the official responsible for ensuring corrective action. 4. Planned Completion Date December 31, 2025. 5. Plan to Monitor Completion The City Council will be monitoring this Corrective Plan.
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Tiffany Deakins Contact Phone Number: 260-248-3176 wcauditor@whitleygov.com Views of Responsible Official: We concur with the fi...
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Tiffany Deakins Contact Phone Number: 260-248-3176 wcauditor@whitleygov.com Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Whitley County will make sure that moving forward we will have all vendors sign a contract or agreement with the “suspension and debarment” verbiage included or will have them sign the “suspension and debarment certification” if they will be receiving $25,000 or more of federal funds. Anticipated Completion Date: Immediately
Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disa...
Recommendation: We recommend that only costs incurred during the period of performance be charged to the grant. For payroll in which pay periods extend over multiple budget periods, we recommend prorating the amount charged to the grant by the days worked within the grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. Create list of grants with pertinent contract terms for monitoring and reference. Highlight grants with term end dates within the fiscal year. 2. Update Grant Tracking workpapers to alert on grant year end and create allocation tab to separate payroll expenses that crossover grant end terms. Review non-payroll expenses to ensure they belong to proper grant term. 3. Monitor progress and review grants at fiscal year end to ensure process was followed. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: 8/31/2025
View Audit 361495 Questioned Costs: $1
Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant managem...
Finding Reference Number: 2024-003 – Period of Performance Federal Program: AL 20.237 High Priority Grant — FMCSA Cluster Name of Contact Person: Tim Adams, CEO Views of Responsible Officials: IRP acknowledges the finding and concurs with the recommendation. Planned Corrective Action: Grant management procedures have been revised to verify that services are received and costs incurred within the authorized period of performance in accordance with 2 CFR § 200.403 before the costs are charged to a federal award. Staff involved in grant management will receive targeted training on 2 CFR requirements related to period-of-performance compliance and allowable cost timing. Anticipated Completion Date: September 30, 2025
View Audit 361417 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will revise the current written cost allocation policy to clearly define how fringe benefits are to be accounted for, allocated and applied across all federal programs. The poli...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will revise the current written cost allocation policy to clearly define how fringe benefits are to be accounted for, allocated and applied across all federal programs. The policy will ensure consistency, compliance with 2 CFR Part 200, and equitable allocation based on actual benefit expended.
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Unif...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure review and approval of grantrelated expenditures. The Group regularly trains staff on allowable cost principles under Uniform Guidance.
View Audit 361368 Questioned Costs: $1
agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to subm...
agreement, the Group will implement grant monitoring internal controls and procedures to ensure that expenditures comply with all earmarking limitations specified in grant agreements and approved budgets. These procedures will track expenditures by budget category and verify compliance prior to submitting reimbursement requests.
View Audit 361368 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance wi...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls to ensure that expenses submitted for reimbursement under federal awards, especially personnel costs, are reviewed for compliance with regard to the period of performance requirements.
View Audit 361368 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including r...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate calculation of payroll costs incurred under the federal programs, including review and monitoring of process and procedures. In addition, documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such expenses, will be retained in accordance with federal regulations.
View Audit 361368 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, sta...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will ensure that all reimbursable costs are submitted for reimbursement in a timely manner. The Group has significant experience in submitting for reimbursement for federal, state, and similar types of grants and contracts.
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to implement internal controls over tracking of expenditures related to federal award grants, especially personnel costs, and the related reimbursed co...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to implement internal controls over tracking of expenditures related to federal award grants, especially personnel costs, and the related reimbursed cost to ensure compliance with federal requirements.
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently ...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will work with management to strengthen its document retention policies and processes and implement internal controls to ensure that all required grant reports are consistently reviewed, approved, submitted, retained and retrievable for the required retention period. This includes quarterly reports, expense reimbursement packets submitted to the grantors, project expenditure reports, or other grant-related records necessary to demonstrate compliance with federal reporting and record retention standards under the federal programs.
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement internal control procedures to establish separate accounts, classification, use of cost centers and project codes to clearly distinguish expenditures by funding s...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement internal control procedures to establish separate accounts, classification, use of cost centers and project codes to clearly distinguish expenditures by funding source, especially federal and state funds, as well as revenues received.
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Gro...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will design and implement a system of internal controls which includes a review process to ensure accurate use of approved fringe benefit rates in all federal reporting. The Group will reconcile budgeted and actual fringe benefit costs regularly to ensure continued compliance.
View Audit 361368 Questioned Costs: $1
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate accounting of payroll costs incurred under the federal programs, including re...
Solvista Health management agrees with the auditor’s finding. In conjunction with the shared services agreement, the Group will implement a system of internal controls that are designed and operating to provide an accurate accounting of payroll costs incurred under the federal programs, including review and monitoring of processes and procedures. Documentation ensuring accurate payroll costs allocated to federal programs, along with support of review and approval of such charges, will be retained in accordance with federal regulations.
View Audit 361368 Questioned Costs: $1
Finding 570038 (2024-006)
Significant Deficiency 2024
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findin...
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend the Corporation review the expenditures submitted to sales taxes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Within 60 days of audit issuance, the Interim CFO will conduct training for finance staff regarding accounts payable invoices and sales tax requirements and coding. Updated accounts payable policies and procedures include a process to ensure that the CFO reviews and codes sales tax when checks are prepared, approved and signed. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 09/30/2025
View Audit 361326 Questioned Costs: $1
Finding 570037 (2024-005)
Material Weakness 2024
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as peri...
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation strengthen its internal controls over cash disbursements. This should include retention of payments supported by valid invoices and proof of payment documentation as well as periodic internal audits to ensure compliance with the documentation requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All purchase-related supporting documentation will be transitioned to paper files to eliminate confusion created by the electronic record-keeping system, and to ensure that all staff requiring access to such documentation can immediately and easily retrieve them. Records will be maintained in the Finance Department office for seven years. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025
View Audit 361326 Questioned Costs: $1
Finding 570036 (2024-004)
Material Weakness 2024
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation implement internal controls over the reconciliation of payroll reports to grant expenditures. This should include regular reconciliations and reviews to ensure that all payroll c...
Supportive Services for Veteran Families Assistance Listing No. 64.033 Recommendation: We recommend that the Corporation implement internal controls over the reconciliation of payroll reports to grant expenditures. This should include regular reconciliations and reviews to ensure that all payroll costs charged to the grant are adequately supported by detailed payroll records. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A payroll salary reconciliation report will be completed after each payroll issued and will be verified against the grant reports, accounting system class coding and employee-specific payroll file(s). Printed reports will be maintained on file in the Finance Department for historical reference. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: 06/12/2025
View Audit 361326 Questioned Costs: $1
THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD...
THE ORGANIZATION WILL USE EXPENDITURE REPORTS BY CLASS TO SUPPORT BASE EXPENDITURES FOR THE PERIOD. WILL BE IN PLACE FOR THE 2025 SINGLE AUDIT AND BEGAN THIS PROCESS IN 2024. KAREN SHARPNACK, EXECUTIVE DIRECTOR KJS@IDAHOIMMUNE.ORG AND NEW CPA FIRM TO BE DETERMINED. THE ORGANIZATION THROUGH ITS BOARD OF DIRECTORS WILL CREATE A “FINANCIAL POLICY COMMITTEE” WHICH WILL BE RESPONSIBLE TO WORK WITH THE EXECUTIVE DIRECTOR, THE NEW CPA TO OUTLINE AND CREATE NEW POLICIES, PROCEDURES AND PROCESSES, ALONG WITH OVERSIGHT OF THE FINANCIAL WELL-BEING OF THE ORGANIZATION AND REPORT TO THE BOARD OF DIRECTORS. IMMEDIATELY, THE PROCESS WILL BEGIN TO RECRUIT THE COMMITTEE ON JUNE 25, 2025.
View Audit 361196 Questioned Costs: $1
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: ...
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Procurement and Suspension and Debarment Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 225GA324N1099 (Year: 2024), 245GA324N1199 (Year: 2024) Questioned Costs: $77,285 Prior Year Finding: FA 2023-001 Description: A review of expenditures charged to the Child Nutrition Cluster revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were reviewed and approved and that the School District's procurement and suspension and debarment procedures were followed. Corrective Action Plans: Berrien will look at the current procedures for expenditures and make sure that every program is following the same protocols. We have a system in place to ensure that we can check suspension and debarment. Also, we have protocols in place to make sure all contracts are current. Estimated Completion Date: 9/30/2025 Contact Person: Jamie Taylor, Finance Director Telephone: 229-686-2081 Email: jamie.taylor@berrien.k12.ga.us
View Audit 361188 Questioned Costs: $1
Department of Health and Human Services Nashville Safe Haven Family Shelter, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Audit period: January 1, 2024 through December 31, 2024 The findings from the schedule of findings and questioned costs are...
Department of Health and Human Services Nashville Safe Haven Family Shelter, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Audit period: January 1, 2024 through December 31, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2024-001 Temporary Assistance for Needy Families – Assistance Listing No. 93.558 Recommendation: We recommend that management compares the mileage reimbursement per the grant allocation worksheets to the mileage reimbursement register to ensure only expenses incurred is being allocated to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Safe Haven will only change mileage reimbursement rates each year at the beginning of a calendar month, since allocations are calculated based on a single mileage rate for the month. Furthermore, Safe Haven will work with our Salesforce consultants to ensure the mechanism used to allocate staff costs is accurately programmed to calculate costs not to exceed actual amounts paid. Lastly, we will make it practice to compare the mileage reimbursement per the grant allocation worksheets to the mileage reimbursement register each month before completion of invoicing. Name(s) of the contact person(s) responsible for corrective action: Ben Piñon, Finance Director. Planned completion date for corrective action plan: August 2025 If the US Department of Health and Human Services has questions regarding this plan, please call Ben Piñon at 615-256-8195 ext. 125.
View Audit 361187 Questioned Costs: $1
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