Corrective Action Plans

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1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $255,270 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $82,459 from the affiliated entity. Implementation date: June 30, 2026
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an up...
1. Recommendations: We recommend management Establish and implement robust internal control policies that strictly prohibit the payment of non-project expenses from the Project funds. 2. Action Taken: Management agrees with the findings and recommendations. Management will review and implement an updated cash disbursement procedure to ensure that Project funds are restricted solely to project-specific operations and are not disbursed on behalf of separate entities. Management is in the process of receiving the full reimbursement of the $59,971 from the affiliated entity. Implementation date: June 30, 2026
As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended August 31, 2025. Finding 2025-001: Allowable Costs – Significant Deficiency in Internal Control Over Compliance...
As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended August 31, 2025. Finding 2025-001: Allowable Costs – Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Management’s Views – Management agrees with the finding. LAJH acknowledges that payroll reimbursement calculations submitted under the federal program were prepared using subsequent employee pay rates rather than the contemporaneous pay rates applicable during the grant performance period and that certain duplicative expenditures were included in error. Management recognizes that these errors resulted in overstated costs totaling $79,825. Corrective Action Plan – LAJH will implement enhanced internal control procedures over the preparation and review of payroll costs charged to federal awards. Specifically, management will require all payroll reimbursement calculations to be supported by contemporaneous payroll registers and employee pay rate documentation applicable to the period during which services were performed. Person Responsible for Corrective Action: Robin Ray, Corporate Controller Anticipated Completion Date: May 31, 2026
Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direc...
Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direct Student Loans Program. The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar
The Agency will ensure that surplus cash calculations are prepared and reviewed timely, and that all components that impact the calculation are accurate and in accordance with GAAP. In addition, for any resulting calculations that indicate surplus cash exists, the Agency will remit the funds to the ...
The Agency will ensure that surplus cash calculations are prepared and reviewed timely, and that all components that impact the calculation are accurate and in accordance with GAAP. In addition, for any resulting calculations that indicate surplus cash exists, the Agency will remit the funds to the residual receipts account within 90 days of fiscal year end.
Finding 2025-001 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Healthcare Services Program Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: For a portion of...
Finding 2025-001 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Healthcare Services Program Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: For a portion of the year, BHD, LLC calculated their indirect cost rate based on the total grant budget and took an equal amount of that per month instead of calculating the indirect cost rate per direct expenditures for each month. When they started to calculate the indirect cost rate per direct expenditures for each month, they used the wrong cost pool per the budget and award. Responsible Individuals: Valarie Howard, CFO Corrective Action Plan: Historically, the indirect cost received by this grant has not been dependent of the direct expenditures. Based on verbal conversations with the HRSA grant project manager, requesting reimbursement for the indirect costs evenly over the year based on the budget submitted was acceptable. Therefore, the accounting treatment has been reflective of that. However, management agrees that recording the indirect cost based on the direct cost expenditures monthly is reasonable and appropriate and will make the change accordingly. The action plan was implemented immediately upon communication of the finding. Due to the timing of the prior year audit and communication of findings, the implementation of the action plan was mid- year during the current fiscal year resulting in a repetitive finding. Anticipated Completion Date: Action plan was implemented directly after issuance of prior year audit and communication of finding to management (March 2025).
Audit Finding Reference: 2025-002 Document Policies and Procedures Over Federal Awards Planned Corrective Action: - Perform a comprehensive review of existing federal award policies and procedures - Develop and formally document policies covering federal award administration, allowable costs, procur...
Audit Finding Reference: 2025-002 Document Policies and Procedures Over Federal Awards Planned Corrective Action: - Perform a comprehensive review of existing federal award policies and procedures - Develop and formally document policies covering federal award administration, allowable costs, procurement, cash management, subrecipient monitoring, reporting, and record retention Planned Implementation Date of Corrective Action: 1/1/2026 Person Resposible for Corrective Action: Finance Director/Senior Accountant Grant Administrator
Finding 2025-004: Allowable Costs – Material Weakness in Internal Controls Over Compliance and Compliance Finding Summary of Finding: Duplicate charges were identified within grant reimbursement submissions across reimbursement periods. Management Response During FY2025, grant reimbursement review p...
Finding 2025-004: Allowable Costs – Material Weakness in Internal Controls Over Compliance and Compliance Finding Summary of Finding: Duplicate charges were identified within grant reimbursement submissions across reimbursement periods. Management Response During FY2025, grant reimbursement review procedures were not sufficiently standardized to consistently identify duplicate charges submitted across reimbursement periods. Management is currently evaluating and formalizing enhanced grant reimbursement review workflows designed to improve consistency of review and reduce the risk of duplicate charges within reimbursement submissions. Planned procedures include reconciliation of reimbursement schedules to the general ledger, review of previously submitted reimbursement activity prior to submission of subsequent requests, and clarification of review responsibilities between management and the outsourced accounting team. Management is in the process of documenting these procedures and plans to implement the enhanced review workflow as soon as practicable. Separately, as part of ongoing remediation and compliance monitoring efforts, management has implemented a recurring quarterly Grant Utilization Review process intended to improve oversight of reimbursement activity, grant utilization, and reconciliation procedures across reimbursement periods. The first review meeting is scheduled for June 2026.
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with federal eligibility requirements. Name, address, and telephone of District contact person: Heather Korten, Director of Business Services 2689 Hoover Ave SE Port Orchard, WA 9836...
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with federal eligibility requirements. Name, address, and telephone of District contact person: Heather Korten, Director of Business Services 2689 Hoover Ave SE Port Orchard, WA 98366 (360) 874-7015 Corrective action the auditee plans to take in response to the finding: 1. Documented Eligibility Review The District will require a documented eligibility review for each student included on any future CWSD application. This review will verify that each student is both: A dependent of active-duty military personnel; and A student with a qualifying severe disability under CWSD program requirements. 2. Comparison to Impact Aid Source Data Prior to submission, the Business Department will compare the students included on the CWSD application to the District’s source documentation for military-connected students, including data maintained through the U.S. Department of Education Impact Aid process. 3. Secondary Review by Business Services The Business Department will perform an independent secondary review of the CWSD application before submission. The application will not be submitted until Business Services has reviewed and documented agreement between the application data and the District’s supporting eligibility records. 4. Special Services Review of Disability Eligibility and Costs The Special Services Department will remain responsible for identifying students with disabilities who may meet the CWSD criteria and for supporting the special education cost information included in the application. 5. Written Procedures and Sign-Off Requirements The District will establish written procedures identifying the staff responsible for preparing, reviewing, approving, and retaining documentation for the CWSD application. The procedures will require documented review and approval by both Special Services and Business Services prior to submission. 6. Documentation Retention The District will retain supporting documentation for each student included on the application, including military-connected status, disability eligibility support, cost documentation, review checklists, and final application approval. 7. Training and Annual Review Staff involved in preparing or reviewing the CWSD application will review applicable program requirements annually before the application is prepared. Anticipated date to complete the corrective action: June 30, 2026
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return fede...
Recommendation: The Department of Social Services should provide the necessary resources and institute procedures to ensure that it uses all information from eligibility, income, and death matches to ensure that it correctly issues benefits to or on behalf of eligible clients. DSS should return federal reimbursements for unallowable expenditures claimed under Medicaid and SNAP. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. DSS staff is in the development phase of implementing new automated procedures to ensure timely and accurate action is taken to discontinue benefits of deceased clients when date of death information is received and matched to the Connecticut Department of Public Health’s State Vital Records Office. Action has been taken to correct the errors cited, including discontinuing the benefits of the individuals that were verified as deceased, and recouping the overpayments as appropriate. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Social Services should amend the contract with its Medicaid recovery audit contractor to comply with federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review the...
Recommendation: The Department of Social Services should amend the contract with its Medicaid recovery audit contractor to comply with federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review the payment methodology at the next contract renewal. Anticipated Completion Date: October 1, 2027 Department of Social Services Contact Person: John Jakubowski, Director of Quality Assurance (860) 424-5855
Recommendation: The Department of Social Services should strengthen internal controls to ensure that it accurately reports and adequately reviews revenues, expenditures, collections, and contingency fees prior to submitting Form CMS 64. The Department of Social Services should strengthen internal co...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that it accurately reports and adequately reviews revenues, expenditures, collections, and contingency fees prior to submitting Form CMS 64. The Department of Social Services should strengthen internal controls to ensure that it tracks, reports, and returns the federal share of overpayments to corresponding federal and state medical assistance programs. The Department of Social Services should resolve the issues affecting the Medicaid receivable balances and file the proper adjustment to correct the errors, unsupported amounts, and corresponding federal reimbursements on Form CMS 64. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department will review internal controls to identify possible corrective actions. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Briana Mitchell, Chief Officer Fiscal Administrative Services 1 (860) 424-5471
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Medicaid services in accordance with federal laws and the Medicaid State Plan. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. The Department identified cases where overrides that were applied during the public health emergency were not removed. This resulted in individuals remaining enrolled inappropriately. Our Business Systems Division is implementing a tiered resolution approach, beginning with individuals enrolled in the Medicare Savings Program and HUSKY-C coverage. Please note: The Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls over cash management to ensure federal funds it draws down for the Block Grant for Prevention and Treatment of Substance Use program are supported by expenditures. Corrective Action Plan as Rep...
Recommendation: The Department of Mental Health and Addiction Services should strengthen internal controls over cash management to ensure federal funds it draws down for the Block Grant for Prevention and Treatment of Substance Use program are supported by expenditures. Corrective Action Plan as Reported by the Department of Mental Health and Addiction Services: To address this issue and prevent its recurrence, management is implementing the following corrective actions: 1. Enhanced Reconciliation Procedures: The Department will strengthen the monthly and pre-drawdown reconciliation process to ensure that all draw requests are fully supported by corresponding program expenditures before submission. This revised process will help prevent errors in future drawdowns and ensure compliance with cash handling requirements. 2. Updated Written Procedures: Written procedures for drawdowns will be updated to clearly define drawdown eligibility criteria, documentation requirements, and approval responsibilities. These revisions will provide clear guidance to staff involved in the drawdown process. 3. Training and Staff Development: Management will conduct training for all relevant staff members involved in the drawdown and reconciliation process. This training will focus on the importance of compliance with federal requirements, internal controls, and the proper documentation needed for drawdowns. Anticipated Completion Date: March 31, 2026 Department of Mental Health and Addiction Services Contact Person: Maureen Goff, Assistant Chief of Fiscal & Administrative Services Maureen.Goff@ct.gov (959) 276-1627
Recommendation: The Department of Public Health should strengthen internal controls over cash management to ensure that federal drawdowns align with the immediate cash needs to administer the program. Corrective Action Plan as Reported by the Department of Public Health: Management Assurance and Fis...
Recommendation: The Department of Public Health should strengthen internal controls over cash management to ensure that federal drawdowns align with the immediate cash needs to administer the program. Corrective Action Plan as Reported by the Department of Public Health: Management Assurance and Fiscal have worked together to identify gaps and inefficiencies in the drawdown tool. Management Assurance will periodically evaluate the drawdown tool’s usefulness and effectiveness as a cash management internal control. Fiscal will continue to monitor grant draws through the use of the improved drawdown tool. Anticipated Completion Date: Ongoing Department of Public Health Contact Person: Chuma Amechi, Fiscal Administrative Manager chukwuma.amechi@ct.gov (860) 509-7233 Ryan Wenzel, Supervising Accounts Examiner ryan.wenzel@ct.gov (860) 509-7822
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational ...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that only eligible recipients receive Money Follows the Person Rebalancing Demonstration services in accordance with federal laws, award terms and conditions, and the Money Follows the Person Operational Protocol. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees in part with this finding. Condition #1: DSS agrees that participation end dates were not updated timely due to cross-system manual entry limitations. Reconciliation procedures and supervisory oversight will be strengthened. Condition #2: DSS agrees that participation suspensions were not consistently reflected across systems due to timing delays. Monitoring and real-time reconciliation controls will be enhanced. Condition #3: DSS agrees approved costs exceeded institutional thresholds in limited cases. Variances were clinically justified, reviewed, and authorized. DSS will strengthen documentation and internal protocols to ensure clearer policy alignment. Condition #4: DSS agrees that the documentation was incomplete in one instance. Internal review standards will be reinforced to ensure comparative cost analyses are consistently documented. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012
Recommendation: The Department of Developmental Services should strengthen internal controls to ensure it obtains the required signatures for the individual plan for all Money Follows the Person Rebalancing Demonstration recipients. The Department of Social Services should conduct an audit of the me...
Recommendation: The Department of Developmental Services should strengthen internal controls to ensure it obtains the required signatures for the individual plan for all Money Follows the Person Rebalancing Demonstration recipients. The Department of Social Services should conduct an audit of the medical provider in accordance with Section 17b-99 of the Connecticut General Statutes to ensure integrity of the Money Follows the Person Rebalancing Demonstration program. Corrective Action Plan as Reported by the Department of Developmental Services: DDS agrees with the finding. The errors were attributed to current manual processes and case management oversight regarding documenting signatures when individual plan (IP) meetings are held remotely rather than in-person. Most of the deficiencies (5 of 6) were isolated to one case manager. The MFP division is small with 3-4 case managers, causing a higher error rate when extrapolated against the sample size. The missing support service records have been forwarded to the Department of Administrative Services for research. There are plans to improve the individual plan process to enhance internal controls through automation. In the interim, case managers and case manager supervisors will be reminded of the IP signature requirements. Department of Developmental Services Anticipated Completion Date: June 30, 2026 Department of Developmental Services Contact Person: Krista Ostaszeski, Health Management Administrator (860) 418-6066 Wayne Siedel, Director of Service Development and Support (860) 418-6041 Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding and the response provided by the Department of Developmental Services. Additional research is needed to determine whether the missing documentation was the provider's responsibility or was due to a billing issue. The Department of Developmental Services is coordinating with the Department of Administrative Services to research this further. Department of Social Services Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Christine Weston, Program Division Director (860) 424-5012
Recommendation: The Department of Social Services should conduct an audit of the medical provider in accordance with Section 17b-99 of the Connecticut General Statutes to ensure integrity of the Money Follows the Person Rebalancing Demonstration program. The Department of Social Services should reco...
Recommendation: The Department of Social Services should conduct an audit of the medical provider in accordance with Section 17b-99 of the Connecticut General Statutes to ensure integrity of the Money Follows the Person Rebalancing Demonstration program. The Department of Social Services should recoup any improper payments issued to medical providers and refund the corresponding federal reimbursements to the Centers for Medicare and Medicaid Services. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with the finding. The improper payment has been recouped and the DSS Audit Division will open an audit of the provider. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Cathie Bussolotta, Director of Internal Audit (860) 424-5548
Recommendation: The Department of Social Services should strengthen internal controls to ensure that each Children’s Health Insurance Program recipient is eligible for the program according to the state plan and federal regulations. Corrective Action Plan as Reported by the Department of Social Serv...
Recommendation: The Department of Social Services should strengthen internal controls to ensure that each Children’s Health Insurance Program recipient is eligible for the program according to the state plan and federal regulations. Corrective Action Plan as Reported by the Department of Social Services: The Department agrees with this finding. Condition #1: This was a processing error and was independently addressed. Condition #2: The findings were for cases that were granted prior to the implementation of the Department’s manual review process, which includes updating third-party information in the Health Insurance Exchange (HIX) system after verifying policy information. This process was officially started in May 2025. It is a post-enrollment function since it is permissible for clients to self-attest to having third-party liability (TPL) at the time of application. We expect to see a reduction in this type of error in future audits. There is an inevitable delay in DSS being notified of any discrepancies with TPL details due to the timing of that information being updated from carriers and then provided to DSS. With our new process, we can close these cases as soon as that information is available to us. Condition #3: There are multiple root causes related to this finding, including Premium Payment Module file transaction issues, reversing system functionality that was temporarily implemented during the COVID-19 Public Health Emergency which resulted in lingering enrollment issues, and staff processing errors. DSS regularly reviews age-out cases to take the necessary actions to close. Please note, the Department will not be returning the questioned costs associated with this finding. According to federal regulations, recoveries based on eligibility errors can only be pursued when identified by programs operating under Centers for Medicare and Medicaid Services’ (CMS) Payment Error Rate Measurement program, per section 1903(u) of the Social Security Act and regulations at Title 42 CFR Part 431, Subpart Q. Anticipated Completion Date: December 31, 2026 Department of Social Services Contact Person: Dan Giacomi, Program Division Director (860) 424-5080
Supportive Housing for Persons with Disabilities (Section 811) – Assistance Listing No. 14.181 Recommendation: We recommend that management establish and implement formal written policies and procedures to ensure surplus cash is either used to pay down debts subject to surplus cash or deposited in t...
Supportive Housing for Persons with Disabilities (Section 811) – Assistance Listing No. 14.181 Recommendation: We recommend that management establish and implement formal written policies and procedures to ensure surplus cash is either used to pay down debts subject to surplus cash or deposited in the residual receipts reserve in a timely manner in accordance with HUD requirements and the project’s Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have strengthened our internal controls by implementing a documented audit trail and a formal monthly reconciliation process for all intercompany activity between Home Share and Accord. Each month, the Contract Accountant prepares and submits to the Vice President of Finance a summary of the year to date activity along with the full outstanding intercompany balance, including prior year amounts. The Vice President of Finance reviews this reconciliation against the Home Share account balances to determine the amount that can be transferred to reduce the intercompany liability in accordance with HUD surplus cash requirements. Once the transfer is approved and completed, the Contract Accountant receives confirmation along with a copy of the ACH transaction to document the transaction. This process is performed and documented as part of each month end close to ensure timely, accurate, and compliant surplus cash transfers. Name(s) of the contact person(s) responsible for corrective action: Jes Cuoco Planned completion date for corrective action plan: May 31, 2025
The City agrees with the finding and will implement the following: (1) develop written policies and procedures to ensure compliance with Uniform Guidance (2 CFR 200), (2) formally adopt the policies and procedures, and (3) distribute policies and train staff on the new procudures.
The City agrees with the finding and will implement the following: (1) develop written policies and procedures to ensure compliance with Uniform Guidance (2 CFR 200), (2) formally adopt the policies and procedures, and (3) distribute policies and train staff on the new procudures.
Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be fo...
Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, the Corporation paid expenses in the amount of $305 on behalf of an affiliate from project cash without HUD approval. The amount due to the Project as of December 31, 2025 is $305. b. Action(s) Taken or Planned on the Finding This finding has been corrected and the affiliate reimbursed the property within the first quarter of 2026.
Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/2...
Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Recommendation: Same as finding reported as #2025-001. Planned corrective action: Management has implemented enhanced grant reimbursement and compliance procedures designed to strengthen oversight, documentation standards, and review procedures. Corrective actions include: 1) Implementation of a formal grant reimbursement and drawdown review process requiring complete supporting documentation prior to submission. 2) Required supporting documentation now includes invoices, proof of payment, payroll documentation, time and effort certifications where applicable, budget verification, and grant period review. 3) All federal reimbursement requests require independent review and approval by the Chief Executive Officer prior to submission to ensure compliance with grant terms and conditions, Uniform Guidance requirements, federal regulations, and GAAP reporting standards. 4) Monthly grant compliance meetings are conducted to review reimbursement activity, grant expenditures, reporting deadlines, allowable costs, and budget variances. 5) Program and finance staff are participating in ongoing grant compliance training related to federal regulations, grant-specific requirements, documentation standards, allowable costs, and financial management procedures. Training efforts include periodic reviews and testing where applicable to reinforce compliance expectations. 6) Implementation of standardized grant tracking and reimbursement monitoring procedures to improve accountability and strengthen oversight. 7) Periodic internal compliance reviews of grant files, reimbursement requests, and supporting documentation to identify and address deficiencies proactively. Responsible officer: Anita Bates, Chief Executive Officer Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen it...
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen its federal grant cash management procedures and will perform and document cost verification prior to all federal grant drawdowns beginning in fiscal year 2026.
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