Corrective Action Plans

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Sociedad para Asistencia Legal de Puerto Rico, Inc. Corrective Action Plan Single Audit 2025 For the Year Ended June 30, 2025 Section I: General Information Auditee: Sociedad para Asistencia Legal de Puerto Rico, Inc. (the Organization) Audit Period: July 1, 2024 – June 30, 2025 Auditor: Galíndez LL...
Sociedad para Asistencia Legal de Puerto Rico, Inc. Corrective Action Plan Single Audit 2025 For the Year Ended June 30, 2025 Section I: General Information Auditee: Sociedad para Asistencia Legal de Puerto Rico, Inc. (the Organization) Audit Period: July 1, 2024 – June 30, 2025 Auditor: Galíndez LLC Date: January 22, 2026 Section II: Financial Statement Findings No findings were reported under Government Auditing Standards. Section III: Federal Award Findings and Questioned Costs Finding No. 2025-001: Bi-weekly Reporting Compliance • Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSFRF) • ALN: 21.027 • Compliance Requirement: Reporting Condition Identified by Auditor: During the reporting test, auditors detected that reports were submitted after the corresponding bi-weekly period. Additionally, expenditures in the reports contained errors related to amounts for employee retentions for payroll taxes, which were included in the reports but were not expenditures incurred by the Organization at that specific moment. Management's Views and Justification: The Organization acknowledges that three (3) out of twelve (12) bi-weekly reports for ALN 21.027 were submitted late. This delay was due to an unintentional error involving a mismatch of dates, as explained in an email to the grantor on the same day as the submission. The grantor acknowledged receipt of the report. Furthermore, the Organization maintains continuous communication with the grantor to validate eligible expenses. The grantor has not verbalized any major discrepancies related to late submissions in the monthly stakeholder meetings. While the Organization recognizes the late submission, it asserts that the delay was minor and promptly addressed. 2 Management's Views and Justification (continues): Management highlights that the Organization also administered major federal programs under FEMA Public Assistance (ALN 97.036) and Hazard Mitigation (ALN 97.039) passed through COR3. These programs were audited and received an unmodified opinion with no findings reported, as confirmed by the COR3 Management Decision Letter dated August 26, 2025 (Determination: "No Action Required"). Corrective Actions Taken or Planned To address the findings and prevent recurrence, Sociedad para Asistencia Legal de Puerto Rico, Inc. is implementing the following measures: 1. Improving Accuracy of Expenditures • Reconciliation Protocol: We will implement a strict protocol where the Finance Director reconciles General Ledger (GL) with bi-weekly reports to ensure that only eligible, incurred expenditures are reported. • Validation: Specific procedures will be added to prevent the inclusion of non-expenditure items (such as employee payroll tax retentions) in the reports. • Automated Checks: We will implement automated checks or validation rules in the reporting process to detect and prevent data entry errors. • Pre-Submission Audit: A compliance officer will conduct pre-submission audits to review expenditures against federal guidelines, ensuring compliance with OMB Circular A-133 and 2 CFR 200. 2. Timely Submission of Reports • Reminder System: A system of calendar reminders has been implemented for all report deadlines. • Accountability: Clear consequences have been established for failing to submit reports on time. • Timeline Assessment: We are evaluating the current reporting timeline to assess if adjustments are needed to allow for adequate review time prior to submission. 3. Communication with Grantor • Proactive Updates: We will proactively communicate with the grantor regarding these corrective actions. • Implementation Timeline: We will provide the grantor with a specific timeline for the full implementation of these protocols. Implementation Details: • Anticipated Completion Date: December 31, 2025 • Responsible Official: Héctor A. Díaz Pomales, Director de Finanzas Sociedad para Asistencia Legal de Puerto Rico, Inc.
Warwick Public Schools has implemented several procedures to strengthen grant management, improve the accuracy and timeliness of required reporting, and ensure appropriate coordination between the Grants and Business Offices. 1. Grants Management Calendar: A shared Grants Management Calendar has bee...
Warwick Public Schools has implemented several procedures to strengthen grant management, improve the accuracy and timeliness of required reporting, and ensure appropriate coordination between the Grants and Business Offices. 1. Grants Management Calendar: A shared Grants Management Calendar has been created and is actively used by the Grants and Business Offices to monitor reporting deadlines and ensure required reports are completed and submitted on time. The calendar identifies the individual responsible for each reporting requirement and is managed by the Director of Federal Programs & Grants, Paul Heatherton. 2. Grant Tracker: A centralized Grant Tracker has been implemented to document key grant information, including the Grant Award Notification (GAN), approved budget, grant-funded positions, and grant end dates. This tracker is shared with the Grants and Business Offices and, when applicable, Human Resources. It supports coordination across departments, particularly for positions funded through grants with defined end dates, such as the Coronavirus State and Local Fiscal Recovery Funds. This process helps the district identify upcoming grant expirations and plan for the continuation or transition of funding for grant-funded positions. 3. Annual Grant Position and Funding Notifications: The Grants Office has established an annual process for providing Human Resources with a transaction notice identifying grant-funded positions and their associated grant fund numbers. This procedure strengthens communication regarding grant-funded staffing and helps ensure that positions are accurately associated with the appropriate funding sources. 4. Federal Grants Management Procedural Guide: Warwick Public Schools intends to develop a Warwick Public Schools Federal Grants Management – Procedural Guide by April 2027. This working guide will include both programmatic and financial procedures to promote consistent grant administration and ensure compliance with applicable federal, state, and grant-specific requirements. The guide will establish clear expectations for grant oversight, reporting deadlines, financial documentation, expenditure monitoring, and coordination among the Grants Office, Business Office, and other relevant departments. It will serve as a reference for staff responsible for administering and monitoring grant-funded programs and expenditures. The Grants Management Calendar, Grant Tracker, and annual grant position and funding notification procedures were implemented as of September 30, 2026. Completion of the Federal Grants Management Procedural Guide by April 2027 will serve as an additional step toward strengthening internal controls, standardizing grant administration, and supporting ongoing compliance.
Finding 1240713 (2025-004)
Material Weakness 2025
Activities Allowed or Unallowed; Allowable Costs/Cost Principles Management Response: Management acknowledges this finding. The audit identified deficiencies in payroll authorization and labor-cost allocation, including missing supervisory approval and insufficient documentation supporting the alloc...
Activities Allowed or Unallowed; Allowable Costs/Cost Principles Management Response: Management acknowledges this finding. The audit identified deficiencies in payroll authorization and labor-cost allocation, including missing supervisory approval and insufficient documentation supporting the allocation of payroll costs among federal programs. The finding resulted in $84,685 of questioned costs. Corrective Action: Nevadaworks will review and strengthen its existing payroll authorization and labor distribution procedures to ensure compliance. 1. All employees will complete time and activity records that accurately reflect work performed. 2. Employees charging time to federal programs will identify the appropriate grant/program allocation. 3. Supervisors will review and approve employee time records before payroll is processed. 4. Payroll allocations will be based on documented and supportable methodologies consistent with the employee’s actual work performed and approved cost allocation plan. 5. Finance will reconcile payroll charges to approved time/activity records on a monthly basis. 6. Any allocation changes or corrections will be documented and approved. 7. Finance will perform periodic reviews of payroll allocations for reasonableness and consistency with grant requirements. 8. Management will evaluate the questioned costs identified by the audit and coordinate with the applicable funding agency regarding any required repayment, adjustment, or other resolution. Responsible Party: Finance Manager/Controller with Program Management oversight. Target Completion: The revised payroll approval and allocation procedures will be implemented immediately and maintained on an ongoing basis. Monitoring: Finance will perform monthly payroll allocation reviews and quarterly compliance testing. Results and corrective actions will be documented and retained.
Corrective Action Plan Management will ensure that we apply the correct indirect cost rate to future agreements. New management is in place at TPFC who understand the indirect cost rate. Timeline for Implementation of Corrective Action Plan July 1, 2025 Contact Person Johanna Dunleavy, CFO
Corrective Action Plan Management will ensure that we apply the correct indirect cost rate to future agreements. New management is in place at TPFC who understand the indirect cost rate. Timeline for Implementation of Corrective Action Plan July 1, 2025 Contact Person Johanna Dunleavy, CFO
2025-004 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Cash Management Recommendation: We recommend the Organization implement formal internal controls over the cash management process, including documented supervisory review and approval ...
2025-004 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Cash Management Recommendation: We recommend the Organization implement formal internal controls over the cash management process, including documented supervisory review and approval of all cash draw requests prior to submission. Cash draw requests should be prepared and supported using information maintained within the accounting system and reconciled to the general ledger to ensure that only allowable, properly recorded Federal expenditures are included in reimbursement requests. Additionally, management should develop and implement a written cash management policy that establishes procedures for preparing, reviewing, approving, reconciling, documenting, and retaining cash draw records in accordance with the Uniform Guidance. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: JCWC is in the process of implementing updated financial policies and procedures to strengthen internal controls over cash management and Federal reimbursement requests. The new Fiscal Policy Manual establishes a specific process for preparing, verifying, reconciling, reviewing, approving, submitting, and retaining Federal reimbursement and cash draw requests. For example, Section 7.2.1, Reimbursement Request Process, requires: 1. Prepare and Verify The Finance & Grants Manager works with Program Staff and Jitasa to identify eligible expenditures and prepares the reimbursement request, ensuring costs are allowable, appropriately allocated, within the approved budget, and supported by documentation. The request shall be prepared using financial information maintained in QuickBooks. 2. Review and Reconcile The appropriate Director reviews the request and supporting documentation for accuracy, allowability, and budget compliance. Jitasa reconciles the requested amount to the applicable QuickBooks general ledger accounts and supporting documentation. Any discrepancy shall be resolved and documented before submission. 3. Approve and Submit The appropriate Director provides documented approval through an approved electronic signature platform. By approving the request, the Director confirms that the request has been reviewed for accuracy, allowable costs, appropriate grant allocation, and compliance with the applicable grant budget and funding requirements. Once approved, the Finance & Grants Manager submits the request to the funder or partner with all required supporting documentation. 4. Retain Records The reimbursement request, supporting documentation, electronic approval, and submitted request are retained in the designated grant records in accordance with Section 10 and applicable funder requirements. The policy therefore establishes a documented supervisory approval and reconciliation process before Federal reimbursement or cash draw requests are submitted. Action Plan: JCWC will finalize and present the Fiscal Policy Manual to the Board for formal adoption and will continue implementing the procedures in the interim. The Finance & Grants Manager will work with program staff and Jitasa to prepare and verify Federal reimbursement and cash draw requests. Requests will be reconciled to the QuickBooks general ledger and supporting documentation, with any discrepancies resolved and documented before submission. The appropriate Director will review and approve each Federal reimbursement or cash draw request prior to submission. JCWC will retain the request, supporting documentation, reconciliation, and approval in accordance with its records retention requirements and applicable Federal requirements. Following Board The appropriate Director will review and approve each Federal reimbursement or cash draw request prior to submission. JCWC will retain the request, supporting documentation, reconciliation, and approval in accordance with its records retention requirements and applicable Federal requirements. Following Board
2025-003 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance and Noncompliance – Allowable Costs Recommendation: We recommend the Organization discontinue reliance on external workbooks as the primary record of Federal expenditures and record payr...
2025-003 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance and Noncompliance – Allowable Costs Recommendation: We recommend the Organization discontinue reliance on external workbooks as the primary record of Federal expenditures and record payroll allocations directly within the accounting system. Management should implement procedures to reconcile payroll expenditures charged to Federal awards to the general ledger and ensure that payroll allocations are supported by approved timesheets or equivalent documentation. Additionally, management should require and document supervisory review and approval of employee timesheets to strengthen internal controls over payroll costs charged to Federal awards. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: In January 2026, JCWC implemented a new payroll and financial management process to strengthen the tracking, allocation, and documentation of payroll costs charged to Federal awards. Under the new process, Jitasa manages JCWC's payroll processing and payroll accounting, with QuickBooks serving as the organization's official accounting ledger. Employee time is allocated to the appropriate grant, contract, class, or organizational activity using approved timesheets. This process no longer relies on an external workbook as the primary accounting record for Federal payroll expenditures. JCWC also implemented a documented supervisory review process for payroll. Employee timesheets are reviewed for accuracy, completeness, and appropriate project allocations as part of the payroll process. Following preparation of payroll, payroll journals are reviewed and approved through DocuSign, providing a documented electronic approval trail prior to payroll processing. The Fiscal Policy Manual formalizes these procedures in Section 5.4, Payroll Authorization and Internal Controls. The policy requires employees to submit timesheets, requires management review of employee time allocations, requires payroll costs charged to grants to be supported by contemporaneous time records, and requires payroll registers to be reviewed after each payroll cycle. Payroll records are retained for a minimum of seven years. Action Plan: JCWC will continue the payroll and financial management procedures implemented in January 2026 and maintain these procedures through its formal fiscal policies and ongoing financial management practices. Jitasa will continue to manage payroll processing and payroll accounting, with JCWC management responsible for reviewing and approving payroll prior to processing and monitoring payroll allocations charged to Federal awards. Employee timesheets will continue to support payroll allocations to grants, contracts, classes, and organizational activities. Payroll journals will continue to be reviewed and approved through DocuSign, providing documented evidence of supervisory review and approval prior to payroll processing. The Finance & Grants Manager will work with Jitasa to ensure payroll expenditures charged to Federal awards are appropriately recorded and identifiable within the accounting system and reconciled to the general ledger. Name(s) of the contact people responsible for correction action: Jennifer Hamilton, Executive Director Noah Jenkins, Conservation Director Sean Connolly, Finance & Grants Manager Jitasa Plan completion date for corrective action plan: January 2026 for implementation of the new process; ongoing monitoring thereafter.
2025-002 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Financial Management Recommendation: We recommend the Organization modify its financial management system to separately identify and track Federal award expenditures within the account...
2025-002 Habitat Conservation – Assistance Lising #11.463 - Material Weakness in Internal Control over Compliance – Financial Management Recommendation: We recommend the Organization modify its financial management system to separately identify and track Federal award expenditures within the accounting records. Management should discontinue reliance on external workbooks as the primary record of Federal expenditures and ensure the accounting system provides complete, accurate, and auditable records sufficient to support Federal financial reporting and compliance with Uniform Guidance requirements. Explanation of disagreement with audit findings: there is no disagreement with the audit findings. Action taken in response to finding: In September 2025, Johnson Creek Watershed Council implemented a new financial management process that separately identifies and tracks Federal award expenditures within its accounting records. JCWC transitioned its bookkeeping and accounting functions to Jitasa, an external accounting firm, with QuickBooks Online serving as the official accounting ledger. Under the new process, Federal grant expenditures are coded to the appropriate grant, project, and funding source within the accounting system. Grant expenditures are reconciled to the QuickBooks general ledger and supporting documentation as part of the grant reimbursement and financial reporting process. External grant tracking worksheets may still be used as supplemental management tools for monitoring project budgets and preparing reimbursement requests; however, they are no longer relied upon as the primary record of Federal expenditures. The new Fiscal Policy Manual formalizes these practices. Section 4.4.4, Cost Allocation, requires direct costs to be charged to the specific grant, contract, or project and shared costs to be allocated using documented methodologies. Section 10.1, Financial Records, establishes QuickBooks as the official accounting ledger, with Jitasa maintaining and reconciling the organization's financial records. Action Plan: JCWC will continue the financial management process implemented in September 2025 and incorporate the process into its formal fiscal policies and procedures. The Finance & Grants Manager will work with Jitasa to ensure Federal award expenditures continue to be appropriately coded and identifiable within QuickBooks. Federal expenditures will be reviewed and reconciled to the general ledger and supporting documentation as part of ongoing grant management and reporting. The Finance & Grants Manager and Executive Director will monitor the process to ensure that external tracking worksheets remain supplemental management tools and that the official accounting records in QuickBooks remain the primary source for Federal expenditure reporting. Name(s) of the contact people responsible for correction action: Jennifer Hamilton, Executive Director Sean Connolly, Finance & Grants Manager Jitasa Mallette Faherty, Board Treasurer Plan completion date for corrective action plan: September 5, 2025 for implementation of the new process; ongoing monitoring thereafter.
Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: A new allocation process was implemented in...
Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: A new allocation process was implemented in September 2025. Starting that month, each employee now completes their timecard in ADP, dividing hours worked by Revenue Source Code (grant or non-grant). Timecards are reviewed each pay period by the employee’s Supervisor for accuracy of time allocation and coding. A report is then generated from ADP to identify the grant allocations and prepare the journal entry. ADP does not allocate time spent on leave (vacation, sick, holiday, jury duty, other leave). Anything not automatically allocated on the ADP report is allocated manually based on the percentage of time the employee spent on that grant during the payroll period. For salaried employees, the Payroll Specialist manually prepares the allocation of wages and benefits to each grant based on the percentage of time the employee coded to that grant in their timecard (ADP does not automatically allocate salaried employees). Once allocations are complete, the Payroll Specialist prepares the journal entry and imports into the accounting system. The journal entry reviewer (the Controller or another team member) completes a detailed review of the manual portion of allocation of wages and benefits to grants. For the portion of wages and benefits that are automatically allocated to based on the approved timecards, ADP internal controls are relied upon. Anticipated completion date: The new process was implemented September 2025.
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, ...
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, the Payroll Specialist began saving physically signed timesheets that document allocations to grants. Beginning August 1, 2025, allocations to grants are captured within the payroll system, ADP, along with the supervisor approval. The Payroll Specialist verifies each line on the timesheet is approved, which the system requires for the employee to receive payment. Anticipated completion date: Corrective action of signed allocation timesheets was implemented July 1, 2025. Corrective action of allocations to grants within ADP was implemented August 1, 2025.
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Housing Hope changed pro...
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Housing Hope changed property management companies in April 2026. The new property management company is working to bring all past due certifications for current tenants up to date. Progress towards this goal is monitored through bi-weekly reports to Housing Hope management. The new property management company maintains a schedule of all certifications due dates and tracks progress towards these dates on a schedule shared with Housing Hope management. Anticipated completion date: December 31, 2026
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding No. 2025-002: Payroll Costs Charged to Federal Awards Were Not Supported by Actual Time and Effort Documentation - Material Weakness Condition and Context During testing of payroll expenditures charged to the Education Innovation and Research Progr...
FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding No. 2025-002: Payroll Costs Charged to Federal Awards Were Not Supported by Actual Time and Effort Documentation - Material Weakness Condition and Context During testing of payroll expenditures charged to the Education Innovation and Research Program (ALN 84.411), exceptions were identified where payroll costs allocated among funding sources were not supported by documentation reflecting actual time and effort performed. Specifically, 12 exceptions totaling approximately $6,600 were identified within a sample of payroll transactions tested. As a result, certain payroll costs charged to federal awards were not supported in accordance with Uniform Guidance requirements applicable to compensation for personal services. Recommendation We recommend that the Organization strengthen policies and procedures governing payroll costs charged to federal awards. Such procedures should require adequate documentation supporting actual work performed, management review and approval of payroll allocations, periodic reconciliations between payroll records and expenditures charged to federal programs, and training for employees responsible for grant administration and payroll processing. Views of Responsible Officials and Planned Corrective Actions Arts for Learning Maryland has existing procedures for allocating payroll costs to federal and non-federal funding sources. However, the Organization acknowledges the need to enhance documentation and monitoring procedures to ensure compliance with Uniform Guidance requirements. The Organization will formally document payroll allocation policies and procedures, including requirements for contemporaneous support demonstrating actual work performed by employees whose compensation is charged to multiple funding sources. Management will implement enhanced review and approval procedures for payroll allocations and will perform periodic reconciliations between payroll records and expenditures charged to federal awards. In addition, the Organization will provide training to employees involved in payroll processing, financial reporting, and grant administration regarding applicable Uniform Guidance requirements. Management will also perform periodic internal reviews to identify and address compliance issues on a timely basis. These improvements will be implemented during fiscal year 2026 to strengthen compliance with federal award requirements and prevent recurrence of similar findings.
Management agrees with the auditor’s finding and will implement the auditor’s recommendation. Person responsible: Jason House Anticipated date of implementation: June 2026
Management agrees with the auditor’s finding and will implement the auditor’s recommendation. Person responsible: Jason House Anticipated date of implementation: June 2026
Identifying Number: Finding 2025-002 - Fringe Benefit Cost Objectives and Internal Controls Corrective Actions Taken or Planned: A documented actual-to-allocated fringe benefit reconciliation will be prepared and independently reviewed by management before fringe benefit costs are finalized for fede...
Identifying Number: Finding 2025-002 - Fringe Benefit Cost Objectives and Internal Controls Corrective Actions Taken or Planned: A documented actual-to-allocated fringe benefit reconciliation will be prepared and independently reviewed by management before fringe benefit costs are finalized for federal grant reporting and/or requests for reimbursement. The reconciliation and supporting allocation calculation will be retained as evidence that fringe benefit charges are supported, accurate, and appropriately allocated to the applicable federal programs. Person(s) Responsible: Essence Montgomery, CFO and Abdul Hadi, Director of Financial Accounting Anticipated Completion Date: October 1, 2026 Management Oversight & Next Steps: Management will communicate these control requirements to accounting personnel and responsible departments and incorporate them into current accounting policies and procedures. Documentation supporting the performance of each control will be retained as part of applicable workpapers and made available for management review and future audit testing.
Identifying Number: Finding 2025-003 - Allowable Costs and Internal Controls Corrective Actions Taken or Planned: No non-payroll expenditure will be charged to a federal award without documented review and approval of the supporting invoice, grant coding, allowability, and confirmation that the expe...
Identifying Number: Finding 2025-003 - Allowable Costs and Internal Controls Corrective Actions Taken or Planned: No non-payroll expenditure will be charged to a federal award without documented review and approval of the supporting invoice, grant coding, allowability, and confirmation that the expenditure has not been charged to another federal award. Supporting documentation and evidence of approval will be maintained with the grant expenditure records to provide a clear audit trail from source documentation to the general ledger and applicable federal award. Person(s) Responsible: Essence Montgomery, CFO; Abdul Hadi, Director of Financial Accounting; and Rushikesh Patel, Accounting Manager Anticipated Completion Date: October 1, 2026 Management Oversight & Next Steps: Management will communicate these control requirements to accounting personnel and responsible departments and incorporate them into current accounting policies and procedures. Documentation supporting the performance of each control will be retained as part of applicable workpapers and made available for management review and future audit testing.
8. 2025-008 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement an internal control policy that satisfies the requirements outlined...
8. 2025-008 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement an internal control policy that satisfies the requirements outlined in 2 CFR section 200.430(g). Planned corrective actions: Heritage University agrees with the recommendation and is strengthening its internal controls over personnel expenses charged to federal awards and sponsored projects. The University is developing and formalizing procedures to ensure personnel expenses are appropriately authorized, supported by institutional records, accurately allocated to benefiting activities, and periodically reviewed for consistency with federal award requirements. The planned process will establish clear roles and responsibilities among Sponsored Programs, Grant Accounting, Principal Investigators, supervisors, Payroll, Academic Affairs, and other appropriate offices involved in the administration of grant-funded personnel expenses. As part of this work, the University plans to strengthen controls surrounding payroll reconciliation, personnel and funding allocation changes, documentation of work performed, monitoring of payroll distributions, and review of salary cost transfers. Procedures will establish appropriate review and approval requirements, documentation standards, monitoring checkpoints, and processes for identifying and correcting discrepancies. The University is also evaluating its time and effort documentation and certification process to ensure it appropriately supports compensation charged to federal awards and is practical, consistent, and sustainable across the institution. As part of this review, the University is assessing faculty contract and workload structures for faculty who also manage or perform work on sponsored programs to ensure instructional, administrative, and grant-funded responsibilities are appropriately identified and supported. This assessment will include collaboration among Academic Affairs, Sponsored Programs, Human Resources, Payroll, and the Business Office to better align faculty workload, contractual responsibilities, and grant-funded activity. The recently established Office of Sponsored Programs provides additional capacity and centralized oversight for this work. The Director of Sponsored Programs, Compliance & Strategic Initiatives, in collaboration with the Business Office and other affected departments, will lead the development and documentation of these procedures, provide training and guidance to responsible employees, and establish ongoing monitoring practices to assess compliance. Final procedures, responsibilities, review frequencies, and documentation requirements will be established as the University completes its review of current processes and applicable federal requirements. Name of Responsible Party: Dr. Yesenia Rodriguez, Rachel Castilleja Anticipated completion date: In Progress
7. 2025-007 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement an internal control policy that satisfies the requirements outlined...
7. 2025-007 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement an internal control policy that satisfies the requirements outlined in 2 CFR section 200.430(g). Planned corrective actions: Heritage University agrees with the recommendation and is strengthening its internal controls over personnel expenses charged to federal awards and sponsored projects. The University is developing and formalizing procedures to ensure personnel expenses are appropriately authorized, supported by institutional records, accurately allocated to benefiting activities, and periodically reviewed for consistency with federal award requirements. The planned process will establish clear roles and responsibilities among Sponsored Programs, Grant Accounting, Principal Investigators, supervisors, Payroll, Academic Affairs, and other appropriate offices involved in the administration of grant-funded personnel expenses. As part of this work, the University plans to strengthen controls surrounding payroll reconciliation, personnel and funding allocation changes, documentation of work performed, monitoring of payroll distributions, and review of salary cost transfers. Procedures will establish appropriate review and approval requirements, documentation standards, monitoring checkpoints, and processes for identifying and correcting discrepancies. The University is also evaluating its time and effort documentation and certification process to ensure it appropriately supports compensation charged to federal awards and is practical, consistent, and sustainable across the institution. As part of this review, the University is assessing faculty contract and workload structures for faculty who also manage or perform work on sponsored programs to ensure instructional, administrative, and grant-funded responsibilities are appropriately identified and supported. This assessment will include collaboration among Academic Affairs, Sponsored Programs, Human Resources, Payroll, and the Business Office to better align faculty workload, contractual responsibilities, and grant-funded activity. The recently established Office of Sponsored Programs provides additional capacity and centralized oversight for this work. The Director of Sponsored Programs, Compliance & Strategic Initiatives, in collaboration with the Business Office and other affected departments, will lead the development and documentation of these procedures, provide training and guidance to responsible employees, and establish ongoing monitoring practices to assess compliance. Final procedures, responsibilities, review frequencies, and documentation requirements will be established as the University completes its review of current processes and applicable federal requirements. Name of Responsible Party: Dr. Yesenia Rodriguez, Rachel Castilleja Anticipated completion date: In Progress
2. 2025-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement an internal control policy that satisfies the requirements outlined...
2. 2025-002 – Activities Allowed or Unallowed and Allowable Costs/Cost Principles – Material Weakness in Internal Controls over Compliance and Instance of Noncompliance Recommendation: The auditors recommend the University implement an internal control policy that satisfies the requirements outlined in 2 CFR section 200.430(g). Planned Corrective Action: Heritage University agrees with the recommendation and is strengthening its internal controls over personnel expenses charged to federal awards and sponsored projects. The University is developing and formalizing procedures to ensure personnel expenses are appropriately authorized, supported by institutional records, accurately allocated to benefiting activities, and periodically reviewed for consistency with federal award requirements. The planned process will establish clear roles and responsibilities among Sponsored Programs, Grant Accounting, Principal Investigators, supervisors, Payroll, Academic Affairs, and other appropriate offices involved in the administration of grant-funded personnel expenses. As part of this work, the University plans to strengthen controls surrounding payroll reconciliation, personnel and funding allocation changes, documentation of work performed, monitoring of payroll distributions, and review of salary cost transfers. Procedures will establish appropriate review and approval requirements, documentation standards, monitoring checkpoints, and processes for identifying and correcting discrepancies. The University is also evaluating its time and effort documentation and certification process to ensure it appropriately supports compensation charged to federal awards and is practical, consistent, and sustainable across the institution. As part of this review, the University is assessing faculty contract and workload structures for faculty who also manage or perform work on sponsored programs to ensure instructional, administrative, and grant-funded responsibilities are appropriately identified and supported. This assessment will include collaboration among Academic Affairs, Sponsored Programs, Human Resources, Payroll, and the Business Office to better align faculty workload, contractual responsibilities, and grant-funded activity. The recently established Office of Sponsored Programs provides additional capacity and centralized oversight for this work. The Director of Sponsored Programs, Compliance & Strategic Initiatives, in collaboration with the Business Office and other affected departments, will lead the development and documentation of these procedures, provide training and guidance to responsible employees, and establish ongoing monitoring practices to assess compliance. Final procedures, responsibilities, review frequencies, and documentation requirements will be established as the University completes its review of current processes and applicable federal requirements. Name of Responsible Party: • Director of Sponsored Programs • Grant Accountant Anticipated Completion Date: In Progress
Finding No.: 2025-011 Federal Agency: U.S. Department of Education AL Program: 84.403 Consolidated Grants Federal Award No.: S403A220002, S403A230002, S403A240002 Area: Cash Management Questioned Costs: 841,180 Views of Auditee and Corrective Actions GDOE does not agree on the criteria and the cause...
Finding No.: 2025-011 Federal Agency: U.S. Department of Education AL Program: 84.403 Consolidated Grants Federal Award No.: S403A220002, S403A230002, S403A240002 Area: Cash Management Questioned Costs: 841,180 Views of Auditee and Corrective Actions GDOE does not agree on the criteria and the cause. The requirement that vendors for federal expenditures are paid either on the same day or within 24 hours after the funds had been received, was a requirement for the TPFA. This requirement was removed in reference to the letter from US Department of Education dated July 19, 2024, wherein the special condition regarding vendor payments was removed. All items comprising the $841,180 questioned cost were all paid within three business days from the date of the drawdown, therefore demonstrating GDOE’s commitment to minimize the time between the drawdown of federal funds and their disbursement. Plan of action and completion date: GDOE will revisit existing SOP on Cash Disbursement Procedures to reflect the Department's current responsibilities following the transition from the TPFA and incorporate applicable U.S. Department of Education Special Conditions and other cash management requirements into GDOE’s written procedures. Plan to monitor and responsible officials: The Federal Programs Division and Financial Affairs Accounts Payable will be responsible for monitoring the implementation of corrective actions. The SOP will be updated during FY2026, with monitoring and compliance procedures ongoing thereafter.
Finding No.: 2025-010 Federal Agency: U.S. Department of Education AL Program: 84.403 Consolidated Grants Federal Award No.: S403A240002 Area: Allowable Costs/Cost Principles Questioned Costs: $0 Views of Auditee and Corrective Actions GDOE agrees with the finding and acknowledges the need to streng...
Finding No.: 2025-010 Federal Agency: U.S. Department of Education AL Program: 84.403 Consolidated Grants Federal Award No.: S403A240002 Area: Allowable Costs/Cost Principles Questioned Costs: $0 Views of Auditee and Corrective Actions GDOE agrees with the finding and acknowledges the need to strengthen internal controls governing the review and processing of Consolidated Grant funded requisitions. As identified in the finding, a random sample of requisitions associated with newly created project account codes did not route to the required Federal Programs reviewer because the applicable workflow had not been established properly. Plan of action and completion date: The Federal Programs Division, Financial Affairs, Procurement Office and FSAIS have coordinated together to address the identified routing deficiency. The Procurement Office is reviewing the system workflow for Consolidated Grant funded requisitions and identifying any requisitions that did not receive the required Federal Programs Division approval. For any such requisition, the Federal Programs Division conducts the required compliance review and provides written confirmation of its determination, which is then attached to the requisition record in MUNIS. Financial Affairs has also coordinated with FSAIS to review and correct the MUNIS workflow to ensure that requisitions generated and routed moving forward are directed to the appropriate Federal Programs Division reviewer before proceeding to the Procurement Office for processing. Plan to monitor and responsible officials: The Procurement Office, FSAIS and Federal Programs Division will periodically review federally funded requisition routing to ensure required workflow steps remain in place and processing does not proceed without the approvals required under GDOE procedures. Identified routing or approval deficiencies will be referred to the appropriate office for correction and follow-up. The Procurement Office will be responsible for ensuring required approvals are completed prior to processing requisitions, FSAIS for maintaining the appropriate system workflow and the Federal Programs Division will be responsible for continuing to conduct compliance reviews. Corrective actions to address the identified routing deficiency have been implemented as of September 2026. The Procurement Office and FSAIS have completed the initial workflow review and corrective measures, and the Federal Programs Division has begun reviewing and documenting affected requisitions as needed. Ongoing monitoring by the Procurement Office and periodic randomized reviews by the Federal Programs Division will continue as part of regular operations.
Asante Health System Corrective Action Plan for FY25 Single Audit Fiscal year end: 09/30/2025 Audit period: 10/01/2024-09/30/2025 Finding 2025-002 Federal Program: FEMA funding is federal financial aid from the Federal Emergency Management Agency’s Disaster Relief Fund (DRF), providing money for com...
Asante Health System Corrective Action Plan for FY25 Single Audit Fiscal year end: 09/30/2025 Audit period: 10/01/2024-09/30/2025 Finding 2025-002 Federal Program: FEMA funding is federal financial aid from the Federal Emergency Management Agency’s Disaster Relief Fund (DRF), providing money for communities to recover from disasters, rebuilding infrastructure, mitigating future risks, and covering essential needs. Duplicate expenditures submitted for FEMA reimbursement resulting in unallowable costs being claimed under the program. Statement of Condition: In six of 40 sample items selected for testwork over activities allowed or unallowed and allowable costs/cost principles related to the program, $469,054 in expenditures out of a total of $1,368,522 expenditures (or 34%) were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) but were related to the same invoices and therefore were duplicate expenditures. Upon further investigation, management identified that a total of $2,636,044 expenditures out of a total of $14,470,349 expenditures related to the program were duplicate expenditures. Further, management’s review that was performed over the underlying program details was not designed at a sufficient level of precision that enabled the identification of the duplication errors. Further, in management’s review for the completed project certification for one of two projects for the program these duplication errors were not identified. Actions Taken and Status: To address this deficiency, the organization has implemented the following corrective actions: 1. Recovery and Adjustment of Duplicate Claims o A complete review of all FEMA reimbursement submissions was performed to identify duplicate expenditures. o Management will work with FEMA to adjust previous reimbursement requests and return any funds received for duplicate expenditures, as required. 2. Enhanced Reconciliation Controls o A detailed reimbursement tracking log has been implemented to identify each invoice: payment date, reimbursement request number, and reimbursement status. o All expenditures submitted for reimbursement will be reconciled against prior submissions before inclusion in a reimbursement request. 3. Training o Finance personnel responsible for federal grant administration and reimbursement submissions have received training on Uniform Guidance requirements, allowable costs, and reimbursement documentation controls. Corrective action training has been completed as of 9/30/2026. Responsible Contact Person: Name: Heather Rowenhorst Title: Chief Financial Officer Department: Administration Phone/Email: 541-789-5098 / Heather.Rowenhorst@asante.org
Finding 1240424 (2025-001)
Material Weakness 2025
The SLFRF Project and Expenditure Report periods have been filed and no further reporting is required from these specific federal grant rewards. Future grants requiring reporting will be thoroughly reviewed for reporting specifications. Although no funds were misspent or inappropriately used, the Co...
The SLFRF Project and Expenditure Report periods have been filed and no further reporting is required from these specific federal grant rewards. Future grants requiring reporting will be thoroughly reviewed for reporting specifications. Although no funds were misspent or inappropriately used, the County understands the need for correct timing when reporting the grant funds held, encumbered, and expended. The County has since created a grant acceptance template, required to be used by all departments, which will be used to identify who is responsible for future grant reporting requirements. The County will work to ensure all affected departments are aware of specific reporting requirements and that those requirements are followed.
Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Kinteh Darboe,...
Authority's Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Kinteh Darboe, Chief of Financial Operations & Management, is responsible for ensuring the deficiencies have been rectified by March 31, 2026.
Management agrees with the finding and will implement procedures to periodically reconcile allocation methodologies to actual expenditures and program activity.
Management agrees with the finding and will implement procedures to periodically reconcile allocation methodologies to actual expenditures and program activity.
Management agrees with the finding and will implement procedures to reconcile reimbursement amounts to actual expenditures and program activity.
Management agrees with the finding and will implement procedures to reconcile reimbursement amounts to actual expenditures and program activity.
Certain non-payroll cost samples tested within the Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (ALN 97.036) were not appropriately supported for the year ended June 30, 2025. Going forward, WellSpan will design and implement enhanced retention policies to ensure a...
Certain non-payroll cost samples tested within the Disaster Grants – Public Assistance (Presidentially Declared Disasters) program (ALN 97.036) were not appropriately supported for the year ended June 30, 2025. Going forward, WellSpan will design and implement enhanced retention policies to ensure appropriate recordkeeping specifically related to expenditures charged to federal grants. Contact Person Responsible for Corrective Action: David Rizzuto, Senior Corporate Controller Anticipated Completion Date: October 31, 2026
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