Corrective Action Plans

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Finding #2025-011 14.267 Continuum of Care Period of Performance Views of Responsible Officials and Planned Corrective Action Management’s Position: Condition 1, 2, & 4 Management concurs with the finding. The questioned cost relates to a payroll charge that was initially assigned to a subsequent Co...
Finding #2025-011 14.267 Continuum of Care Period of Performance Views of Responsible Officials and Planned Corrective Action Management’s Position: Condition 1, 2, & 4 Management concurs with the finding. The questioned cost relates to a payroll charge that was initially assigned to a subsequent CoC Planning Grant during the payroll reimbursement process because funding was available under that grant after the prior funding source had been exhausted. During the drawdown review, management identified that the pay period occurred prior to the start of the grant’s period of performance and therefore was not eligible to be charged to that federal award. Upon identification of the issue, the payroll cost was excluded from the reimbursement request and was not included in a federal drawdown. The appropriate corrective action was to reclassify the expense from the CoC Planning Grant to a local funding source. However, at the time the issue was identified, the accounting staff responsible for overseeing payroll reimbursements and related accounting adjustments were in the process of transitioning responsibilities. As a result, while the ineligible cost was not reimbursed with federal funds, the required accounting reclassification was not completed until the subsequent fiscal year. Corrective Actions: Management has strengthened and formalized its payroll reimbursement review procedures to ensure that grant period-of-performance requirements are verified prior to classification of payroll expenses. Management has also established procedures for documenting and tracking identified exceptions to ensure that required accounting adjustments are completed timely and reviewed by supervisory personnel. The RPE Accounting Department will be responsible for ensuring payroll reimbursement classifications are reviewed for compliance with applicable grant period-of-performance requirements. Accounting personnel responsible for payroll reimbursements and related accounting adjustments will maintain documentation of identified exceptions and ensure required adjustments are completed and reviewed by supervisory personnel. Condition 3 Management does not concur with the finding. Explanation of Disagreement: The Manual Journal Voucher (MJV) referenced by the auditor reflects a reclassification of payroll costs between federal grants. While the payroll expenditure relates to a pay period ending June 14, 2025, the expenditure was not ultimately charged to the grant with a period of performance ending December 31, 2024. The purpose of the MJV was to remove the payroll expenditure from the original grant and reclassify it to the appropriate federal grant. The corresponding entry within the same journal voucher charged the expenditure to a grant whose period of performance encompassed the payroll pay period. As a result, the payroll expenditure was not charged to a federal award outside of its period of performance. Management believes the exception resulted from reviewing only one side of the reclassification entry rather than the complete transaction. The supporting MJV demonstrates that the expenditure was removed from the grant with the expired period of performance and reassigned to the appropriate federal award. Accordingly, management respectfully requests reconsideration of this exception. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: Condition 1, 2, & 4 The enhanced payroll reimbursement review procedures and exception tracking procedures have been implemented.
Community Projects Funding / Congressionally Directed Funding – Assistance Listing No. 17.289. Recommendation: CLA recommends the Organization revise the indirect costs calculation process to review program-only costs, rather than entity-wide costs. Develop policies and procedures to incorporate app...
Community Projects Funding / Congressionally Directed Funding – Assistance Listing No. 17.289. Recommendation: CLA recommends the Organization revise the indirect costs calculation process to review program-only costs, rather than entity-wide costs. Develop policies and procedures to incorporate appropriate internal controls over indirect cost calculations; ensure the performer of the internal control has the required knowledge & understanding of compliance requirements & accounting to catch errors during the review & approval process. There is no disagreement with this audit finding. Action taken in response to finding: In January 2026 we recevied an email from DOL outlining the correct way to allocate indirect costs. We made those adjustments to our indirect calculations and will adjust any previous overstated reimbursements. Name(s) of the contact person(s) responsible for corrective action: Tracey Hunter. Planned completion date for corrective action plan: May 2026
Management acknowledge the improper treatment of the expenditure for the specific period. The expenditure in question was for a one-year marketing services agreement supporting activities under the FDA 503B award. The vendor required payment in advance as a condition of service delivery, and the cos...
Management acknowledge the improper treatment of the expenditure for the specific period. The expenditure in question was for a one-year marketing services agreement supporting activities under the FDA 503B award. The vendor required payment in advance as a condition of service delivery, and the cost was incurred for legitimate grant-related purposes within the approved scope of work and period of performance. The expenditure was fully documented, allocable to the award, reasonable in nature, and directly connected to approved programmatic objectives. Management acknowledges that the transaction involved payment for services extending across a future service period. Specifically, 2 CFR 200 does not prohibit recipients from entering into prepaid contractual arrangements for allowable services necessary to support award implementation, particularly where such arrangements reflect standard vendor business practices and operational necessity. Further, the organization’s actions must be evaluated in the context of significant federal payment administration changes that began in February 2025. Historically, the organization received advance funding under the award consistent with the cash management principles contemplated under 2 CFR 200.305. Beginning in 2025, however, the organization was required to operate under a reimbursement-based process requiring submission of supporting documentation prior to payment release. This materially altered the organization’s working capital position and limited its ability to independently finance operational expenditures for extended periods pending reimbursement. As a result, management was required to make operational decisions necessary to ensure continuity of approved grant activities while balancing vendor requirements, cash flow limitations, and evolving federal reimbursement practices. The organization did not receive excess federal cash, improperly retain federal funds, incur unallowable costs, or use award funds outside the approved project scope. The questioned transaction reflects a timing and payment structure issue rather than a violation of fundamental federal compliance requirements. Management also notes that 2 CFR 200.305 expressly contemplates advance payment methodologies and recognizes that reimbursement-only environments may create operational hardships for recipients lacking sufficient working capital. The organization’s actions were undertaken in good faith to maintain uninterrupted program operations under materially changed federal payment conditions. Importantly, the expenditure was allowable, the services supported approved award objectives, the costs were incurred during the award period, supporting documentation exists, no misuse or diversion of federal funds occurred, and no financial harm to the federal government resulted. Note also that going forward, PDA will record future services and subscriptions to prepaid and amortize based on the periods stipulated on the vendor invoices.
Recommendation: It is recommended the Center evaluate and update it internal controls and procedures to ensure costs are appropriately considered when preparing the Center's monthly RFRs. Management Corrective Action Plan: The Center will evaluate its current procedures related to the RFRs and recog...
Recommendation: It is recommended the Center evaluate and update it internal controls and procedures to ensure costs are appropriately considered when preparing the Center's monthly RFRs. Management Corrective Action Plan: The Center will evaluate its current procedures related to the RFRs and recognizes the need to strengthen controls over the preparation of monthly RFRs. The Finance Department will implement additional review procedures to ensure prepaid contracts are properly amortized over the proper benefit period, and expenses are reported in the appropriate benefit period. Responsible Individual & Contact Info: Finance Director-Hilda Valdez Senior Accountant-Dominikue Martinez Executive Director-Nadia Ochoa Anticipated Completion Date: As soon as possible
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
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