Corrective Action Plans

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Finding 2025-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – June 30, 2026 Management agrees with the finding. Remediation: Fairview has correc...
Finding 2025-001 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date – June 30, 2026 Management agrees with the finding. Remediation: Fairview has corrected the payroll reimbursement request for the inaccurate payroll charges identified in the finding. To prevent recurrence, Fairview will enhance controls over payroll review processes to ensure accuracy prior to submission. These enhancements include reinforcing review expectations with project directors and including detailed review procedures for validating pay rate and wage calculations prior to reimbursement submissions. Management believes these actions will improve the accuracy of payroll charges and ensure compliance with federal program requirements.
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal co...
INVOICE CODING - Criteria: Costs are necessary and reasonable for the performance of the federal award and allocable under the principles of 2 CFR 200, Subpart E. Condition: One invoice charged to the grant in the amount of $1,955 should have been allocated to a different grant. Context: Internal control review procedures did not correctly identify that the invoice was charged to the incorrect grant. Effect: Cost was charged to the wrong grant. Cause: Error in invoice coding. Recommendation: Review procedures should be enhanced to ensure approved costs are charged to the appropriate grant. Corrective Action: This mistake of grant attribution was subsequently corrected completely. The issue was attributable to a manual process that has been replaced by electronic processing. The electronic procurement system significantly reduces and in most cases eliminates data entry and manual translation between procurement and posting to a particular grant. Adequate review and oversight processes are in place and this issue does not reflect a systemic failure. Responsible Party: Claudine Lurvey, VP of Finances.
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and...
Finding 2025-005: Crime Victim Assistance Documented Review and Approval Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should expand its financial reporting review procedures to require the documented review and approval of all performance reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: During the fiscal year, the Organization properly implemented procedures that require the documented review of the monthly financial reports, including the corresponding indirect cost calculations. The Organization will expand these policies and procedures to require the documented review and approval of all performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00...
Finding 2025-004: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures Type of Finding: Control U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20253442-00, E20252994-00, E20254307-00, and E20252103-00 Award Year End: September 30, 2025 Recommendation: The Organization should establish and maintain written internal control procedures that cover the required five components of internal control for each area of compliance for each of its federal programs. The Organization should educate all employees working with federal programs of the Organization’s procedures and monitor compliance with them. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by June 30, 2026. If the U.S. Department of Justice has questions regarding this plan, please call Megan Hennessey at (616) 494-1724.
Corrective Action: All vouchers require Town Manager and Finance Director to approve and sign all vouchers prior to payment. Efforts are in place to make this a high priority even in busy times. The number of transactions processed greatly increased relative to Federal dollars, but the Town is commi...
Corrective Action: All vouchers require Town Manager and Finance Director to approve and sign all vouchers prior to payment. Efforts are in place to make this a high priority even in busy times. The number of transactions processed greatly increased relative to Federal dollars, but the Town is committed to internal controls. Anticipated Completion Date: Immediately Contact Person: Elizabeth Draper and Brian Rosso
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and th...
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and the policy historically observed by the Organization of 72 working hours. Auditor Recommendation: Advance Funds- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review to ensure federal funds are limited to minimum amounts needed for immediate cash requirements as indicated in the Uniform Guidance. Corrective Action: Advance Funds- Internal controls have been updated and there is an additional level for reviewing requests. The Executive Director is provided a list of all funds available after each draw down and the amounts drawn down are matched to the GL and GFR. This responsibility will be transferred to the Deputy Director once the new Fiscal Manager is in place. There is a schedule for the date the funds are allowed to be requested that fall within the 72-hour window posted in the Finance office and the Executive Director is notified before any requests are processed. The current Finance officer is meeting every 2 weeks for training with NDRN and policies, Uniform Guidance, MIP processes, and federal grants are reviewed in these meetings. Timeline: Advance Funds- TA with NDRN: Every 2 weeks starting April 22, 2026. Fiscal Manager: Posting for the position will be up by end of June 2026. 72-Hour Listing: Created and posted 6/1/26 Finding: Payroll Expenses- During our testing of allowable costs, 2 of the 20 time sheets selected did not contain approval signatures. Auditor Recommendation: Payroll Expenses- We recommend that management update its internal control policies to establish formal backup/interim approval authorities. When primary supervisors are out of the office on vacation or leave, a designated alternative official must be authorized to review and approve timesheets timely to ensure the continuity of internal controls. Corrective Action: Payroll Expenses- Payroll review: Payroll packets are reviewed during and after the payroll process to ensure all timesheets are approved and signed off by both the Executive Director and Board of Directors when appropriate. Executive Director’s timesheets and authorizations are presented to the Board of Directors when signing checks for review and approval. Procedures have been updated to include a secondary review of the timesheets at the end of each payroll cycle. Timeline: Payroll Expenses- Payroll review: After every payroll beginning 4/23/26 Finding: Prepaid Rent- As of September 30, 2025, a total of 14 months of rent payments were recognized in the general ledger and had been drawn from the PAIMI program. Total questioned costs related to these prepaid transactions, prepaid at year end, totaled $3,855.80. Auditor Recommendation: Prepaid Rent- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review of all general ledger disbursements against grant draws to ensure federal funds are limited to minimum amounts needed for immediate cash requirements. Corrective Action: Prepaid Rent- We received permission and were encouraged by our federal funders to pre-pay rent. We will not be pre-paying rent going forward. The Executive Director meets weekly with both PADD and PAIMI program managers to review processes. Timeline: Prepaid Rent- PADD and PAIMI program manager meetings: ongoing since before audit. Finding: Program Income- Our testing of allowable costs under the PADD grant identified two specific transactions where expenditures were fully reimbursed by federal funds despite being offset by program income and/or being erroneously drawn. Because these transactions relate to the same journal entry recognized in the general ledger, these are considered isolated instances. Auditor Recommendation: Program Income- We recommend that management design and implement formal, written internal control procedures to identify, track, and account for all program income generated by PADD grant activities within the general ledger. Corrective Action: Program Income- We received confirmation from the federal partners that we should spend the $16,165 legal fees from 2023, in April 2026. Those funds were not drawn down during PPE 4/30/26 and 5/15/26. Timeline: Program Income- $9104 was used to cover the PADD draw down for 4/30/26. No additional funds were drawn down. The remaining $7061 was used to cover part of the funds requested for 5/15/26. Additional funds were requested during the 5/15/26 draw down to cover remaining expenses. Nevada Disability and Law Center 2820 W Charleston Blvd, Suite 11 Las Vegas, NV 89102 EIN: 88-0327392 Jessica Crain, Deputy Director (Jessica@ndalc.org) (702) 257-8150 ext. 7122 phone (702) 257-8170 fax
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and th...
Findings (2025-001, 2025-002, 2025-003) Finding: Advance Funds- In accordance with 45 CFR 75.305(b)(1) [refer to “Prepaid Rent” above]. Of the 24 cash advances received, one advance was held for six working days, which is in excess of “immediate cash needs” as outlined in the Uniform Guidance and the policy historically observed by the Organization of 72 working hours. Auditor Recommendation: Advance Funds- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review to ensure federal funds are limited to minimum amounts needed for immediate cash requirements as indicated in the Uniform Guidance. Corrective Action: Advance Funds- Internal controls have been updated and there is an additional level for reviewing requests. The Executive Director is provided a list of all funds available after each draw down and the amounts drawn down are matched to the GL and GFR. This responsibility will be transferred to the Deputy Director once the new Fiscal Manager is in place. There is a schedule for the date the funds are allowed to be requested that fall within the 72-hour window posted in the Finance office and the Executive Director is notified before any requests are processed. The current Finance officer is meeting every 2 weeks for training with NDRN and policies, Uniform Guidance, MIP processes, and federal grants are reviewed in these meetings. Timeline: Advance Funds- TA with NDRN: Every 2 weeks starting April 22, 2026. Fiscal Manager: Posting for the position will be up by end of June 2026. 72-Hour Listing: Created and posted 6/1/26 Finding: Payroll Expenses- During our testing of allowable costs, 2 of the 20 time sheets selected did not contain approval signatures. Auditor Recommendation: Payroll Expenses- We recommend that management update its internal control policies to establish formal backup/interim approval authorities. When primary supervisors are out of the office on vacation or leave, a designated alternative official must be authorized to review and approve timesheets timely to ensure the continuity of internal controls. Corrective Action: Payroll Expenses- Payroll review: Payroll packets are reviewed during and after the payroll process to ensure all timesheets are approved and signed off by both the Executive Director and Board of Directors when appropriate. Executive Director’s timesheets and authorizations are presented to the Board of Directors when signing checks for review and approval. Procedures have been updated to include a secondary review of the timesheets at the end of each payroll cycle. Timeline: Payroll Expenses- Payroll review: After every payroll beginning 4/23/26 Finding: Prepaid Rent- As of September 30, 2025, a total of 14 months of rent payments were recognized in the general ledger and had been drawn from the PAIMI program. Total questioned costs related to these prepaid transactions, prepaid at year end, totaled $3,855.80. Auditor Recommendation: Prepaid Rent- We recommend that management design and implement formal, written internal control procedures to ensure compliance with cash management requirements. Specifically, management should implement a supervisory review of all general ledger disbursements against grant draws to ensure federal funds are limited to minimum amounts needed for immediate cash requirements. Corrective Action: Prepaid Rent- We received permission and were encouraged by our federal funders to pre-pay rent. We will not be pre-paying rent going forward. The Executive Director meets weekly with both PADD and PAIMI program managers to review processes. Timeline: Prepaid Rent- PADD and PAIMI program manager meetings: ongoing since before audit. Finding: Program Income- Our testing of allowable costs under the PADD grant identified two specific transactions where expenditures were fully reimbursed by federal funds despite being offset by program income and/or being erroneously drawn. Because these transactions relate to the same journal entry recognized in the general ledger, these are considered isolated instances. Auditor Recommendation: Program Income- We recommend that management design and implement formal, written internal control procedures to identify, track, and account for all program income generated by PADD grant activities within the general ledger. Corrective Action: Program Income- We received confirmation from the federal partners that we should spend the $16,165 legal fees from 2023, in April 2026. Those funds were not drawn down during PPE 4/30/26 and 5/15/26. Timeline: Program Income- $9104 was used to cover the PADD draw down for 4/30/26. No additional funds were drawn down. The remaining $7061 was used to cover part of the funds requested for 5/15/26. Additional funds were requested during the 5/15/26 draw down to cover remaining expenses. Nevada Disability and Law Center 2820 W Charleston Blvd, Suite 11 Las Vegas, NV 89102 EIN: 88-0327392 Jessica Crain, Deputy Director (Jessica@ndalc.org) (702) 257-8150 ext. 7122 phone (702) 257-8170 fax
Views of Responsible Officials of the Auditee: The Board agreed with the finding. The Board implemented procedures to ensure compliance with the U. S. Code of Federal Regulations Title 2, Part 200.318, of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Aw...
Views of Responsible Officials of the Auditee: The Board agreed with the finding. The Board implemented procedures to ensure compliance with the U. S. Code of Federal Regulations Title 2, Part 200.318, of the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) and the Code of Alabama 1975, Title 39, by conducting training with all personnel. Purchasing Cooperatives will not be used when purchases are under the Public Works Law.
2025-001 Aging Cluster-Special Programs for the Aging, Title III, Part B, Grants for Supportive Services and Senior Centers- Assistance Listing No. 93.044. Special Programs for the Aging, Title III, Part C, Nutrition Services- Assistance Listing No. 93.045. Nutrition Services Incentive Program- Assi...
2025-001 Aging Cluster-Special Programs for the Aging, Title III, Part B, Grants for Supportive Services and Senior Centers- Assistance Listing No. 93.044. Special Programs for the Aging, Title III, Part C, Nutrition Services- Assistance Listing No. 93.045. Nutrition Services Incentive Program- Assistance Listing No. 93.053 Condition Found Out of forty payroll transactions tested, we noted 14 instances where part-time employees did not have their timecard approved by their supervisor. We consider this condition to be a material weakness relating to the Allowable Costs/Cost Principles compliance requirement. Statistical sampling was not used in making sample selections. Corrective Action Plan DuPage Senior Citizens Council will strengthen controls over payroll timecard approval to ensure all part time employee timecards are reviewed and approved by an appropriate supervisor prior to payroll processing. Management will formalize and document supervisory approval requirements within written payroll procedures. Payroll will not be processed unless all required timecards reflect documented supervisory review and approval. Oversight of compliance with these procedures will be supported through periodic review by the Executive Director and the outsourced accounting firm through documented policy and process reviews. Responsible Person for Corrective Action Plan Executive Director, with support from the Payroll Clerk Implementation Date of Corrective Action Plan DSCC began implementing this process in May 2025. The corrective action was effective immediately at that time and is considered fully implemented.
2025-001 Special Education Cluster – 84.027, 84.173 Recommendation: We recommend procedures be implemented to ensure that time and effort certifications are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in ...
2025-001 Special Education Cluster – 84.027, 84.173 Recommendation: We recommend procedures be implemented to ensure that time and effort certifications are completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Following the identification of this omission at the end fiscal 2025, the district immediately re-established the time and effort documentation procedures and monitoring processes. Note that all staff charged to the grant in FY25 are employees who are wholly assigned to provide direct services to special education students. Time and effort documentation has been fully restored as of July 1, 2025 and is currently being maintained and monitored. Name(s) of the contact person(s) responsible for corrective action: Julie Kirrane, Bedford Public Schools Dir. of Finance. Planned completion date for corrective action plan: Corrective action has been completed.
Management’s Response Regarding Corrective Action Taken or Planned These rules apply to costs charged directly to federal programs, such as the 5311 grants that require a 44.67% match when used for operating expenses. All maintenance and administrative staff time is eligible as direct costs for thes...
Management’s Response Regarding Corrective Action Taken or Planned These rules apply to costs charged directly to federal programs, such as the 5311 grants that require a 44.67% match when used for operating expenses. All maintenance and administrative staff time is eligible as direct costs for these grants as their time is only spent on transit activities and not administrating non-transit programs. Staff apply payroll costs and on either actual vehicle miles or hours based their type of work, as recommended by the National Rural Transit Assistance Program, for time by staff that cannot be directly tied to a specific grant source.
2025-003 Material Weakness in Internal Control over Compliance - Review of Project Costs U.S. Department of Homeland Security Federal Emergency Management Agency Passed through State of Iowa Department of Homeland Security & Emergency Management Federal Assistance Listing Number (ALN): 97.036 Federa...
2025-003 Material Weakness in Internal Control over Compliance - Review of Project Costs U.S. Department of Homeland Security Federal Emergency Management Agency Passed through State of Iowa Department of Homeland Security & Emergency Management Federal Assistance Listing Number (ALN): 97.036 Federal Award Year: 2024 Compliance Requirement: Allowable costs/Cost Principles; Internal Control over Compliance Criteria - The Uniform Guidance requires the City to establish and maintain effective internal control over compliance for federal awards, including controls to reasonably ensure that costs charged to federal programs are allowable, properly supported, and comply with applicable federal requirements and the terms and conditions of the award. Condition - The City did not have adequately designed and implemented review controls over certain material project costs included in reimbursement requests submitted to FEMA. Our testing identified that key review procedures intended to verify the eligibility, accuracy, and supporting documentation of project costs were not consistently performed or evidenced for certain large-dollar transactions. Cause - The condition resulted from insufficient formalization and documentation of review procedures, as well as inadequate segregation of duties and oversight for the review of high­ dollar project costs prior to submission to FEMA. Effect - The absence of effective review controls over material project costs increases the risk that ineligible, unsupported, or incorrectly calculated costs could be included in reimbursement requests without timely detection and correction. This deficiency is considered a material weakness in internal control over compliance for the FEMA Public Assistance program. Recommendation - We recommend that the City design and implement formal, documented review procedures over material project costs included in FEMA reimbursement requests. These procedures should include defined review responsibilities, documentation of the review performed, and supervisory oversight to ensure that all high-dollar or complex transactions are reviewed for eligibility, accuracy, and adequate supporting documentation before submission. Views of Responsible Officials� Management agrees with the finding.
2025-002 - FEMA Public Assistance - Allowable Costs/Cost Principles - Questioned Cost U.S. Department of Homeland Security Federal Emergency Management Agency Passed through State of Iowa Department of Homeland Security & Emergency Management Federal Assistance Listing Number (ALN): 97.036 Federal A...
2025-002 - FEMA Public Assistance - Allowable Costs/Cost Principles - Questioned Cost U.S. Department of Homeland Security Federal Emergency Management Agency Passed through State of Iowa Department of Homeland Security & Emergency Management Federal Assistance Listing Number (ALN): 97.036 Federal Award Year: 2024 Criteria - Under FEMA Public Assistance program requirements and applicable federal cost principles, only eligible costs incurred by the applicant, and supported by appropriate documentation, may be claimed for reimbursement. Donated services are subject to specific eligibility criteria and documentation standards and, in certain circumstances, are not allowable as reimbursable project costs. Condition - During our testing of allowable costs, we noted that the City claimed reimbursement from FEMA for donated services that did not meet the eligibility requirements for reimbursement under the Public Assistance Program. Cause - The condition resulted from a miscommunication between the Public Works Director and payables processing clerks to process payment for an invoice that indicated donated services. Effect - As a result, ineligible costs were submitted to FEMA for reimbursement. Although the amount is not material to the federal program as a whole, it represents noncompliance with federal program requirements. Recommendation - We recommend that the City enhance its procedures over the review of costs included in FEMA reimbursement requests to ensure that donated services are evaluated in accordance with FEMA Public Assistance program requirements and are excluded from reimbursement claims when not eligible. The City should correspond with the Iowa Department of Homeland Security and Emergency Management and FEMA to discuss the proper resolution for the solution. Views of Responsible Officials - The City will immediately be in contact witH the governing authorities and work quickly and effectively to resolve the issue and will strive to obtain and understanding of the grant requirements and strengthen controls to ensure it is communicated well.
2025-006 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirement (Significant Deficiency) Contact Name – Robert Mooney Position – Chief Financial Officer Phone Number – rmooney@corusinternational.org Estimated date of com...
2025-006 – Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs/Cost Principles Requirement (Significant Deficiency) Contact Name – Robert Mooney Position – Chief Financial Officer Phone Number – rmooney@corusinternational.org Estimated date of completion – September 30, 2026 Corrective Action Plan – Corus management concurs with this finding. In early 2025 Corus’ USAID funded project in Haiti was terminated and we were required to close down the project within two months. At that time, the security situation in Haiti was volatile and our Haiti employees were unable to regularly access the office and none of our US-based employees were permitted to travel to Haiti to assist with the project close out. As part of the close-out, Corus employed the services of a local courier company (none of the US-based courier companies were operating in Haiti at that time due to the security issues) to ship all physical supporting documentation to our offices in the US. Unfortunately, those documents were never received and despite several follow ups with the courier company, we were unable to locate the documents. The key learning was that we need to ensure that going forward all physical accounting related supporting documentation is digitized in a timely manner. This requirement was already a part of our document management policies and procedures. However, we were not regularly tracking compliance. It is important to note that the new Finance & Accounting solutions will enforce staff to digitally capture supporting documentation at the point of transaction entry, thereby transitioning us to a digital first organization.
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes th...
2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes the importance of maintaining complete and readily accessible documentation to support all federal expenditures in accordance with institutional policy and federal compliance requirements. The University will reinforce documentation and record retention requirements with all relevant personnel, including finance staff, grant administrators, and principal investigators. Additionally, management will implement enhanced controls to ensure that all required supporting documentation is properly maintained and centrally accessible. This will include transitioning toward a more standardized and, where feasible, electronic document management process to reduce the risk of missing records. Furthermore, periodic monitoring procedures will be established, including routine reviews of disbursement files to confirm the presence of required supporting documentation. Any identified deficiencies will be promptly addressed, and corrective actions will be taken to prevent recurrence. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and ...
2025-003: Period of Performance Compliance Action Taken/Planned: Management acknowledges the instances identified in which disbursements were processed after the award's period of performance. While no questioned costs were noted, the University recognizes that timely processing of expenditures and drawdowns is critical to ensuring compliance with federal requirements governing grant periods. To Strengthening Grant Closeout Procedures management will establish a formal grant closeout timeline to begin 90 days prior to the award end date, require principal investigators (PIs) and grant administrators to review all outstanding obligations and ensure timely submission of final expenses and implement a standardized closeout checklist to confirm all costs are recorded within the allowable period To Enhanced Monitoring of Grant Periods management will develop and maintain a centralized tracking system for all federal awards, including start and end dates, generate monthly reports identifying grants nearing expiration (within 90, 60, and 30 days) and distribute reports to Pis, Grants Accounting, and Finance leadership for proactive management. For timely processing and drawdown controls management will require all invoices and expenditures to be submitted within a defined timeframe (e.g., within 30 days of service or project completion), establish internal deadlines for processing disbursements and drawdowns prior to the grant end date and implement a review step within Grants Accounting to verify that expenses fall within the period of performance before payment is released. The grants department will conduct mandatory training for PIs, grant managers, and finance staff on period of performance requirements and federal compliance expectations and reinforce accountability for timely submission and processing of expenditures Management will also put in place for any costs identified outside the period of performance will require, documented justification, review and approval by the Director of Grants Accounting and CFO, and verification of allowability under award terms or sponsor approval, if applicable. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
Views of Responsible Officials: Management acknowledges that a formal internal review and approval process over Federal drawdowns was not in place during the audit period, particularly for the more frequent drawdowns that moved from monthly to weekly. The change in drawdown practices, including perf...
Views of Responsible Officials: Management acknowledges that a formal internal review and approval process over Federal drawdowns was not in place during the audit period, particularly for the more frequent drawdowns that moved from monthly to weekly. The change in drawdown practices, including performing draws on a more frequent basis, was implemented in response to managing cash flow and external risks.Management notes that oversight was performed on a periodic basis, specifically each quarter end. Starting in May 2026, one financial party will calculate the Federal pull amount using actual costs and a 10% indirect rate, the Executive Director will review and sign off, and the Director of Grandfamilies & Kinship Support Network will initiate pulling funds from the Federal system.
Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the a...
Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 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. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2026
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 ...
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. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2026
1. Implementation of Formal Written Policy MCHA implemented a comprehensive Tenant File Review Policy and Procedure in November 2025. The policy: • Establishes mandatory monthly file review requirements • Defines standardized file selection methodology • Requires consistent documentation of all revi...
1. Implementation of Formal Written Policy MCHA implemented a comprehensive Tenant File Review Policy and Procedure in November 2025. The policy: • Establishes mandatory monthly file review requirements • Defines standardized file selection methodology • Requires consistent documentation of all reviews • Assigns clear roles and responsibilities for oversight and implementation • Requires reviews to be completed monthly without exception, regardless of workload or competing priorities 2. Review Frequency and File Selection • A minimum of 14 tenant files per month are reviewed: o 7 files from the prior month (retrospective review) o 7 files from the upcoming/proactive review group • Files are selected through a randomized process within Compliance Manager, ensuring: o Representation across annual reexaminations, interim reexaminations, and new admissions o A consistent and unbiased sampling of program activity 3. Standardized Review Procedures All file reviews are conducted using a uniform, HOTMA-compliant audit checklist, requiring verification of: • Income and asset calculations • Third-party verification documentation • Required HUD forms and signatures • Accuracy of subsidy determinations (TTP, HAP, utility allowance) • Proper application of payment standards and program requirements 4. Documentation and Internal Control Measures MCHA established a centralized internal tracking system (Excel-based) to document and monitor all file reviews and corrections. • The tracking log: o Is accessible to Case Managers for visibility o Has restricted editing access limited to the Compliance Manager and HCV Program Manager • The log includes: o File selected and review date o Identified deficiencies o Date file is submitted for audit o Date file is returned for correction o Date corrections are completed and formally signed off This process ensures: • A complete audit trail of all reviews and corrections • Separation of duties • Data integrity and accountability 5. Correction and Verification Process • All identified deficiencies must be corrected within established timeframes • Corrections may include: o File documentation updates o Participant or owner follow-up • No file is closed until: o Corrections are verified o Compliance is confirmed by management o Final sign-off is documented 6. Oversight and Accountability • The Program Manager is responsible for: o Overall oversight of the policy and procedures o Ensuring monthly compliance with review requirements o Confirming all deficiencies are resolved prior to closure • The Compliance Manager is responsible for: o Execution and implementation of the review process o Conducting detailed file audits o Maintaining and controlling the tracking log o Monitoring and documenting all correction activity This structure ensures clear segregation of duties, accountability, and consistent oversight. 7. Staff Training and Acknowledgment • All Case Managers received formal training in November 2025 • Each staff member signed a written acknowledgment confirming: o Receipt of the policy o Understanding of requirements • Documentation has been: o Provided to the auditors o Retained for compliance verification Status of Corrective Action Corrective actions were fully implemented in November 2025 and are currently in effect. Planned Completion Date Completed – November 2025 Responsible Officials • HCV Program Manager – Oversight and compliance monitoring • Compliance Manager – Implementation and audit execution Conclusion MCHA believes the corrective actions implemented fully address the identified deficiency. The Authority has established formal written policies, strengthened internal controls, and implemented a structured and sustainable monitoring process. These measures ensure: • Consistent and timely tenant file reviews • Documented tracking and accountability of corrections • Ongoing compliance with HUD program requirements MCHA is confident that these controls prevent recurrence of the issues identified in this finding.
Corrective Action Plan Actions Planned – The HRA will implement and monitor controls to ensure policies and procedures related to tenant eligibility determinations and recertifications are consistently followed. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 3...
Corrective Action Plan Actions Planned – The HRA will implement and monitor controls to ensure policies and procedures related to tenant eligibility determinations and recertifications are consistently followed. Official Responsible – Sarah Abe, HRA Administrator Planned Completion Date – December 31, 2026 Disagreement With or Explanation of Finding – The HRA agrees with this finding. Plan to Monitor – Sarah Abe, HRA Administrator, will oversee the process to ensure tenant checklists for eligibility are completed and a separate program specialist is assigned to review and sign off on the checklists.
A designated Finance staff member with knowledge of the Uniform Guidance requirements will be responsible for overseeing SEFA preparation for each fiscal year-end. A grant-by-grant SEFA reconciliation will be completed prior to yearend close, with particular attention to period-end cutoff. The SEFA ...
A designated Finance staff member with knowledge of the Uniform Guidance requirements will be responsible for overseeing SEFA preparation for each fiscal year-end. A grant-by-grant SEFA reconciliation will be completed prior to yearend close, with particular attention to period-end cutoff. The SEFA will be independently reviewed by the Finance Director and compared to grant expenditure reports before the audit commences. Management will engage its external accountants earlier in the year-end close process.
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit f...
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend that the County enact controls to assure employees included in grant are included in reporting submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement procedures to ensure that all reports are reviewed prior to submission. Names of the contact person responsible for corrective action: Pat Paquin, Finance Manager Planned completion date for corrective action plan: December 31, 2026
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