Corrective Action Plans

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Finding Number 2025-208: The Department’s Indirect Cost Rate Proposal contained multiple errors. Federal Program: 66.468 - Drinking Water State Revolving Fund Related to Prior Finding: N/A Agency’s view: Due to staff turnover, DEQ agrees that sufficient supporting documentation could not be located ...
Finding Number 2025-208: The Department’s Indirect Cost Rate Proposal contained multiple errors. Federal Program: 66.468 - Drinking Water State Revolving Fund Related to Prior Finding: N/A Agency’s view: Due to staff turnover, DEQ agrees that sufficient supporting documentation could not be located to recreate the data and calculations from the initial indirect cost rate proposal (ICRP) packet. DEQ does not agree with the ‘Cause’ statement of the Management Letter that says, “documentation to support the modified ICRP was not available at the time of our review.” DEQ had the documentation supporting the negotiated rate with the Environmental Protection Agency (EPA). The Legislative Services Office (LSO) Audit Division audited the initial indirect cost rate proposal (ICRP) only, which had errors, but not the final packet that was modified and approved by EPA. The rate used by DEQ for FY25 was reviewed, modified (negotiated) and approved by EPA. Corrective Action: DEQ has had significant turnover in the fiscal office, which has resulted in gaps of knowledge of policies and practices. In summer 2025, DEQ leadership reorganized the fiscal department to improve efficiency, enhance oversight of grants and contracts, and strengthen financial controls. The fiscal office is currently in a rebuilding phase and is dedicated to training and developing staff, implementing best practices, and documenting processes and procedures, including those for federal grant compliance. The agency reached out to our federal oversight agency for assistance and direction with preparing and submitting the indirect cost rate proposal for FY27. We have and are committed to maintaining a file with all supporting documentation used to compile and prepare current and future proposals, as required by 2 CFR 200. Training and developing staff is an ongoing process, along with following updated federal rules and regulations. DEQ staff worked with the Environmental Protection Agency’s Indirect Cost Rate Negotiator to submit the indirect cost rate proposal packet for FY27 and we anticipate significantly reduced errors with the calculations and support for that submittal. Anticipated Corrective Action Date: December 31, 2026 Responsible for Corrective Action: Linda Brown, Financial Executive Officer Linda.Brown@deq.idaho.gov (208) 373-0292
Finding Number 2025-205: The Cost Allocation Plan (CAP) used in fiscal year 2025 was not approved by the RSA as required and contained multiple errors. Federal Program: 84.126 - Rehabilitation Services - Vocational Rehabilitation Grants to States Related to Prior Finding: N/A Agency’s view: The agen...
Finding Number 2025-205: The Cost Allocation Plan (CAP) used in fiscal year 2025 was not approved by the RSA as required and contained multiple errors. Federal Program: 84.126 - Rehabilitation Services - Vocational Rehabilitation Grants to States Related to Prior Finding: N/A Agency’s view: The agency agrees with the finding as we were using the cost allocation plan which was originally approved by RSA but needed to be updated when the state changed to a new accounting system (Luma). The updated plan was submitted to the Indirect Cost Division with the Department of Education in January of 2026. After conversations with both RSA and the VRTAC we withdrew our submission in September of 2026 when the Department of Education began their evaluation of the new plan. It was determined that we will negotiate an indirect cost rate rather than use the updated Cost Allocation Plan. Corrective Action: Based on conversations with the Indirect Cost Division, RSA, the state audit team, and the VR TAC team we determined it would be best for the agency to work with the Indirect Cost Division to establish an indirect cost rate. Switching from using the Cost Allocation Plan that we had been using for 16 years, abruptly, to a 15% indirect cost rate April 1, 2026 created multiple hurdles and changes that we have been trying to overcome with the help of the VR TAC team’s intensive assistance. We are in the process of creating a system that will address the errors that were found by the state auditors. The Indirect Cost Division states that we need to begin the new plan July 1, 2027. They have provided us with a template, and we will complete that and work with them to ensure this rate is ready to begin using July 1, 2027. Previously, annually, we submitted a document by email to the Indirect Cost Division indicating that we were re-certifying the same Cost Allocation Plan. We did not receive responses, and we took that to mean it was okay to continue using the same plan each year. From 2021-2025 this was done and there was one year it was submitted later than when we typically (October 1) sent it. In the meeting with the Indirect Cost Division, Andre Hylton, told us that once our indirect rate was established, it would be approved for two years and then after review, it would be on a 5 year review schedule. Anticipated Corrective Action Date: We anticipate the template to be completed by January 15, 2027 and to begin using the new rate July 1, 2027. Responsible for Corrective Action: Corey Bresina, Administrative Services Manager cbresina@icbvi.idaho.gov (208) 334-3220
Finding Number 2025-204: Multiple errors were identified in the amounts reported on the Rehabilitation Services Administration reports required for the Rehabilitation Services-Vocational Rehabilitation Grants to states. Federal Program: 84.126 - Rehabilitation Services - Vocational Rehabilitation Gr...
Finding Number 2025-204: Multiple errors were identified in the amounts reported on the Rehabilitation Services Administration reports required for the Rehabilitation Services-Vocational Rehabilitation Grants to states. Federal Program: 84.126 - Rehabilitation Services - Vocational Rehabilitation Grants to States Related to Prior Finding: N/A Agency’s view: The agency agrees with the finding as we were using the cost allocation plan which changes the numbers from the ones used by the audit team and found from Luma (the state accounting system). Corrective Action: Corrective Action Objectives:  Ensure that future RSA reports are complete, accurate, consistent, and fully supported by documentation.  Establish and implement clear, standardized reporting procedures.  Retain documentation necessary to justify all reported amounts.  Identify and correct errors in previously submitted reports and communicate corrections to RSA.  Strengthen staff competencies and ensure adequate staffing levels to support proper grant reporting. Actions To Be Taken:  Form a Reporting Review Team comprising program, fiscal, and data analysts to review reports prior to submission.  Develop standardized RSA Reporting Procedures, including: o Step-by-step instructions for preparing RSA-17. o Required supporting documentation for each line item. o Definitions of allowable expenditures and required classifications. o Review and approval workflows.  Established a double-verification process, requiring two qualified staff members to independently verify all numeric entries prior to submission.  Implement a centralized documentation repository for financial records, worksheets, cost allocation documents, and reconciliation statements.  Establish a mandatory documentation checklist that must be completed before a report can be sent for approval.  Create standardized reconciliation templates tying reported amounts directly to the general ledger or supporting program records.  Complete a retrospective review of all RSA submissions for the necessary reports.  Identify inaccuracies, variances, and documentation gaps.  Develop corrected versions of each affected report.  Prepared a formal communication package for RSA including: o Corrected reports o Explanation of errors o Documentation supporting corrected amounts Conclusion: This Corrective Action Plan establishes a comprehensive strategy to resolve reporting errors, strengthen documentation practices, and prevent future inaccuracies in RSA federal grant reporting. Through strengthened controls, trained staff, and rigorous review processes, the Commission will ensure ongoing compliance and improved accountability. Anticipated Corrective Action Date: October 30, 2026 Responsible for Corrective Action: Corey Bresina, Administrative Services Manager cbresina@icbvi.idaho.gov (208) 334-3220
Finding Number 2025-201: The Commission did not include administrative costs in required reports for the Federal Funding and Accountability Transparency Act (FFATA). Additionally, the Commission did not have any documentation to support adequate controls over FFATA reporting. Federal Programs: 93.04...
Finding Number 2025-201: The Commission did not include administrative costs in required reports for the Federal Funding and Accountability Transparency Act (FFATA). Additionally, the Commission did not have any documentation to support adequate controls over FFATA reporting. Federal Programs: 93.044 - Special Programs for the Aging, Title III, Part B, Grants for Supportive Services and Senior Centers 93.045 - Special Programs for the Aging, Title III, Part C, Nutrition Services Related to Prior Finding: N/A Agency’s view: The Commission agrees with this finding. Corrective Action: The Commission acknowledges that the sub-award amounts reported under ALNs 93.044, 93.045, and 93.053 did not include all allocable administrative costs for the subrecipient tested. We have taken the following corrective actions, all of which were implemented during the audit following identification of this issue: 1. Revised FFATA Sub-Award Reports - The Commission revised the affected FFATA subaward reports in SAM.gov to include the administrative costs allocable to each of the three tested ALNs for the sub-recipient identified in the finding. The revised reports were provided to LSO for review on 06/18/2026. 2. Revised FFATA Reporting Policy Implemented: The Commission developed a documented policy governing FFATA sub-award data entry, review, and approval. The policy establishes the following: • The Financial Technician is responsible for entering all FFATA sub-award data and must confirm that reported amounts include direct program costs and administrative costs allocable to the sub-award. • The Financial Specialist Senior is required to review all FFATA entries for accuracy and completeness. The Financial Specialist will document their review. This step is the specific control that was absent during the audit period. • Documentation of each review and approval must be retained. Purpose: To document SCO Corrective Action Plan. Source: Ethan Draves, Financial Specialist, Pr. Tickmark Legend: Agrees with the agency response provided in Section 2815. Corrective action contains all requirements required by 2 CFR 200.511(c) (contact name, corrective action, anticipated completion, and an explanation if the auditee disagrees). Agency didn't specifically include if they agree or disagree with the finding Anticipated Corrective Action Date: The Commission issued a memorandum to LSO on 06/18/2026 identifying the revisions made to the FFATA reports and providing the policy. That memorandum is incorporated by reference into this response. This finding and corrective action is completed. Responsible for Corrective Action: Vicki Yanzuk, Operations Manager Vicki.yanzuk@aging.idaho.gov 208-577-2847
Finding 2025-003: Deficiencies in Cost Allocation Plan and Methodology Condition: During our review of the Organization's cost allocation plan, we noted the Organization's monitoring report identified deficiencies in the current allocation methodology. Specifically, the space allocation schedule doe...
Finding 2025-003: Deficiencies in Cost Allocation Plan and Methodology Condition: During our review of the Organization's cost allocation plan, we noted the Organization's monitoring report identified deficiencies in the current allocation methodology. Specifically, the space allocation schedule does not fully reconcile based on allocated square footage, the space allocation includes cost categories that are not allowable under the indirect cost allocation (ICA) budget category, including wages, employee benefits, maintenance costs, reserve expenditures, and contractual services. Additionally, both the space allocation schedule and telephone allocation schedule contain line items identified as "other" or "other costs" without sufficient detail to identify the nature of the expenditures being allocated. Criteria: Federal and state grant requirements require costs charged to programs to be allocated using a reasonable, documented methodology that accurately reflects the relative benefits received by each program. Cost allocation plans should clearly identify the types of costs included in each allocation pool and maintain sufficient detail to support the basis of the allocations. Responsible Person: Chief Fiscal Officer, Wipfli Outsourced Controller Advisory Services, Lena Hicks, Executive Director, Governing Board Finance Committee. Corrective Action Plan: To support remediation of this finding, the Agency has added Wipfli Outsourced Controller Advisory Services as a controller-level resource. With this support, management will revise the cost allocation plan and supporting schedules so that costs are allocated using reasonable, consistent, and documented methods based on the relative benefits received by each program and in accordance with applicable federal and state grant requirements. Wipfli Outsourced Controller Advisory Services will assist with revising the plan, validating schedules, reviewing allowability and consistency, and developing sustainable controller-level processes. The Executive Director and Governing Board Finance Committee will approve the revised plan and monitor implementation. Implementation Date: The cost allocation plan revision is in progress and will be approved and implemented by December 31st, 2026. The plan will be reviewed annually thereafter.
Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition As part of our audit procedures, we selected a sample of 60 payroll transactions for review. Our testing incl...
Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition As part of our audit procedures, we selected a sample of 60 payroll transactions for review. Our testing included examining employee human resource files, including signed W-4 and I-9 forms, approved pay rates, timesheets with supervisory approval, and related payroll reports. We recalculated hours and compensation based on approved pay rates and compared the results to the payroll reports. During our review, we noted that management did not record and compensate all employee hours in the appropriate period based on the time and effort performed. Specifically, two employees were not properly compensated for one day of personal time off and 1.12 hours of overtime related to the administration of the CBS Food Program. These amounts were subsequently adjusted and paid in a later period. Recommendation We recommend that management strengthen its payroll review controls to ensure that employee compensation, including personal time off and overtime, is accurately calculated, reviewed, approved, and paid in the appropriate period. The review should include comparing approved timesheets, pay rates, payroll reports, and any leave or overtime documentation before payroll is finalized. Management should also document its review and establish a follow-up process to identify and correct payroll discrepancies timely. Repeat Finding: No Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: CBS Food Program will revise its compensation plan to include formal payroll processing procedures. These procedures will require an independent review of timesheets against payroll records before payroll is issued and will establish criteria and timelines for promptly investigating and correcting any discrepancies. Name of the contact person responsible for corrective action: Jonathan Shahar, CEO Jonathan@cbsfoodprogram.com Planned completion date for corrective action plan: June 30, 2026
Finding 1239798 (2025-003)
Material Weakness 2025
FINDING 2025-003 Finding Subject: Highway Planning and Construction- Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officia...
FINDING 2025-003 Finding Subject: Highway Planning and Construction- Activities Allowed or Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corrective Action Plan for this identified material weakness modified opinion, is first to recognize that strengthened internal controls will reduce/eliminate non-compliance submissions, thereby resulting in potential loss of Federal awards to the County of Floyd. The Commissioners have realigned and separated the Operations and Financial functions of Operations, to ensure greater attention to compliance. The identified material weakness with modified opinion occurred prior to the County’s realignment. It is desirous of the Floyd County Commissioners that compliance to all federal/state/and local awards are strictly adhered to and the separation of Operations and Finance strengthen this commitment. The Internal Controls will require that both the Chief Operations Officer and Chief Financial Officer review and sign as approval, ensuring that cross-referencing ledger expenditures for filing of reimbursement to Federal awards are compliant. The process will also ensure that any duplication of any reimbursements are eliminated. Anticipated Completion Date: The anticipated completion date of the Corrective Action Plan identified above will occur September 30, 2026 reporting as the exposure of this finding-weakness, is being addressed. Commissioners actions to ensure compliance and oversight were strengthened with the separation of Operations and Finance.
FA 2025-01 Internal Controls over Wage Rate Requirements Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Repeat of Prior Year Finding: Description: Special Tests and Provision...
FA 2025-01 Internal Controls over Wage Rate Requirements Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Repeat of Prior Year Finding: Description: Special Tests and Provisions Material Weakness Material Noncompliance U.S. Department of Education Georgia Department of Education COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund S425U210012 (Year: 2022) FA 2024-001 Description: A review of construction-related expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed that the School District's internal control procedures were not operating to ensure that Wage Rate Requirements were followed appropriately. Corrective Action Plans: The Meriwether County School District is committed to maintaining full compliance with the Davis-Bacon Act and related Federal wage requirements for all construction projects funded with Federal dollars. To ensure compliance, we are implementing clear, documented procedures to verify that all construction-related contracts include the appropriate wage provisions and that certified payroll records are submitted weekly and in a timely manner by all contractors and subcontractors. The following steps outline how the district will develop, implement, and monitor these procedures: Development and Implementation Procedures 1. Contract Template Updates All standard construction contract templates will be updated to include Davis-Bacon prevailing wage rate requirements, certified payroll provisions, and enforcement language. 2. Inclusion in Bid Documents and RFPs All bid solicitations and RFPs for federally funded construction projects will explicitly reference the applicable Federal wage determinations and required payroll documentation. 3. Pre-Award Contractor Communication Contractors will be notified in writing of their obligations under the Davis-Bacon Act during the bid process and again at contract award. 4. Pre-Construction Orientation Pre-construction meetings will be held with contractors and subcontractors to review Davis-Bacon requirements, wage determinations, and payroll submission expectations. Monitoring and Enforcement Procedures 1. Certified Payroll Collection Contractors will be required to submit certified payrolls weekly for each week of work performed. A checklist and calendar will be maintained by the project manager to track submissions. 2. Payroll Verification Process Submitted certified payrolls will be reviewed for completeness, accuracy, and compliance with wage rates. Spot checks (e.g., worker interviews or site visits) will be conducted periodically. 3. Centralized Document Storage All certified payrolls and compliance records will be stored in a centralized, secure digital file system accessible by authorized district staff and available for audit or federal review. 4. Compliance Reporting and Follow-Up Any instances of non-compliance will be documented and addressed promptly. Corrective actions may include written warnings, payment withholdings, or notification to oversight agencies. 5. Internal Audits and Staff Training The district' s Federal Programs Director will conduct internal quarterly audits as necessary when Federal funds are being used to verify proper procedures are being followed, and ongoing training will be provided to staff involved in procurement, contracting, and facilities management. By implementing these procedures, the district will ensure that all federally funded construction contracts fully comply with applicable wage laws and that payroll records are collected, reviewed, and maintained in a timely and transparent manner. Regular monitoring and staff accountability will help ensure continued legal compliance and project integrity. Estimated Completion Date: June 30, 2025 Contact Person: Carrie Chambers, Federal Programs Director Telephone: 706-441-0601 Email: carrie.chambers@mcssga.org
Plan: Implement internal controls in the Department for matching to be updated monthly in order to evaluate matching level. Director of prevention will work with the accounting team to keep records up to date in order for accounting to make appropriate matching JEs as the grant year progresses. Impl...
Plan: Implement internal controls in the Department for matching to be updated monthly in order to evaluate matching level. Director of prevention will work with the accounting team to keep records up to date in order for accounting to make appropriate matching JEs as the grant year progresses. Implementation Date: Beginning of Fiscal Year 27- October 2026 Responsible Party: Director of Prevention will oversee the staff report of Matching for the grant and ensure that these internal controls are taking place and report to the accounting department as necessary.
Plan: Implement a policy to ensure appropriate review by management of program is in place to ensure all grant costs are approved by management and on to higher leadership for final review. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reent...
Plan: Implement a policy to ensure appropriate review by management of program is in place to ensure all grant costs are approved by management and on to higher leadership for final review. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
Plan: Implement a policy to ensure appropriate review by management of program is in place to ensure all grant costs are approved by management and on to higher leadership for final review. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reent...
Plan: Implement a policy to ensure appropriate review by management of program is in place to ensure all grant costs are approved by management and on to higher leadership for final review. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
During the period ended December 31, 2025, the Company distributed $20,931 in excess of surplus cash available for distribution. a. Comments on the Finding and Each Recommendation Management agrees with the finding and recommendation. Adequate procedures were not in place to ensure distributions wer...
During the period ended December 31, 2025, the Company distributed $20,931 in excess of surplus cash available for distribution. a. Comments on the Finding and Each Recommendation Management agrees with the finding and recommendation. Adequate procedures were not in place to ensure distributions were reviewed and limited to available surplus cash in accordance with HUD requirements. b. Action(s) Taken or Planned on the Finding The project's management agrees with the auditor’s finding. As of December 31, 2025, there is $51,268 of available surplus cash. Had the questioned costs of $20,931 not been paid, then surplus cash would have been $72,199. Therefore, since current year surplus cash has been reduced, the questioned costs are deemed to be repaid.
Project paid expenses on behalf of an affiliate in the amount of $1,550.00 from Project funds without prior HUD approval. As of December 31, 2025, the affiliate owed the Project $1,550.00. a. Comments on the Finding and Each Recommendation Management agrees with the findings and recommendation. The ...
Project paid expenses on behalf of an affiliate in the amount of $1,550.00 from Project funds without prior HUD approval. As of December 31, 2025, the affiliate owed the Project $1,550.00. a. Comments on the Finding and Each Recommendation Management agrees with the findings and recommendation. The payment was made in error due to an oversight into the invoice approval process. b. Action(s) Taken or Planned on the Finding The affiliate reimbursed the Project for the full amount of $1,550.00 on 04/29/2026. Management implemented an additional approval control in RealPage requiring review and approval by the Housing Director and/or the Property Manager prior to payment processing. This control helps ensure invoices are charged to the correct property and prevents one project from paying expenses on behalf of another project or affiliate. Management will continue to monitor compliance with these procedures.
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies to retain proof of amounts requested for reimbursement. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
Corrective Action: UVNR is strengthening its time-and-effort reporting procedures through the use of Timesheets.com as its primary time-and-effort reporting system. Program-specific account codes have been added to allow employees to record actual hours worked by program or cost objective when check...
Corrective Action: UVNR is strengthening its time-and-effort reporting procedures through the use of Timesheets.com as its primary time-and-effort reporting system. Program-specific account codes have been added to allow employees to record actual hours worked by program or cost objective when checking in and out. Airtable is being utilized as a supplemental tool to document employee work performance and programlevel activities. These records are reviewed during monthly supervision meetings to assess alignment between reported activities, program responsibilities, and personnel allocations. UVNR will formalize documented supervisory review and approval of employee timesheets and establish monthly reconciliation of actual hours recorded in Timesheets.com against payroll distributions and funding allocations. Any discrepancies between budgeted allocations and actual time worked will be documented and corrected accordingly. Management will periodically monitor compliance and retain supporting documentation for personnel costs charged to federal awards. Due Date of Completion: December 31, 2026 (ongoing monthly reconciliation and monitoring thereafter). Responsible Parties: Executive Director.
Finding 2025-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, C. Cash Management, I. Procurement, Suspension and Debarment, N. Special Tests and Provisions Identification of the federal program: Research and Development Cluster Federal Agency: U.S. Department of Health a...
Finding 2025-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, C. Cash Management, I. Procurement, Suspension and Debarment, N. Special Tests and Provisions Identification of the federal program: Research and Development Cluster Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.273, Alcohol Research Programs Pass-Through Grantors: University of Louisville Research Foundation; Vanderbilt University Medical Center; Brown University Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.399, Cancer Control Pass-Through Grantor: NRG Oncology Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.846, Arthritis, Musculoskeletal, and Skin Diseases Research Pass-Through Grantor: Regents of the University of Michigan Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Regents of the University of Michigan Federal Agency: U.S. Department of Agriculture Assistance Listing No: 10.557, WIC Special Supplemental Nutrition Program for Women, Infants, and Children Pass-Through Grantor: Kentucky Cabinet for Health and Family Services – Department of Public Health Division of Adult & Child Health Award Period: January 1, 2025 through December 31, 2025 Summary of finding: A material weakness in internal control over compliance was issued related for the noted findings on the identified programs of Norton Healthcare, Inc. and Affiliates (the Corporation). While the Corporation has procedures in place to process and record transactions, the Corporation did not retain documentation to sufficiently support the design and operation of internal controls over the applicable compliance requirements for the listed federal programs. Furthermore, internal controls over management’s accumulation and review of such expenses for allowability were not suitably designed as it pertained to final approval of expenses incurred. Furthermore, the Corporation’s payroll department did not retain documentation to evidence the review of unapproved timesheets. Planned corrective action: Research Awards - Norton Healthcare has created Uniform Guidance-compliant policies regarding research expenditures using federal funds; those policies will be implemented. Additionally, standard work instructions regarding the documentation to be completed and retained have been created and will be implemented. A process to review vendors for suspension or debarment prior to engaging with them will be implemented. Additionally, all staff involved in the process of procuring goods and services using federal funds in the research department will receive training on the Uniform Guidance and the allowable cost and procurement principles therein. Anticipated completion date: December 31, 2026 Responsible contact person: Matthew Hawthorne Foundation Awards – Norton Healthcare will develop, document, approve and implement comprehensive policies and standard work instructions addressing applicable Uniform Guidance requirements for foundation expenditures. The policies will establish requirements and internal controls for the administration, financial management, monitoring and close out of federal awards. Standard work instructions will also be created and implemented that provide detailed procedures to consistently execute and document the requirements. Anticipated completion date: December 31, 2027 Responsible contact person: Jane Brooks
Responsible contacts: Laura, CFO; Agnes, Controller; Steve, Staff Accountant - AR; the Program Director responsible; Staff Accountant - AP (vacant). Interim AP: Trina performs the coding check under Agnes' review until AP is filled and trained. Program staff supply expense support; Trina supports hi...
Responsible contacts: Laura, CFO; Agnes, Controller; Steve, Staff Accountant - AR; the Program Director responsible; Staff Accountant - AP (vacant). Interim AP: Trina performs the coding check under Agnes' review until AP is filled and trained. Program staff supply expense support; Trina supports historical review. AEA will evaluate each expenditure based on its documented business purpose, the nature of the activity supported, and the benefit received by the Federal award. The approved budget will guide classification but will not, by itself, establish that a cost is allowable or allocable. Expenses supporting administrative activities will be classified under the applicable award’s administrative-cost requirements, with consistent direct or indirect treatment and no duplicate recovery. Classification decisions and supporting documentation will be retained. 1. Budgeted Expenses visibility. The Program Director will provide the current approved detailed budget, category definitions, and coding instructions to staff who request, incur, or approve expenses, and to AP, Steve, and Agnes. Approved amendments will be shared promptly. Program staff will document each expense's purpose, benefiting activity, fund/award, and proposed category. Evidence of budget distribution and staff instruction will be retained. 2. Expenses coding. AP should also review the invoice, business purpose, benefiting activity, and allocation support. A cost should not pass review merely because it fits an available budget line. Costs must satisfy award restrictions, budget category, receive consistent treatment, and be adequately documented. AP will compare each expense and its support with the approved budget categories and coding instructions before accepting grant coding. Incorrect, unclear, or unsupported submissions will be rejected as coded and returned to Program staff. AP will work with the Program to document corrections and escalate unresolved disagreements to Agnes, then Laura as needed. Disputed coding will not support an award charge or claim until resolved. 3. Budget – Actual expense review. Monthly and before each financial report, Steve will prepare an expense report with the approved budget, current-period and cumulative actual expenses, remaining budget, and variance by category. Actuals will reconcile to the general ledger. Program will review the transaction-level coding. AP and Program staff will investigate variances and classification errors, including administrative costs in program categories. Agnes will review the analysis and proposed corrections; Steve will update reports after approved entries are posted. Program retains financial-review responsibility. Steve or the designated submitter will release only the approved version; later coding changes require renewed review. Oversight and historical correction. Agnes, the Program Director, and Trina will review the expenditures and similar 2026 charges through implementation, document conclusions, and process supported corrections through the journal-entry approval workflow. Laura will oversee implementation and address significant classification judgments, required funder resolution, and report revisions. Anticipated completion For awards ending, Sept 30, 2026, historical review will be completed by October 15, 2026. Interim controls begin October 1, 2026; procedures and training by October 30, 2026; historical review by November 30, 2026. Anticipated completion: January 15, 2027. Monthly monitoring and pre-submission approvals continue thereafter.
Responsible contact(s): Agnes, Controller, for methodology and review; Laura, CFO, for approval; Program Managers for benefit evidence. Participating staff: AP Staff Accountant after onboarding; Trina for interim AP documentation; Steve for claim reconciliation; Trina for allocation-workpaper checks...
Responsible contact(s): Agnes, Controller, for methodology and review; Laura, CFO, for approval; Program Managers for benefit evidence. Participating staff: AP Staff Accountant after onboarding; Trina for interim AP documentation; Steve for claim reconciliation; Trina for allocation-workpaper checks. During 2026, management has been working on a documented, consistently applied allocation methodology. 1. Approve a written allocation plan. Agnes will finalize shared-cost pool, the activities benefiting, the allocation driver, calculation, source records, update frequency, and approval responsibility. Program Managers will substantiate benefit, and Laura will approve the plan. Personnel allocations will follow actual activity under finding 2025-006, not budget availability. 2. Use supportable drivers. Potential drivers include occupied square footage for space-related costs, assigned users for licenses, and documented usage for shared services. These are proposed examples, not AEA's established methodology. The selected basis must fit the benefit received, include all benefiting Federal and non-Federal activities, and be documented. Available grant balances will not determine the allocation. 3. Support each calculation. Trina, and subsequently the AP Staff Accountant, will retain the invoice and approved allocation worksheet showing the full cost, driver quantities, proportions, allocated amounts, and fund/category coding. Agnes and later Trina will check calculations and reconciliation to the source amount; Laura and subsequently Agnes will approve. Steve will reconcile the approved allocation to billed costs and retain supporting references. 4. Prevent inconsistent or duplicate recovery. Agnes will review changes in space, staffing, users, or program activity and update the basis when warranted, with formal quarterly review. Directly charged costs will be excluded from any indirect recovery of the same cost. General administrative pools will follow the applicable indirect-cost method and award limitations; costs will not be shifted to another award to overcome a funding deficiency. 5. Resolve the historical population. Agnes and Program Managers will review 2026 allocations through final implementation. Any reconstructed basis will use credible period-specific evidence, not unsupported hindsight percentages. Laura will approve supported corrections and direct funder resolution where needed. Training will cover invoice preparation, benefit documentation, and approval. Anticipated completion Documented review of all new shared-cost allocations: October 15, 2026. Written allocation plan and training: October 30, 2026. Review of cited items and similar allocations: November 30, 2026. Anticipated completion: February 15, 2027.
Responsible contact(s): Agnes, Controller, and Laura, CFO. Program Directors, Program Managers/Supervisors are accountable for approval of actual work performed. Participating staff: Steve is the allocation preparer; AP Staff Accountant after training; Trina for reconciliation; employees, supervisor...
Responsible contact(s): Agnes, Controller, and Laura, CFO. Program Directors, Program Managers/Supervisors are accountable for approval of actual work performed. Participating staff: Steve is the allocation preparer; AP Staff Accountant after training; Trina for reconciliation; employees, supervisors, and payroll support. Effective Jan 2026, AEA has replaced unsupported flat budget-based salary charges with documented allocations reflecting actual work performed. During the 1st half of 2026, allocation entries were not done monthly; starting in July 2026, the allocations entries have been done monthly. 1. Document actual activity. Employees are recording actual work by award/project and administrative or other non-Federal activity for each pay period in Salesforce. Supervisors and/or Program Managers with direct knowledge review accuracy, program benefit, and grant/category coding. A Paycom (payroll platform) check register report supplies gross pay, compensated absence, and benefit records. Payroll records cover total compensation activity. 2. Reconcile before charging awards. Steve prepares the payroll-to-award allocation. Laura has been reconciling allocations against the grant budgets, and program staff has approved the expenses before invoicing. Starting Q4, 2026, Steve will reconcile allocations to payroll and the ledger, Agnes/Trina will review and post the allocation entries; and the program staff will continue to approve before billing. 3. Control fringe and exceptions. Finance will support fringe and leave treatment under a written, consistently applied method and applicable award terms; it will not use an unsupported flat fringe percentage. Supervisors will resolve missing or changed activity records promptly. Unsupported amounts will be excluded from Federal claims pending resolution, without withholding employees earned pay. 4. Train and monitor jointly. The Salesforce support team has provided training for the employees for entering and for approval. Laura has trained the Finance, and payroll support on activity documentation, allocation changes, and deadlines. Steve will retain the approved allocation with each relevant billing package. Anticipated completion: For awards ending, Sept 30, 2026, historical review will be completed by October 15, 2026. Update written method: October 30, 2026. Anticipated completion after operating-effectiveness review: January 29, 2027.
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records ar...
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records are reviewed and supported by appropriate documentation. Management should also implement monitoring procedures to verify that participant counts and listings are complete, accurate, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: Sound Generations is updating procedures to strengthen controls over recording participant information, including participant profiles and meal services. Administrative staff will conduct regular site visits to train and monitor site staff and volunteers on these procedures. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2027.
Enhanced Mobility of Seniors and Individuals with Disabilities – Assistance Listing No. 20.513 Recommendation: Management should review and strengthen its controls over the allocation of expenditures to federal programs to ensure costs charged to federal awards are allowable, properly supported, and...
Enhanced Mobility of Seniors and Individuals with Disabilities – Assistance Listing No. 20.513 Recommendation: Management should review and strengthen its controls over the allocation of expenditures to federal programs to ensure costs charged to federal awards are allowable, properly supported, and allocated in accordance with applicable federal requirements. Management should also ensure that only allowable costs are included in the allocation methodology used to distribute indirect or shared expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations has improved and simplified the allocation of general disbursements to make it easier to follow for review and for auditors to follow. Planned completion date for corrective action plan: June 2026.
Special Programs for the Aging, Title III, Part C, Nutrition Services – Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate p...
Special Programs for the Aging, Title III, Part C, Nutrition Services – Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate processes and controls to ensure payroll is allocated correctly for Federal programs, in accordance with the underlying supporting documentation, and that only allowable costs are included in the allocation pool. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations has improved and simplified the allocation of payroll to make it easier to follow for review and for auditors to follow. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2026.
Finding 1239546 (2025-003)
Material Weakness 2025
Upmc
PA
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Rya...
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Ryan White, Part D) Condition: Ryan White, Part C and Part D require the use of program income under the additive method, which requires program income earned from a federally funded program is added to the federal award amount and used to further program objectives. Under the method, allowable expenditures of program income are included on the SEFA. UPMC’s SEFA did not include expenditures related to program income, which were allowable. UPMC’s preliminary SEFA did not include these expenditures, which resulted in the incorrect identification of major programs. The SEFA was subsequently corrected. Corrective action plan: UPMC has remediated the control deficiency as of the period ending December 31, 2025, and has appropriately revised its processes and internal controls to expenditures of program income in the SEFA for impacted programs. Completion: September 2026
We concur with the findingrelated to deficiencies in our approval process and thresholds set bycompany policies. We have documented our approval policies accordingly and implemented anew approval system using email starting in the fourth quarter of fiscal year 2026. This systemis designed to accurat...
We concur with the findingrelated to deficiencies in our approval process and thresholds set bycompany policies. We have documented our approval policies accordingly and implemented anew approval system using email starting in the fourth quarter of fiscal year 2026. This systemis designed to accurately capture approvals and expenses by project/grant. Comprehensivetraining sessions will be conducted forall affected employees to ensurethey are proficient in using the new system. We will also research other possible technologies to assist with thedocumentation of approvals.
Finding 1239496 (2025-001)
Material Weakness 2025
Audit period: For the Year Ended December 31, 2025 The findings for the Year Ended December 31, 2025, from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS SIGNIFICANT DEFICIE...
Audit period: For the Year Ended December 31, 2025 The findings for the Year Ended December 31, 2025, from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS SIGNIFICANT DEFICIENCY 2025-001 No process is in place to compare or revise budgeted amounts to allocate time to Federal programs vs. actual time recorded on manual timesheets. [repeat finding 2023-005] Recommendation: Management should establish procedures to ensure payroll costs charged to federal awards are supported by records that accurately reflect the work performed. This should include reviewing available project-level labor data, reconciling payroll allocations to supporting time and effort records, and updating allocations as necessary for each pay period to ensure costs are charged to the appropriate programs and funding sources based on actual activity here. Action Taken: We agree with the findings. During 2025, JVS implemented enhancements within Paylocity that allow employees to electronically review and update their labor allocations, strengthening internal controls over payroll cost allocation. Management has also enhanced its review and monitoring procedures surrounding labor allocation changes. While these improvements have significantly reduced the risk of misallocations, remediation efforts remain ongoing, including implementing a new payroll software in September 2026. JVS continues to refine its processes to ensure labor costs are accurately recorded and that any necessary allocation corrections are identified and addressed through timely review and adjustment procedures. Name of responsible persons: Yashica Ansberry Director of People & Culture Fahim Hakami Senior Accountant Anticipated completion date: Q4 2026
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