Corrective Action Plans

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Allowable Costs and Activities Condition: Payroll costs were allocated to grants in a manner inconsistent with the time and effort documentation provided. Recommendation: Management should reinforce the requirement to retain time and effort documentation for all employees that are allocated to multi...
Allowable Costs and Activities Condition: Payroll costs were allocated to grants in a manner inconsistent with the time and effort documentation provided. Recommendation: Management should reinforce the requirement to retain time and effort documentation for all employees that are allocated to multiple grants and implement a review process whereby the allocation percentages used are compared to the employee attestations provided. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: TCA Health is enhancing its time and effort and payroll allocation processes to ensure charges to grants align with documented effort. We are building on our monthly review process for time and effort by formalizing a review in which payroll allocation percentages are compared to signed attestations, with Finance documenting any corrections and follow-up. We are also partnering with HR to ensure all Personnel Action Forms (PAFs) include appropriate grant coding and to require an updated PAF whenever an employee’s grant funding or allocation changes. In addition, TCA Health is implementing an automated integration between ADP and Sage Intacct so that approved timesheets flow directly into payroll and grant reporting, improving accuracy and the audit trail. We will leverage the systems and limit manual entry. Name(s) of the contact person(s) responsible for corrective action: Bob Van Gilder Planned completion date for corrective action plan: 9/1/26 If the U.S. Departments above have questions regarding this plan, please call Veronica Clarke, Chief Executive Office, at 773-928-5090.
Identifying Number: 2025-001 Finding: Material Weakness in Internal Control and Material Noncompliance, Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Actions Taken or Planned: While the ARP ESSER Federal programs are no longer funded, there are other Federal programs...
Identifying Number: 2025-001 Finding: Material Weakness in Internal Control and Material Noncompliance, Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Actions Taken or Planned: While the ARP ESSER Federal programs are no longer funded, there are other Federal programs that the District receives funding from. Therefore, the administrators in the District who apply and write the grants, specifically the Director of Learning & Instruction, Amabel Crawford, and the Director of Student Support Services, Jackie Janicke, will continue to participate, effective July 1, 2025, in all trainings from the Illinois State Board of Education regarding the programs they have applied for and will additionally confirm that the expenditures written into the grant are allowable under the federal guidelines for each program.
Corrective Action Plan: The Organization concurs with this finding and has implemented enhanced internal controls to ensure all timesheets charged to federal awards are properly reviewed and approved in accordance with policy; specifically, The Organization has established a requirement that all tim...
Corrective Action Plan: The Organization concurs with this finding and has implemented enhanced internal controls to ensure all timesheets charged to federal awards are properly reviewed and approved in accordance with policy; specifically, The Organization has established a requirement that all timecards must be reviewed and approved no later than the fifth day following each pay date, supported by monitoring procedures to track completion and identify any exceptions, and has also implemented a formal delegation protocol requiring supervisors to designate an alternate qualified approver when they are unavailable to ensure approvals occur timely and consistently. Person responsible for corrective action: Tamara Robinson Crayton - Controller Anticipated Completion Date: Initial implementation is in place by June 2026.
Finding 2025‐007: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Period of Performance Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 9...
Finding 2025‐007: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Period of Performance Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing, not all expenditures allocated to the federal program had documentation of review and approval. In addition, an expenditure was determined to be unallowed. Responsible Individuals: Janet Warren, Director of Financial Operations Corrective Action Plan: Management agrees with the finding. The Organization will enhance internal control policies to ensure all expenditures are reviewed and approved prior to payment to ensure that all payments are necessary and correct. Anticipated Completion Date: June 5, 2026.
Management agrees with the finding and acknowledges that procurement approval documentation was not consistently retained during the audit period. Management notes that the finding primarily relates to documentation and retention of approval evidence, including reliance on verbal approvals and docum...
Management agrees with the finding and acknowledges that procurement approval documentation was not consistently retained during the audit period. Management notes that the finding primarily relates to documentation and retention of approval evidence, including reliance on verbal approvals and documentation gaps associated with system transitions. To address this finding, management has implemented corrective actions requiring documented, written approval for procurements prior to execution. The organization will use standardized approval workflows to ensure procurement approvals are properly evidenced, retained, and available for audit review. Management has also established a centralized repository for procurement records to improve accessibility, consistency, and document retention. In addition, management will enhance data backup and migration procedures to reduce the risk of documentation loss during future system transitions. These procedures will be incorporated into formal policies and standard operating procedures. Management will monitor compliance to ensure procurement documentation and approval controls are consistently followed across federally funded programs. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026. Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations
Finding No. 2025-006 – Internal control deficiencies over accounting for federal funds received from the United States Department of Homeland Security (DHS) Corrective Action Plan Single Audit 2025 Page 6 April 30, 2026 Condition During our procedures over the Authority’s funds received from FEMA we...
Finding No. 2025-006 – Internal control deficiencies over accounting for federal funds received from the United States Department of Homeland Security (DHS) Corrective Action Plan Single Audit 2025 Page 6 April 30, 2026 Condition During our procedures over the Authority’s funds received from FEMA we noticed the following: 1. Return of interest earned on FEMA-related funds totaling approximately $211,853 was not timely recorded in the general ledger and was subsequently recorded through a post-closing entry dated January 26, 2026. 2. Management initially misclassified approximately $6 million received under the Coronavirus State and Local Fiscal Recovery Funds as state funds rather than federal awards. As a result, the amount was originally excluded from the Schedule of Expenditures of Federal Awards (the Schedule). Views of Responsible Officials and Corrective Actions It should be noted that, although certain funds received were not properly identified as working capital advances, those funds were properly considered as received from FEMA through the COR-3 office of the Government of Puerto Rico. This situation basically arises because the federal funds coming from FEMA are being handled by outside consultants, without any coordination with the Federal Funds Management Office (FFMO). The Authority’s management will ensure that, in the future, the FFMO will coordinate with the assigned outside consultants all the efforts necessary for the proper handling, identification and classification of funds received from FEMA. Name(s) of the Contact Person(s) Responsible for Corrective Action Romel Pedraza Claudio. P.E. – Assistant Executive Director for Planning & Engineering Elena González – DEA Finance Miguel La Torre – Interim Finance Director Anticipated Completion Date During FY-2026-2027
The Council agrees with finding 2025-003 and will follow its policy to report direct costs and appropriate cost allocations in expense-based programs.
The Council agrees with finding 2025-003 and will follow its policy to report direct costs and appropriate cost allocations in expense-based programs.
CORRECTIVE ACTION PLAN -For FY 2025 Audit Finding FINDING: 2025-002-ALN 14.872: U.S. Department of Housing and Urban Development’s (HUD’s) Capital Fund Program CRITERIA: 24 CFR 905.202(j) requires financial assistance to make improvements to existing public housing units. CONDITION: During the audit...
CORRECTIVE ACTION PLAN -For FY 2025 Audit Finding FINDING: 2025-002-ALN 14.872: U.S. Department of Housing and Urban Development’s (HUD’s) Capital Fund Program CRITERIA: 24 CFR 905.202(j) requires financial assistance to make improvements to existing public housing units. CONDITION: During the audit, it was discovered a purchase of a maintenance vehicle was made with funds under Budget Line Item 1480, “General Capital Activity”. HUD has issued guidance stating such purchase is considered an operational cost and CFP 1480 BLI cannot be used for such purchase. PLAN FOR CORRECTION: Management has reviewed 24 CFR 905.200 and 24 CFR 905.202 and will ensure no future purchases of maintenance vehicles, or equipment, will be planned to use any funds under the CFP BLI 1480, “General Capital Activity”. CONTACTS FOR PLAN: Chris Wallen – Finance Manager Ph. (503) 623-8387 Ext. 332 cwallen@wvpha.org Christian Edelblute - Executive Director Ph. (503) 623-8387 Ext. 314 cedelblute@wvpha.org
1. Termination of responsible parties
1. Termination of responsible parties
• The Employee responsible for overriding the internal controls and improperly authorizing disbursements without sufficient documentation was terminated from employment by the board of directors on April 2, 2026.
• The Employee responsible for overriding the internal controls and improperly authorizing disbursements without sufficient documentation was terminated from employment by the board of directors on April 2, 2026.
2. Mandatory Disclosures
2. Mandatory Disclosures
• In accordance with 2 CFR 200.13 on April 2, 2026, the organization notified its Federal Awarding Agency in writing of the audit finding and on April 6, 2026 a “Grant or Contract Fraud Complaint” was file with the U.S. Department of Health and Human Services Office of Inspector General.
• In accordance with 2 CFR 200.13 on April 2, 2026, the organization notified its Federal Awarding Agency in writing of the audit finding and on April 6, 2026 a “Grant or Contract Fraud Complaint” was file with the U.S. Department of Health and Human Services Office of Inspector General.
3. Strengthening Documentation Requirements
3. Strengthening Documentation Requirements
• Implement standardized documentation checklists for all disbursements
• Implement standardized documentation checklists for all disbursements
• Require complete supporting documentation prior to payment approval
• Require complete supporting documentation prior to payment approval
4. Enhanced Review and Approval Process
4. Enhanced Review and Approval Process
• Establish formal pre-payment approval workflows
• Establish formal pre-payment approval workflows
• Require documented supervisory approval for all expenditures
• Require documented supervisory approval for all expenditures
• Implement secondary review for federally funded transactions
• Implement secondary review for federally funded transactions
5. Segregation of Duties
5. Segregation of Duties
• Reassign roles to separate authorization, processing, and reconciliation functions
• Reassign roles to separate authorization, processing, and reconciliation functions
• Implement compensating controls where staffing limitations exist
• Implement compensating controls where staffing limitations exist
6. Staff Training and Compliance Education
6. Staff Training and Compliance Education
• Provide mandatory training on Uniform Guidance (2 CFR Part 200)
• Provide mandatory training on Uniform Guidance (2 CFR Part 200)
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