Corrective Action Plans

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In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent...
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent co-mingling of cash, we will begin a plan to break apart the funds for each program - Spencer, COCC, 3rd and 11th. Each quarter, we access payroll allocations to better reflect employees’ use of time and actual costs incurred by program and by LITC property. Public Housing and COCC training is planned that all finance staff will attend to make sure proper HUD procedures, rules, and guidelines are followed. The plan is to reduce the receivable down to $-0- as soon as possible and within 5 years.
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened controls to ensure that all Head Start/ Early Head Start charges are adequately documented, properly approved, and reviewed for compliance with allowable cost requirements. The Organization has implemented...
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened controls to ensure that all Head Start/ Early Head Start charges are adequately documented, properly approved, and reviewed for compliance with allowable cost requirements. The Organization has implemented processes requiring documented approval for Head Start/Early Head Start charges. Required support includes invoices or payroll documentation, allocation support when applicable, evidence of allowability, and documented supervisory approval. Finance will verify that required support is complete before costs are charged to the program. Periodic internal monitoring procedures are currently being performed to review Head Start/ Early Head Start expenditures for documentation sufficiency, evidence of approval, and compliance with allowable cost principles. Any deficiencies identified will be corrected timely, and recurring issues will be addressed through staff training or process improvements. Management will review the questioned costs identified in the audit and determine the appropriate corrective action, including obtaining additional supporting documentation or reclassifying costs, as needed. Responsible Party: Chief Financial Officer, with support from the Finance Team and Head Start Program Leadership. Anticipated Completion Date: Updated processes have been implemented and are currently in operation to mitigate the risk of future findings. Monitoring Plan: Management will perform quarterly reviews of Head Start/ Early Head Start expenditures. Results will be reviewed with the CFO and Program Leadership, and any corrective actions will be documented and tracked through resolution.
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened its grant accounting, financial close and reporting controls to ensure that grant revenue, receivables, expenses, refundable advances and SEFA amounts are recorded accurately and in the appropriate reporti...
Corrective Action Plan: Management concurs with the findings. Sheltering Arms has strengthened its grant accounting, financial close and reporting controls to ensure that grant revenue, receivables, expenses, refundable advances and SEFA amounts are recorded accurately and in the appropriate reporting period. During fiscal year 2025, the Finance department experienced significant personnel changes. New management performed a transaction review to determine whether transactions were properly allocated and recorded. During this review, several transactions totaling $741,113 were identified as having been allocated to the incorrect fiscal period. In addition, the $357,774 liability resulted from an adjustment made by a contractor in March 2025 that incorrectly allocated CACFP revenues and related expenses to fiscal year 2024. Responsible Party: Chief Financial Officer, with support from the Finance Team. Anticipated Completion Date: Updated processes have been implemented and are currently in operation to mitigate the risk of future findings. Monitoring Plan: Management will perform monthly reviews of grant reconciliations, cost transfers, and significant grant-related journal entries to ensure transactions are recorded accurately, supported by appropriate documentation, and recognized in the proper reporting period.
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The...
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The Organization will implement enhanced grant management procedures to ensure that federal funds are obligated and utilized within the approved period of availability. Corrective actions include: 1. Maintaining a centralized grant tracking system that identifies award periods, obligation deadlines, expenditure deadlines, and closeout requirements. 2. Requiring quarterly reviews of grant balances and project progress by program and finance personnel. 3. Establishing written procedures for monitoring unobligated balances and addressing delays in project implementation. Providing training to program managers and fiscal staff regarding federal grant requirements, including obligation and period-of-performance requirements. Requiring management review of all federal awards at least 90 days prior to expiration to identify and address any risk of unexpended or unobligated funds. Anticipated Completion Date: Immediately
The City is currently implementing measures to ensure the actual hours worked is correctly coded.
The City is currently implementing measures to ensure the actual hours worked is correctly coded.
Name of Auditee: Central Falls Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2025 CAP Prepared by: Bridgett Duquette, Executive Director Phone: (401) 727-9090 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 20...
Name of Auditee: Central Falls Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: September 30, 2025 CAP Prepared by: Bridgett Duquette, Executive Director Phone: (401) 727-9090 (A) Current Finding on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendations, please see below for action taken. (b) Action taken - The Authority will submit all required documentation to HUD. (c) Planned implementation date of corrective action - Completed by September 30, 2026.
Moving forward, the Chamber will use an employee’s timesheet to bill wages to federal awards. When preparing reimbursement requests, the staff will calculate the wage amount that is equal to the number of hours each employee self-attested to working to the federal grant by coding the hours on their ...
Moving forward, the Chamber will use an employee’s timesheet to bill wages to federal awards. When preparing reimbursement requests, the staff will calculate the wage amount that is equal to the number of hours each employee self-attested to working to the federal grant by coding the hours on their timesheet for the applicable pay periods. If a true-up of wage expenses is done at any time during the cycle of the federal grant, the Chamber will maintain adequate documentation (the employee timesheets) to indicate how the true-up was calculated. The calculation provided by the staff will be reviewed by the Executive Director prior to the reimbursement request being submitted to the granting agency.
The Band has developed and initiated a procedure to subject all employees with access to vulnerable populations to be subjected to background investigations. The Band has instituted these procedures; however, they were initiated post the September 30, 2025 financial statements. OMB will continue to ...
The Band has developed and initiated a procedure to subject all employees with access to vulnerable populations to be subjected to background investigations. The Band has instituted these procedures; however, they were initiated post the September 30, 2025 financial statements. OMB will continue to monitor this process in a quarterly review with Human Resources.
Finding – 2025-003 Allowable Costs and Cost Principles and Activities Allowed and Unallowed – Significant Deficiency in Internal Controls Over Compliance Federal Program: Provider Relief Funds Assistance Listing Number: 93.498 Year(s): 2025 Federal Agency: US Department of Health and Human Services ...
Finding – 2025-003 Allowable Costs and Cost Principles and Activities Allowed and Unallowed – Significant Deficiency in Internal Controls Over Compliance Federal Program: Provider Relief Funds Assistance Listing Number: 93.498 Year(s): 2025 Federal Agency: US Department of Health and Human Services Corrective Action: The Division will enhance controls to ensure that documentation of cost review is retained and stored for audit purposes. The Division will continue to train field staff on the importance of document retention. 1. Internal process to be continued throughout FY 2026. 2. The program managers and/or contract billing specialist will save all work pertaining to an invoice/bill (i.e. monthly, quarterly, addendums, etc.) and electronically via email submit to program directors for review and approval before submission can proceed to granting agency to ensure accuracy and for contract fulfillment and requirements. 3. The program managers and/or contract billing specialist will save all documentation of the reviewed and submitted process to the regional internal digital file storage system, as well as send a copy of the finance department for review/approval/storage for audit purposes and the finance department will lastly make sure it is filled out and fulfills the requirement of the contract, as a last line of grant requirement fulfillment. 4. Continued training of field staff and program directors to occur. Anticipated Completion Date: 10/01/2026 Responsible Contact Person: Kendall Phillips, Grants & Contracts Accountant
Finding – 2025-002 Allowable Costs and Cost Principles and Activities Allowed and Unallowed – Significant Deficiency in Internal Controls Over Compliance, Noncompliance Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal...
Finding – 2025-002 Allowable Costs and Cost Principles and Activities Allowed and Unallowed – Significant Deficiency in Internal Controls Over Compliance, Noncompliance Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: US Department of Treasury Corrective Action: The Division will enhance controls and processes around the allocation of personnel-related costs, including retaining calculations and allocations of personnel costs that are charged to the grant. 1. Internal process to be continued throughout FY 2026. 2. The program directors will provide finance with a thorough written and grantor approved plan on all program staff that are to have time allocated to grant funded operations. Should any deviations of allocations of salary or staff occur from initial approved plan the program staff will provide written approval from the grantor to the finance department. 3. Billing staff for grant funded programs will provide all calculations via excel spreadsheets based on and ties to UKG Payroll data per payroll cycle. The calculations will be reviewed/approved electronically and saved/stored to the regional internal digital file storage system, as well as provided to the finance department for audit purposes. 4. Continued training of field staff and program directors to occur. Anticipated Completion Date: 10/01/2026 Responsible Contact Person: Kendall Phillips, Grants & Contracts Accountant
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting schedules Reconciliation • Perform quarterly true-ups between budget and actual Training • Train staff on allocation methodology and documentation Monitoring • Conduct periodic reviews and report results to management
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in Paylocity reflecting actual time worked Integration with Payroll Allocation • Ensure payroll allocations are based on actual time and effort • Perform monthly Finance review of payroll allocations Policy Updates • Update payroll and cost allocation policies to align with Uniform Guidance (§200.430) Training • Provide training to staff and annual refresher courses Monitoring and Oversight • Perform quarterly reviews and report to Audit and Finance Committees
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitorin...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitoring • Perform quarterly compliance reviews
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in Paylocity reflecting actual time worked Integration with Payroll Allocation • Ensure payroll allocations are based on actual time and effort • Perform monthly Finance review of payroll allocations Policy Updates • Update payroll and cost allocation policies to align with Uniform Guidance (§200.430) Training • Provide training to staff and annual refresher courses Monitoring and Oversight • Perform quarterly reviews and report to Audit and Finance Committees
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we wil...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we will perform a detailed review of all salaries charged to federal grants to ensure there is no salary over the cap. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules and/or enhance monitoring controls where possible. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures for the specific grants will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective ac...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective actions: 1. Establish standardized procedures requiring all operating sites to submit enrollment forms and Income Eligibility Forms prior to reimbursement claims being submitted. 2. Develop a monitoring checklist to verify that all required participant documentation is collected, complete, and retained. 3. Require monthly compliance reviews of participant files for each operating site. 4. Provide additional training to site administrators regarding CACFP eligibility documentation and retention requirements. Responsible Party Jeff Reynolds and Sonja Williams Expected Completion Date September 30, 2026
The Child and Family Services Agency (CFSA) concurs with the findings as stated. CFSA will review the intradistrict mandate with the Office of the Chief Technology Officer to gain greater clarity into their budgetary allocation of expenditure methodologies to subsidiary agencies, including CFSA, wit...
The Child and Family Services Agency (CFSA) concurs with the findings as stated. CFSA will review the intradistrict mandate with the Office of the Chief Technology Officer to gain greater clarity into their budgetary allocation of expenditure methodologies to subsidiary agencies, including CFSA, with a goal of providing the requested information to auditors during future audits. CFSA will initiate training for management staff to address appropriate practice for time keeping and approvals by September 30, 2026.
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income su...
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This would be automating the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. DCWET will work with DICM to request that a JIRA ticket be created to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The ESA DPO needs to conduct staff training (re-training) of all SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to providing adequate training to SSRs involved in updating customers’ employment information in DCAS. The DCWET Deputy Administrator will take the lead with the DPO counterpart to implement the necessary training starting before September 30, 2027.
The Department of Health (DC Health) concurs with the finding. DC Health and OCFO will coordinate the development and implementation of a standard operating procedure to ensure that program administrators are implementing a secondary review of journal requests and OCFO accountants maintain a trackin...
The Department of Health (DC Health) concurs with the finding. DC Health and OCFO will coordinate the development and implementation of a standard operating procedure to ensure that program administrators are implementing a secondary review of journal requests and OCFO accountants maintain a tracking record of all journal requests and properly review each request to ensure the expenditure is not duplicated via a journal entry.
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury)...
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury) regarding the use of funds. DMPED has evaluated its procedures to ensure only allowable expenses are charged to the program as required under 2 CFR Section 200.403. DMPED determined in FY25 that it needed to seek approval from the awarding Federal agency on allowable costs, which it completed in 2026.
FINDING – Federal Award Finding 2025-001: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Allowable Costs / Period of Performance Repeat Finding: No Condition: During our testing over all...
FINDING – Federal Award Finding 2025-001: Agency: U.S. Department of Health and Human Services (CSBG) Program: Community Service Block Grant (AL No. 93.569) Significant Deficiency and Noncompliance over Allowable Costs / Period of Performance Repeat Finding: No Condition: During our testing over allowable costs, we identified 2 transactions in the amount of $38,225 that were incurred in fiscal years 2022 and 2023; however, those costs were recorded as federal expenditure and revenue in fiscal year 2025. The current CSBG grant covering fiscal year 2025 covers the period October 1, 2024 – September 30, 2025, as such, those costs were recorded outside of the period of performance and as such are unallowable. Recommendation: We recommend that management strengthen controls over the timing of federal expenditure recognition to ensure costs are recorded in the proper period of performance. Additionally, the entity should implement procedures to review and reconcile expected expenses to actual invoices received on a periodic basis to ensure all vendor invoices have been timely received. Auditee Response and Corrective Action Plan: UPO has recently implemented two methods for procuring goods and services to address the noted condition. Use of the P-Card for micropurchases and the Purchase Request for larger purchases. P-Card purchases will allow recurring vendor invoices and payments to be captured in real time and recorded in the appropriate billing and funding period. Mandatory use of Purchase Request/PO for all other purchases, to allow the program and finance team to monitor invoices and obligations, and record them within the funding period.
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implement...
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implemented corrective actions through the full implementation of a new enterprise resource planning system, Fusion. Under this process, all timecards are now entered, reviewed, and approved directly within Fusion and cannot be processed for payment unless they have been formally approved by appropriate management personnel. This ensures proper documentation, accountability, and adherence to internal control policies. Name of Person Responsible for the Plan: Katherine Hill, Manager of Accounting Jason Lynn, Vice President of Finance and Controller Anticipated Completion Date of the Plan: Completed – fully implemented with the rollout of the Fusion system (May 2025).
We concur with the finding and are implementing procedures to address all issues. The payroll allocation errors identified were caused by inconsistent application of time allocation procedures at the employee level and insufficient monitoring controls to detect misallocations in a timely manner. CAP...
We concur with the finding and are implementing procedures to address all issues. The payroll allocation errors identified were caused by inconsistent application of time allocation procedures at the employee level and insufficient monitoring controls to detect misallocations in a timely manner. CAP plans to reimburse the related unallowable costs to the Federal Government by June 30, 2026. To address these issues, CAP is enhancing its internal controls over payroll allocations. CAP will conduct mandatory refresher training for applicable staff on time allocation requirements to reinforce compliance expectations. Additionally, CAP has implemented a new accounting system that will allow for the use of validation rules designed to prompt time allocations when employees charged to federal funding engage in non-federal activities. CAP will also perform periodic reviews of payroll allocations to ensure that they align with employees’ current duties and funding sources, and these reviews will be documented and performed by personnel independent of the preparer. These actions are designed to improve the accuracy and consistency of payroll allocations and ensure compliance with federal cost principles. CAP expects to fully implement these corrective actions by June 2026.
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