Corrective Action Plans

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Poverty and Social Reform Institute Dba Leaps and Bounds Family Services has updated the policies and procedures for the agency to reflect the Uniform Guidance requirements regarding the process and controls used to administer federal awards. These changes address the issue of non-compliance by form...
Poverty and Social Reform Institute Dba Leaps and Bounds Family Services has updated the policies and procedures for the agency to reflect the Uniform Guidance requirements regarding the process and controls used to administer federal awards. These changes address the issue of non-compliance by formally addressing the roles and responsibilities in writing of who at the agency is responsible for insuring that the Uniform Guidance is followed. The updated policy covers the areas of: allowable costs, cash management, procedures, and conflicts of interest. The new policy will be presented and reviewed for approval at the July 22nd, 2026, board meeting. We believe this corrective action plan will address the non-compliance and bring the agency into full compliance moving forward.
Finding No. 2025-001 Preparation of the schedule of expenditures of federal awards Responsible Personnel: John M. Quinata, Executive Manager During the audit, the Authority reviewed the federally funded airport improvement projects (AIP) to ensure that all applicable items charged to the projects we...
Finding No. 2025-001 Preparation of the schedule of expenditures of federal awards Responsible Personnel: John M. Quinata, Executive Manager During the audit, the Authority reviewed the federally funded airport improvement projects (AIP) to ensure that all applicable items charged to the projects were accounted for. Correcting entries were made to FY25 and FY24 was restated to address the identified misstatements. To prevent future issues from occurring, the Authority has updated its procedures to enhance the process for identifying federal receivables and controls for reviewing and reconciling the SEFA with financial statement records. Timely reviews will take place at least quarterly. Any future changes to the process must be discussed, agreed upon with management, and documented.
As noted above, The Trust for Tomorrow continues to add compensating controls each year when possible. For example, beginning in fiscal year 2026, the Organization’s outsourced accountant is slated to pick up additional responsibilities, such as preparation of bank reconciliations. We will continue ...
As noted above, The Trust for Tomorrow continues to add compensating controls each year when possible. For example, beginning in fiscal year 2026, the Organization’s outsourced accountant is slated to pick up additional responsibilities, such as preparation of bank reconciliations. We will continue to review our processes to determine where duties can be segregated amongst existing staff and/or outsourced accountant further. Lastly, the board will continue to provide close oversight of the Organization and evaluate that oversight on a consistent basis.
Finding 2025-001 – Unallowable and Unallocable Expenditure Charged to a Federal Award
Finding 2025-001 – Unallowable and Unallocable Expenditure Charged to a Federal Award
Federal Agency: U.S. Department of Health and Human Services, passed thru the Texas Workforce Commission
Federal Agency: U.S. Department of Health and Human Services, passed thru the Texas Workforce Commission
Type of Finding: Significant Deficiency/Noncompliance
Type of Finding: Significant Deficiency/Noncompliance
Compliance Requirement: Allowable Costs/Cost Principles
Compliance Requirement: Allowable Costs/Cost Principles
The Board will strengthen its internal control procedures over federal program expenditures by enhancing the review and approval process to ensure that all costs charged to federal awards are allowable, allocable, reasonable, and adequately supported in accordance with Uniform Guidance requirements ...
The Board will strengthen its internal control procedures over federal program expenditures by enhancing the review and approval process to ensure that all costs charged to federal awards are allowable, allocable, reasonable, and adequately supported in accordance with Uniform Guidance requirements and the terms and conditions of applicable grant awards. In addition, the Board will provide training to fiscal and program staff on Federal cost principles, allowability requirements, and appropriate cost allocation methodologies to improve compliance and consistency in the charging of expenditures to Federal (and State) programs.
Prior to recording the expenditure of the virtual reality headsets on the general ledger, Board management sought guidance on multiple attempts from the Texas Workforce Commission (TWC) Fiscal T/A division regarding the appropriate treatment of the cost, but did not receive a response before payment...
Prior to recording the expenditure of the virtual reality headsets on the general ledger, Board management sought guidance on multiple attempts from the Texas Workforce Commission (TWC) Fiscal T/A division regarding the appropriate treatment of the cost, but did not receive a response before payment was required. However, the Board will continue to work with TWC to determine the appropriate resolution and disposition of the questioned costs and will implement any corrective actions necessary to ensure compliance with Texas Workforce Commission and the Federal requirements as prescribed by the Uniform Guidance.
Marcos Gonzales, Board Financial and Data Analyst
Marcos Gonzales, Board Financial and Data Analyst
Cash Management Moving to Work Demonstration Program AL No. 14.881 Other matter required to be reported in accordance with 2 CFR 200.516(a) Condition: Out of the 66 grant drawdowns during the year, 19 drawdowns were tested and it was noted that 1 of the drawdowns was made in advance of the supportin...
Cash Management Moving to Work Demonstration Program AL No. 14.881 Other matter required to be reported in accordance with 2 CFR 200.516(a) Condition: Out of the 66 grant drawdowns during the year, 19 drawdowns were tested and it was noted that 1 of the drawdowns was made in advance of the supporting invoices being paid to the vendors and subsequently the invoices were not paid within three business days, as required. Auditor’s Recommendations: The Agency should continue to develop and implement internal controls over grant management to coordinate capital fund draws with the timing of invoice payments. Action Taken: Action Due Date Responsible Person This finding occurred prior to the staff receiving the results of the previous audit. There have been no additional invoice payments outside of the 3-day allowable time. Staff developed and implemented an internal tracking document to ensure payments are made within three days of the draw. Complete – May 2025 Accounting Technician, Kary Smith, Lauren Hodgens and Ryan Bates
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: As a part of the audit process, a reclassification entry was made to move an additional 12 months of reserve funds from the cash swe...
Federal Agency Name: Department of Agriculture Program Name: Community Facilities Loans and Grants Federal Financial Assistance Listing Number: 10.766 Finding Summary: As a part of the audit process, a reclassification entry was made to move an additional 12 months of reserve funds from the cash sweep general fund to a separate bookkeeping account. The Hospital had excess cash available to cover the required reserve amount for the fiscal year. Responsible Individuals: Renae Karst, Chief Financial Officer Corrective Action Plan: Management will fund the reserve account from the cash sweep general fund and will monitor the separate bookkeeping account throughout the year to ensure the reserve is properly funded throughout the year as required by the loan documents. Anticipated Completion Date: June 30, 2026
Management acknowledges the importance of cash management policies with regards to reimbursable programs. Day Kimball Healthcare is committed to full compliance with federal cash management requirements and takes seriously its obligation to request reimbursement only after program expenditures have ...
Management acknowledges the importance of cash management policies with regards to reimbursable programs. Day Kimball Healthcare is committed to full compliance with federal cash management requirements and takes seriously its obligation to request reimbursement only after program expenditures have been both incurred and paid. During fiscal year 2025, the employee responsible for previous reporting of these expenses retired, and the job function of submission and review of this grant passed on to other individuals. Management recognizes that our existing review process did not include a sufficient control step to verify payment status prior to submission of reimbursement requests, and employees have now been trained on proper procedure, which includes confirmation of payment of expenses before submission is allowed. In addition, the reviewer is now aware of this requirement and confirmation of payment is now a part of this individual’s responsibilities as well. Going forward into fiscal year 2026 Management believes these controls will prevent similar findings from occurring. Sheena Farner, Director of Budget & Financial Reporting, will oversee this corrective action plan to be fully implemented by September 30, 2026.
Finding 2025-004 Plan: Management acknowledges this finding. The surplus cash deposit was not made within the required 90-day timeframe following fiscal year-end because an Owner-Certified REAC submission was filed while awaiting completion of the audited financial statements. Management incorrectly...
Finding 2025-004 Plan: Management acknowledges this finding. The surplus cash deposit was not made within the required 90-day timeframe following fiscal year-end because an Owner-Certified REAC submission was filed while awaiting completion of the audited financial statements. Management incorrectly believed the surplus cash calculation and deposit could be deferred until the audited REAC was submitted. To prevent this from occurring in the future, management has implemented a procedure requiring surplus cash to be calculated immediately following fiscal year-end, regardless of whether an Owner-Certified REAC or Audited REAC is submitted. Management will estimate and deposit any required surplus cash into the Residual Receipts Account within HUD's required 90-day timeframe and make any necessary adjustments after the audited financial statements are completed. Management has reviewed HUD requirements with applicable staff and will monitor future year-end submissions to ensure compliance with all surplus cash deposit requirements. Contact: Jackie Oliveira-Director of Affordable Housing Completion Date: 03/31/2026
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization...
Finding Number: 2025-001 Finding Title: Procurement Controls (Significant Deficiency) Name of Contact Person: Janice Clark, Chief Finance & Operations Officer Corrective actions implemented or in process include the following: 1. Enhanced Procurement Oversight and Centralized Review The Organization, building on its established procurement policies, implemented stricter headquarters oversight and approval requirements for higher-risk and higher-dollar procurements, including defined approval thresholds for procurement solicitations, evaluation activities, and contract execution. Specialized and international procurements now require additional senior-level review and involvement, regardless of value. 2. Strengthened Vendor Due Diligence and Market Research Procedures The Organization updated procurement procedures to require expanded documentation of vendor due diligence and market research activities, including enhanced validation of vendor qualifications, procurement support documentation, and vendor representations associated with federal procurements. 3. Enhanced Monitoring of Procurement Documentation and Compliance Requirements Management implemented strengthened review procedures over procurement advertisements, vendor certifications, geographic code compliance documentation, and other supporting procurement records. The revised procedures also require additional review and escalation for identified procurement irregularities or inconsistencies. 4. Advance Payment and Approval Controls The Organization implemented revised controls governing advance payments, including enhanced approval requirements for significant prepayments and additional supporting documentation requirements for high-risk payment arrangements. 5. Procurement Evaluation and Technical Assistance The Organization enhanced procurement evaluation oversight by requiring additional Headquarters participation in evaluation activities for procurements exceeding defined thresholds. In addition, the Organization engaged specialized procurement and logistics resources to provide technical assistance and support for international procurement activities. 6. Personnel Actions and Training The Organization took personnel actions in response to the investigation findings and implemented enhanced procurement and compliance training for relevant personnel involved in procurement and grants management activities. Management believes these corrective actions appropriately address the control deficiencies identified in the finding and strengthen the Organization’s internal control over compliance related to procurement activities under federally funded programs. Anticipated Completion Date: Substantially completed as of April 6, 2026, with ongoing monitoring and training activities continuing through fiscal year 2026.
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: April 2026
Section 202 HUD-Insured Mortgage– Assistance Listing No. 14.157 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 202 HUD-Insured Mortgage– Assistance Listing No. 14.157 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: October 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management has made all required deposits to the residual receipts account as of May 2025 and the cash account was whole before the sale that took place on November 30, 2025. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: May 31, 2025
The Alabama Department of Public Health will ensure all expenditures are adequately documented, based on true and accurate invoices, and allowable under the federal award. • The Immunization Division continues to reorganize with the new leadership team. Staff reviews grant guidance semi-annually, or...
The Alabama Department of Public Health will ensure all expenditures are adequately documented, based on true and accurate invoices, and allowable under the federal award. • The Immunization Division continues to reorganize with the new leadership team. Staff reviews grant guidance semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation are being reviewed for source documents against grant guidance by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied before forwarding to Finance. • Grant monitoring staff use the Risk Assessment and Subrecipient monitoring policy to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • ADPH Bureau of Financial Services has developed and required the use of a Subrecipient Field Voucher form to include certification statement referencing 2 CFR200 in regard to invoices, along with conducting ffirther reviews of invoices before uploading into STAARS for payment. • All program grant staff have access to attend all available Finance and Grant training courses. • ADPH Bureau of Financial Services has created a Grant Management Centralized Guidance Repository in the ADPH Document Library for access by all ADPH staff • ADPH Bureau of Financial Services is developing an ADPH Grant Manual. • ADPH Bureau of Financial Services will develop policies and procedures related to media usage, college awareness campaigns, and sponsorships to ensure adequate documentation is available to verify the allowability of the expenditures in relation to various programs.
Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm....
Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm. A drawdown policy will be established for the July 2026 Board Meeting for approval.
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