Corrective Action Plans

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Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and perf...
Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and performance reports.
Finding 2024-002: Cash Management / Matching / Interest Earned. Contact Person: Duane K. McMullen Jr., Director of Fiscal Affairs. Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding a...
Finding 2024-002: Cash Management / Matching / Interest Earned. Contact Person: Duane K. McMullen Jr., Director of Fiscal Affairs. Recommendation: The County should establish a separate fund to account for the activity of the Children and Youth program. Response: The County agrees with the finding and created a new fund – Fund 07 – in the County’s accounting software and will begin creating corresponding revenue and expense accounts to match the existing structure within the new fund. This has been a work in process and has been slow to implement. Due to the turnover of the Director of Fiscal Affairs. The new Director of Fiscal Affairs is currently working to correct missing months transfers, and hopes to have the process stream lined once all past entries are posted. The County also opened a separate checking account at The Juniata Valley Bank for the Children and Youth Fund for all revenue and expenses beginning January 1, 2025. The County continues to engage an external third-party contractor provider familiar with Children and Youth Agency financial matters to assist in the transition. The County also made the affirmative decision to capitalize that fund with the prior year’s County-match at the start of the calendar year and continue to fund, as needed, throughout the year to ensure the necessary County match is attained. The Children and Youth Agency will continue to ensure compatibility and proper recording in MUNIS, the County accounting system, of all financial transactions to match with the internal accounting system maintained by the Children and Youth Agency. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will continue to engage with the external service provider and the Children and Youth Finance Director and overall Child and Youth Agency Director to monitor proper posting of financial transactions in the appropriate fund to match all transactions posted in the internal accounting system maintained by the Children and Youth Agency. Date for Completion: December 31, 2025.
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could includ...
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could include: signatures on reports, emails indicating review and approval from appropriate individuals, retention of meeting agendas and minutes to corroborate that review occurred during the meetings, etc. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, the COO (or the Director of Finance, once hired) will conduct a documented review and written approval of all federal draw requests prior to submission to USAID. This review will be evidenced by either1. A signed and dated approval on the draw request form, or 2. A saved electronic record (e.g., email approval) in the grant’s shared compliance folder. SFP will also retain relevant meeting minutes or other supporting documentation demonstrating review in accordance with 2 CFR §200.303(a) requirements for internal controls. Name(s) of the contact person(s) responsible for corrective action: Anna Gabis Planned completion date for corrective action plan: October 31, 2025
Federal Award Finding: 2024-001 Material Weakness in Internal Control over Cash Management Name and Contact Person: Laurie Stuart, Executive Director Corrective Action: The Organization has evaluated and revised the processes and procedures regarding cash management and reporting, in efforts to mini...
Federal Award Finding: 2024-001 Material Weakness in Internal Control over Cash Management Name and Contact Person: Laurie Stuart, Executive Director Corrective Action: The Organization has evaluated and revised the processes and procedures regarding cash management and reporting, in efforts to minimize the time elapsing between the transfer of funds from the awarding agency and disbursement by the Organization. The Organization also has processes in place for maintaining detailed records supporting all grant payments, disbursements to vendors, and tracking of grant advances still outstanding. Additionally, the Organization is monitoring interest earned on grant advances and has processes in place to remit interest as appropriate when required in accordance with Uniform Guidance. Management has appointed an individual to oversee these processes for each grant. Management will also submit a revised annual financial report [FFR] for USFWS Agreement No. F23AC02320 to correct any errors related to cash on hand amounts reported. Proposed Completion Date: December 31, 2025
Corrective Action Plan Year Ended December 31, 2024 Finding 2024-001 – Cash Management – Pass-Through Entities Condition: Texas Biomed Research Institute (Texas Biomed) did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days ...
Corrective Action Plan Year Ended December 31, 2024 Finding 2024-001 – Cash Management – Pass-Through Entities Condition: Texas Biomed Research Institute (Texas Biomed) did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days of requests for reimbursement received by Texas Biomed. In 18 instances, Texas Biomed paid subrecipients after 30 days of receipt of the request for reimbursement from the subrecipient, resulting in noncompliance with 2 CFR 200.305(b)(3). Corrective Action Plan: Effective June 1, 2023 Texas Biomed implemented enhanced controls to ensure timely entry of subrecipient invoices into the financial system and timely approvals by Principal Investigators (PIs) of invoices. While these controls were operating effectively after the implementation date, turnover within the Accounts Payable team had not been anticipated and led to delayed payment processing. In mid-2024, Texas Biomed implemented a new electronic AP/invoice system as part of a comprehensive Enterprise Resource Planning system (and associated supporting systems) conversion to enhance efficiencies and functionality. With implementation of new systems, control enhancements enabled by the systems were implemented. This included setting up subawards as Purchase Orders, which enabled automation of a previously manual process to secure PI approval of invoices. Accounts Payable staff have been trained on how to properly enter subaward invoices into the system to trigger electronic routing to the PI for approval. While these steps will streamline the approval process, a further mitigating control will be implemented, with Accounts Payable staff periodically tracking approvals of pending subrecipient invoices and notifying the appropriate Sponsored Program Administrator for follow up with PIs in the event of delayed approvals. Responsible Parties: Eva Zepeda, Director, Finance; Michelle Hyde, Controller Completion Date: September 30, 2024
Finding 1156477 (2024-002)
Material Weakness 2024
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.
Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create...
Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create an internal control for drawdown request and report approval and review. The Organization should ensure these policies are followed for all drawdowns, reports and that documentation related to these policies are maintained. Views of Responsible Officials: Management agrees with the finding and recommendation. To address this, the Organization will update its Cash Management Policy to implement a documented, two-level review and approval process for all drawdown requests and reports, requiring both preparer and approver sign-off and develop a standard checklist to ensure each drawdown is supported by allowable, documented expenditures prior to submission. The Grants Manager will conduct quarterly internal reviews to ensure this process is being followed. Contact information for this finding: If the U.S. Department of Labor has questions regarding this schedule, please call Brandi Janke at (816) 520-4404. Completion Date: September 2025
Recommendation – The Project should ensure the surplus cash calculation is made in a manner that allows for a timely deposit of any required deposit to the residual receipts account. If there are cash flow issues preventing the deposit from taking place, the Project needs to contact HUD and request ...
Recommendation – The Project should ensure the surplus cash calculation is made in a manner that allows for a timely deposit of any required deposit to the residual receipts account. If there are cash flow issues preventing the deposit from taking place, the Project needs to contact HUD and request a waiver if allowed. Views of Responsible Officials and Planned Corrective Actions – Management will calculate an estimated surplus cash calculation amount and deposit them into the residual receipts account within the required time frame. Name and Title of Responsible Official – Sabine Cox, Comptroller Anticipated Completion Date – Once the funds are received.
View Audit 368750 Questioned Costs: $1
Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation ...
Finding 2024-003 Material Weakness in Controls over Compliance and Material Noncompliance – Cash Management Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – There were four drawdowns made in relation to the fiscal year 2024 expenses for the grant. For two out of the four drawdowns, management erroneously drew down in excess of the expenses incurred. Corrective Action Plan – Henry Ford Health agrees with this finding. As of August 31, 2025, the grant is in a net receivable position, so no adjustment is required. An additional level of review is being added to the drawdown process to improve the control environment and reduce the associated risk of error. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602 Questioned Costs: $1
Finding 2024-003 – Subrecipient Cash ManagementAssistance Listing No.: MultipleThe Office of Sponsored Programs ( OSP) will address the recommendation and review its current processes, policies, and procedures to minimize the time between invoice receipt and the transfer of federal funds to the subr...
Finding 2024-003 – Subrecipient Cash ManagementAssistance Listing No.: MultipleThe Office of Sponsored Programs ( OSP) will address the recommendation and review its current processes, policies, and procedures to minimize the time between invoice receipt and the transfer of federal funds to the subrecipient. This includes implementation of the following preventative controls to ensure that payments are made within the required timeline: a. Active communications with Principal Investigators of subawards on invoice approval timeline at award initiation and creation of procedures for documenting and advising OSP of invoices requiring correction and /or modification. b. Work with Post Award Staff to ensure that adequate documentation is created and maintained related to the follow-up that occurs when issues are being investigated and resolved that cause a delay in invoice processing.c. Development and utilization of a report for internal reporting and tracking of pending sub-invoices payments approaching the 30-day deadline. d. Implementation of the Invoice Receipt Date as a required field for subaward invoicing in Workday rather than the optional field it is at present. Responsible Official: Cate Ekstrom, Director of Research
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Proposed Completion Date: January 1, 2026
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and ...
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that the five transactions tested that did not have documentation of appropriate approval occurred prior to August 2024, the remediation date of Finding 2023-002. Completion Date: Matter was remediated in August 2024
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-004: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: The Company opened a residual receipt account and plans to deposit $3,633. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
View Audit 368559 Questioned Costs: $1
Finding: The Organization erroneously identified certain federal grants as state funded grants on the Schedules. Additionally, certain grant funding was omitted from the Schedules that was identified through the audit that had various federal/state grant requirements applicable to them. Contact Pers...
Finding: The Organization erroneously identified certain federal grants as state funded grants on the Schedules. Additionally, certain grant funding was omitted from the Schedules that was identified through the audit that had various federal/state grant requirements applicable to them. Contact Person Responsible for Corrective Action: Sean Jackson, Chief Executive Officer Corrective Action Planned: Isles operation, service delivery and finance staff are dedicated to ensuring that funding is used appropriately and in accordance with any restrictions set forth by the funder. The following procedures have been refined to ensure all funding sources are reflected accurately going forward. 1. When grant funding is received, the staff person who receives the award notice will request a new revenue code specific to the new grant award from the Finance Department. In order for Finance Department to generate that code, the staff person must provide the following information: a. Funder (either federal, state, county, city, or private entity) b. Grant number c. Amount d. Grant period e. Department f. Initiative code - internal code for specific areas of work g. Revenue code h. Revenue GL Code (4017 – Federal // 4016 – State // 4015 – City etc.) i. Reporting Requirements - Monthly, Quarterly, progress reports, etc. j. Include attachment of actual grant 2. Appropriate finance staff reviews provided contract along with the information outlined in item 1, confirms accuracy of the information, and then creates the appropriate codes in accounting software. 3. Appropriate finance staff creates and reviews the Schedules and Director of Finance reviews report before the Schedules are prepared annually. 4. GN-06 report requested by Finance in advance to closing the books to reconcile funding source to grants each year. Anticipated Completion Date: December 31, 2025.
DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will d...
DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will develop a match policy to include documented review and signed document retention for matching contributions, ensuring compliance with CFR §200.306. a. We will then follow this policy and retain signed documentation of matching contributions. Proposed Completion Date – October 31, 2025
Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any rev...
Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any reviews will be documented with an approval via a formal email confirmation. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail
Finding 2024-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
The Foundation immediately paid the vendor the full amount upon learning of this finding from the auditor and verified that the vendor received the payment. The recording of Grant Revenue/Accounts Receivable and Grant Expenses/Accounts Payable is now done for each grant expense immediately upon appr...
The Foundation immediately paid the vendor the full amount upon learning of this finding from the auditor and verified that the vendor received the payment. The recording of Grant Revenue/Accounts Receivable and Grant Expenses/Accounts Payable is now done for each grant expense immediately upon approval from the Foundation and submission to New York State for reimbursement. This was previously not done. The changes to the recognition of revenue and expenses are already in effect and should eliminate any future finding related to the non-payment of expenses that have been reimbursed through grants.
View Audit 368162 Questioned Costs: $1
While we acknowledge the auditor’s observation, management does not concur that the absence of formal timesheets equates to unsupported labor charges. Employees completed assigned responsibilities under the Sexual Risk Avoidance Education grant. Salaries were charged consistent with approved budgets...
While we acknowledge the auditor’s observation, management does not concur that the absence of formal timesheets equates to unsupported labor charges. Employees completed assigned responsibilities under the Sexual Risk Avoidance Education grant. Salaries were charged consistent with approved budgets and federal cost principles. During the audited (12-month) period, total payroll expenses allocated to the grant reflected actual performance of program activities as contracted. Accordingly, we believe the costs are fully allowable and the questioned amount of $40,495 is valid program expense. To address auditor concerns, we will utilize the documentation of program detail and timekeeping information within the Educator Tracker to accurately charge time and effort each pay period. The Educator Tracker will include all pertinent details including staff assignments, grant source per assignment, and supervisor approval. Anticipated completion: October 15, 2025. Responsible party: Kimberly Danon, Director of Youth Education.
View Audit 368035 Questioned Costs: $1
Finding #2024-001 – Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Passed through Texas Commission on Environmental Quality, Nonpoint Source Implementation Grants, Low Impact Development 2020, Assistance Listing #66.460, Contract period: 11/06/20 – 04/30/26, ...
Finding #2024-001 – Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Passed through Texas Commission on Environmental Quality, Nonpoint Source Implementation Grants, Low Impact Development 2020, Assistance Listing #66.460, Contract period: 11/06/20 – 04/30/26, Contract number: 582-21-10148. Condition and context: Under the terms of its agreement with the Texas Commission in Environmental Quality, HARC receives reimbursement for a percentage of the expenditures incurred in performance of the funded program. Donated services utilized in performance of the program were included in reimbursement submitted to the grantor. Recommendation: Re-emphasize to program and accounting personnel federal grant requirements for the allowability of in-kind donations. Management’s response: Management concurs with the finding. This issue arose because the non-federal flow-through sponsor required certain in-kind cost share amounts to be invoiced as direct expenses, which conflicted with federal cost principles. It is important to note that while the questioned costs increased reported revenue for 2024, the program had unreimbursed expenditures. Corrective actions were implemented in the first half of 2025, including the hiring of new Grants and Contracts Management staff and strengthening of internal controls, to ensure compliance with federal requirements and prevent recurrence in future reporting. Responsible officer: Carmen Osier, Director of Business Operations. Estimated completion date: June 30, 2025.
View Audit 368026 Questioned Costs: $1
Finding 2024-006 See response to finding 2024-002.
Finding 2024-006 See response to finding 2024-002.
View Audit 368025 Questioned Costs: $1
2024-004 FINDING: Period of Performance Responsible Officials: Daniel Ainslie, Finance Director, Jamie Toennies, Grants Division Manager Corrective Action Plan: Written communication will be sent to department directors and staff involved in grant administration addressing the compliance requirement...
2024-004 FINDING: Period of Performance Responsible Officials: Daniel Ainslie, Finance Director, Jamie Toennies, Grants Division Manager Corrective Action Plan: Written communication will be sent to department directors and staff involved in grant administration addressing the compliance requirements associated with Period of Performance. This communication will specifically state that no federal funds will be spent outside of this time period without written approval by grantor and/or approved budget modification. In addition, the City’s Uniform Grant Guidance Polices/Procedures will be updated to include a section on Period of Performance compliance requirements. Anticipated Completion Date: December 31, 2025
View Audit 367944 Questioned Costs: $1
Continued training of cost center managers. Throughout the summer we have had the Finance Manager training Community Eds administrative team and responsible grant managers to get compliance with Time and Effort requirements.
Continued training of cost center managers. Throughout the summer we have had the Finance Manager training Community Eds administrative team and responsible grant managers to get compliance with Time and Effort requirements.
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