Corrective Action Plans

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2025-001 Significant Deficiency in Internal Control and Compliance over Major Programs Funding Agency: Department of Defense ALN: 12.002 Recommendation: JSP recommends the Organization strengthen internal controls over cash management by establishing formal payment processing timelines, implementing...
2025-001 Significant Deficiency in Internal Control and Compliance over Major Programs Funding Agency: Department of Defense ALN: 12.002 Recommendation: JSP recommends the Organization strengthen internal controls over cash management by establishing formal payment processing timelines, implementing monitoring procedures to track outstanding reimbursement requests, and conducting supervisory reviews to ensure subrecipient payments are made promptly. Contact person responsible for corrective action: Taylor McEachern, Accounting Manager The EDC agrees with the findings. Management acknowledges that reimbursement payments to subrecipients were not consistently made within 30 calendar days of receipt of the payment request as required by 2 CFR 200.305(b)(3) and agrees that internal controls over cash management should be strengthened. Management notes that during the audit period the EDC experienced delays in receiving payments from the federal awarding agencies associated with this and other grants, which contributed to the condition; management is taking action to ensure that the EDC’s cash-flow timing does not affect the timeliness of subrecipient reimbursements going forward. To correct the conditions, management will implement the following: • Establish formal, written payment processing timelines governing the review and disbursement of subrecipient reimbursement requests, with a defined internal deadline that ensures payment within the 30-calendar-day requirement. • Implement monitoring procedures to log and track all outstanding reimbursement requests from date of receipt through payment, so that requests approaching the deadline are flagged and prioritized. • Conduct periodic supervisory reviews of the payment log to confirm requests are being processed timely and to identify and resolve any delays. • Monitor the timing of drawdowns and reimbursements from the federal awarding agencies and, where recurring delays affect the EDC’s ability to pay subrecipients timely, have an action plan to process the payments within the 30-calendar-day requirement. The Accounting Manager will be overseeing the payment tracking process and report monthly to the C&I Director and Grant Manager to reinforce accountability for timely disbursement Anticipated completion date: September 2026
Condition: The Association’s controls were not effective to ensure it was recognizing revenue and unearned revenue for reimbursement-based programming in the same period the expenditure occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...
Condition: The Association’s controls were not effective to ensure it was recognizing revenue and unearned revenue for reimbursement-based programming in the same period the expenditure occurred. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Containment Advanced funds are recorded as deferred revenue at time of receipt. Periodic adjustments are made through the Accounts Receivable (AR) module as part of the monthly-end close (MEC) process to reclassify unearned revenue as the related expenditures are incurred. Root Cause The root cause was that, in prior years, grant revenue and related accruals were not consistently reconciled to expenditures. Cash receipts were recognized as grant revenue without adequately considering the timing of the related expenditures. For awards that crossed fiscal periods, this resulted in variances between earned and deferred revenue and, in some cases, expenditures exceeding available grant funding. Action Taken OCCDA has implemented the use of the Accounts Receivable (AR) module for grant revenue reporting and reconciliation. Grant activity is reviewed as part of the monthly-end close (MEC) process, including reconciliation of expenditures, reimbursements, and deferred revenue. Monthly management reports have also been updated to include both earned revenue and deferred revenue, providing management with improved visibility into grant activity and supporting timely recognition of grant revenue.
Audit Finding Reference: 2025-001 Corrective Action Plan: Reimbursement Request Review and Approval Documentation Finding: The Center was unable to provide documentation demonstrating that reimbursement requests submitted to federal funding agencies received supervisory review and approval by the Co...
Audit Finding Reference: 2025-001 Corrective Action Plan: Reimbursement Request Review and Approval Documentation Finding: The Center was unable to provide documentation demonstrating that reimbursement requests submitted to federal funding agencies received supervisory review and approval by the Controller prior to submission. While reimbursement requests were reviewed, evidence of such review and approval was not consistently documented and retained. Root Cause: The review and approval process existed; however, formal documentation evidencing the Controller’s review and approval was not consistently retained with the reimbursement request records. Corrective Action: The Center has implemented enhanced procedures to ensure that all reimbursement requests submitted under federal awards receive documented supervisory review and approval prior to submission. Grant accounting staff will prepare the reimbursement request and supporting documentation and submit the complete package to the Controller for review. The Controller will review the request for accuracy, allowability, allocability, reasonableness, adequate supporting documentation, reconciliation to grant records and approved budgets, and compliance with applicable federal regulations and award requirements. Approval will be documented through electronic approval, email authorization retained with the reimbursement records, or signature and date on the reimbursement package or standardized checklist prior to submission. Preventive Measures: The Center has developed a standardized reimbursement request checklist that must be completed and retained with each reimbursement package. Grant accounting personnel will be trained on the revised documentation requirements, and the Executive Director will perform quarterly spot checks of reimbursement request files to confirm that evidence of review and approval is consistently maintained. Any exceptions identified will be addressed through corrective training and process improvements. Responsible Parties: Controller, Grant Accounting Staff, and Executive Director. Implementation Date: Effective immediately upon adoption. Evidence of Completion: Completed reimbursement request checklists, documented Controller approvals through signature, electronic approval, or retained email authorization, supporting reimbursement documentation, and quarterly monitoring documentation.
To Prevent this from occurring in the future, ACED will implement a formal review and reconciliation process prior to submitting all HOME Drawdown requests. Expenditures will be recorded in JDE and reconciled to the supporting documentation before any reimbursement is submitted to HUD. . A tracking ...
To Prevent this from occurring in the future, ACED will implement a formal review and reconciliation process prior to submitting all HOME Drawdown requests. Expenditures will be recorded in JDE and reconciled to the supporting documentation before any reimbursement is submitted to HUD. . A tracking process will be put in place to know the submission of payment request and the drawn down A supervisor review will verify that all expenditures have been accurately recorded, properly completed, and supported before drawdown is approved. Timetable of dates for performance of planned corrective action steps including completion date: Effective immediately, all HOME drawdown vouchers will require the corresponding journal entry to be completed and posted in JDE prior to submitting the drawdown request to HUD. This procedure will be followed for all future HOME reimbursements. Description of monitoring to be performed to ensure corrective action steps are taken: Management will review each HOME drawdown prior to submission to confirm that: the 1. The related journal entry has been completed and posted in JDE 2. The recorded expenditures agree to the drawdown voucher 3. Supporting documentation has been reconciled and approved.
ACED accounting staff will make the journal entry to reclassify the expenditure. The accounting staff will document more closely all program income and consistently record all expenditures in the appropriate expenditure accounts. D. Timetable of dates for performance of planned corrective action ste...
ACED accounting staff will make the journal entry to reclassify the expenditure. The accounting staff will document more closely all program income and consistently record all expenditures in the appropriate expenditure accounts. D. Timetable of dates for performance of planned corrective action steps including completion date: This will be an immediate action as of July 8, 2026. Description of monitoring to be performed to ensure corrective action steps are taken: The accounting staff will maintain a tracking sheet of the dates of the expenditures and notate the accounts the items were recorded to and this will be reviewed by the Assistant Director of Finance.
Corrective action steps taken and/or planned: We have reviewed the Cash-on-Hand reports and determined that the issue stems from program income balances being carried over and erroneously added to the grant balances each reporting period. Since program income is the first funding drawn down before e...
Corrective action steps taken and/or planned: We have reviewed the Cash-on-Hand reports and determined that the issue stems from program income balances being carried over and erroneously added to the grant balances each reporting period. Since program income is the first funding drawn down before entitlement funding it should be a zero balance at the end of the quarter. We will implement a process for the accounting staff to pull the PR01 – HUD Grants and Program Income report to compare the program income balance, when completing the Cash-on Hand report each quarter to verify program income expenditures. D. Timetable of dates for performance of planned corrective action steps including completion date: This process will be immediately implemented for the 2nd quarter 2026, Cash-on-Hand report. E. Description of monitoring to be performed to ensure corrective action steps are taken: The Cash-on-Hand report and all supporting documentation will be submitted to the Assistant Director or Finance, as well as the Assistant Director of Operations for review to ensure accuracy before the report is submitted in the IDIS system for HUD’s approval.
Corrective action steps taken and/or planned: Allegheny County Health Department will send a supplemental check of $241,000 for interest earned through November 2025 to the Department of Health and Human Services. Timetable of dates for performance of planned corrective action steps including comple...
Corrective action steps taken and/or planned: Allegheny County Health Department will send a supplemental check of $241,000 for interest earned through November 2025 to the Department of Health and Human Services. Timetable of dates for performance of planned corrective action steps including completion date: All required activities will be completed by 09/30/2026. Description of monitoring to be performed to ensure corrective action steps are taken: ACHD Finance Manager, Financial Planning Supervisor, and Grants Manager will monitor the situation to ensure the supplemental payment is issued to the Department of Health and Human Services.
Management is aware of the finding and will develop the following action plan to correct. The CFO, John Murray, will be responsible to correct the recognized deficiency. The plan will be for management to contact and work with HUD Technical Assistance to try to get all rejected filings previously su...
Management is aware of the finding and will develop the following action plan to correct. The CFO, John Murray, will be responsible to correct the recognized deficiency. The plan will be for management to contact and work with HUD Technical Assistance to try to get all rejected filings previously submitted to accepted status. If problems cannot be resolved, management’s plan is to hire a new third party consultant to work with HUD Technical Assistance to submissions up to date.
Corrective Action Planned: The Authority will draw down CFP funds on a reimbursement basis or can ensure subsequent disbursement within three business days to ensure compliance with 31 CFR Part 205.
Corrective Action Planned: The Authority will draw down CFP funds on a reimbursement basis or can ensure subsequent disbursement within three business days to ensure compliance with 31 CFR Part 205.
2025-01: Segregation of Duties Name of contact person: Katie Sponberger, Executive Director Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compens...
2025-01: Segregation of Duties Name of contact person: Katie Sponberger, Executive Director Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. The costs of segregating certain duties exceeds the benefit and therefore, nonfinancial employees will be trained to provide some assistance in these areas. Proposed completion date: The Board will implement the above procedure immediately.
REVIEW OF REPORTS Federal Agency: U.S. Department of Agriculture Federal Program Title: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Pass-Through Agency: Minnesota Department of Health Federal Award Identification and Year: 252MN0004W1...
REVIEW OF REPORTS Federal Agency: U.S. Department of Agriculture Federal Program Title: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Assistance Listing Number: 10.557 Pass-Through Agency: Minnesota Department of Health Federal Award Identification and Year: 252MN0004W1003, 2025 Pass-Through Numbers: 252MN0004W1003 Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Recommendation: It is recommended the Agency implement policies and procedures to ensure that there are adequate controls overall all compliance requirements for federal grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Agency will review policies and procedures and implement change as necessary.. Name of the contact person responsible for corrective action plan: Maggie Rothstein, Administrator Planned completion date for corrective action plan: December 31, 2026
There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that reimbursement requests were not consistently supported by reconciliations to actual expenditures and that existing review procedures d...
There is no disagreement with the audit finding. Action planned/taken in response to finding: Management concurs with the finding. The Organization acknowledges that reimbursement requests were not consistently supported by reconciliations to actual expenditures and that existing review procedures did not provide sufficient assurance that draw requests complied with federal cash management requirements. Management is implementing revised procedures requiring all draw requests to be supported by detailed expenditure reconciliations, payroll reports, invoices, and other supporting documentation prior to submission. In addition, management has formally instituted a policy requiring all reimbursement requests to be submitted on an official Request for Reimbursement form, accompanied by a written statement describing the purpose of the reimbursement and the related expenditures, and supported by appropriate source documentation. The Organization will also establish an enhanced review process requiring independent verification of supporting documentation before reimbursement requests are submitted. Each completed Request for Reimbursement form, together with the related expenditure reconciliation and supporting documentation, must be reviewed and approved by the Chief Executive Officer (CEO) before any drawdown or reimbursement request is submitted. Evidence of the CEO’s review and approval will be retained with each request to demonstrate compliance with federal cash management requirements under the Uniform Guidance (2 CFR 200.305). Management is committed to ensuring future draw-down requests (including those already submitted during the subsequent year) are based solely on actual allowable expenditures incurred and are submitted in compliance with federal cash management requirements. Name(s) of the contact person(s) responsible for corrective action: Edward Murphy, Asante Muyungga, Charity Gutierrez, Anthony Parker, Bennett Baber, Jannell Robinson. Planned completion date for corrective action plan: June 30th, 2027
The Organization recognizes four drawdowns for supplies were budgeted estimates and that incurred supplies costs were subsequently more than the estimates. Cash management procedures were corrected in June 2025 to include only incurred supplies expenses in drawdown requests
The Organization recognizes four drawdowns for supplies were budgeted estimates and that incurred supplies costs were subsequently more than the estimates. Cash management procedures were corrected in June 2025 to include only incurred supplies expenses in drawdown requests
Condition: NIST Recovery Reports were prepared without evidence of a secondary review or approval by an individual independent of the preparer and knowledgeable of grant requirements. Planned Corrective Action: The Controller will prepare the monthly NIST Recovery Report and submit the report to the...
Condition: NIST Recovery Reports were prepared without evidence of a secondary review or approval by an individual independent of the preparer and knowledgeable of grant requirements. Planned Corrective Action: The Controller will prepare the monthly NIST Recovery Report and submit the report to the Vice President of Operations for review and approval. The Vice President of Operations will provide documented evidence of the review and approval to the Controller. Upon receipt of the documented evidence of review, the Controller will request that the Vice President of Operations initiate the recovery of the monthly NIST reimbursement amount. Contact person responsible for corrective action: Alan Kowalewski Anticipated Completion Date: 08/20/2026
Condition: During testing of subrecipient payments, we identified 15 instances in which payments to subrecipients were made more than 30 calendar days after receipt of a complete and approved invoice. Planned Corrective Action: During the audit period, the organization experienced delays in processi...
Condition: During testing of subrecipient payments, we identified 15 instances in which payments to subrecipients were made more than 30 calendar days after receipt of a complete and approved invoice. Planned Corrective Action: During the audit period, the organization experienced delays in processing certain subrecipient invoices. As a result, some subrecipients were not paid in accordance with the requirements of 2 CFR 200.305(b)(3). To address this finding, management has implemented the following corrective actions: Revised internal procedures to ensure payments are made within 30 calendar days of the approval of subrecipient invoices, regardless of when reimbursement is received from the federal awarding agency. Implemented a weekly aging report to identify subrecipient invoices approaching payment due dates and to ensure timely resolution. Provided additional training to the program, finance and the management teams on federal payment requirements and internal procedures. Established periodic management reviews to monitor compliance with payment timeliness requirements and identify process improvements as needed. Management fully implemented all corrective actions as of June 30, 2026. Contact person responsible for corrective action: Nancy Cummins, Controller Anticipated Completion Date: June 30, 2026
The City has reviewed the circumstances that resulted in the duplicate reimbursement and has strengthened its procedures for grant reimbursement requests involving invoices that have not completed the City's normal accounts payable posting process. Reimbursement requests shall include only expenditu...
The City has reviewed the circumstances that resulted in the duplicate reimbursement and has strengthened its procedures for grant reimbursement requests involving invoices that have not completed the City's normal accounts payable posting process. Reimbursement requests shall include only expenditures that have been paid, recorded in the City’s financial system, and posted to a closed accounting period, unless the grant agreement or grantee processing times mandates earlier submission. Invoices or other expenditures manually included in a reimbursement request prior to posting in the City's financial system will be separately identified and tracked. Prior to preparing subsequent reimbursement requests, these items will be reconciled against posted expenditures to ensure that amounts previously claimed are not included a second time. The City believes this additional reconciliation control, together with the repayment of the questioned amount, appropriately addresses the finding and reduces the risk of duplicate reimbursement requests in the future.
2025-03: Approval for expenditures Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Propose...
2025-03: Approval for expenditures Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: A member of management or the Board of Directors will review and authorize all disbursements. This authorization will be evidenced by the initialing of each disbursement reviewed. Proposed completion date: The Board will implement the above procedure immediately.
2025-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensat...
2025-01: Segregation of Duties Name of contact person: Rhonda Gordon, Program Coordinator Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregating certain duties is not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.
Finding # 2025-001 Type: Material weakness Assisting Listing Number: 14.251 Federal Agency: Department of Housing and Urban Development Name of Federal Program: Economic Development Initiative Finding: Management had not established formal policies and procedures requiring review and approval of dra...
Finding # 2025-001 Type: Material weakness Assisting Listing Number: 14.251 Federal Agency: Department of Housing and Urban Development Name of Federal Program: Economic Development Initiative Finding: Management had not established formal policies and procedures requiring review and approval of drawdown requests before funds were drawn from the federal payment system. Recommendation: Management should establish and document procedures requiring all federal cash drawdown requests to be reviewed and approved by an individual independent of the preparer prior to submission. The review should include verification that the requested amount is supported by eligible expenditures incurred or immediate cash needs, as applicable under the terms of the federal award. Evidence of the review and approval should be retained with the drawdown documentation. Corrective Action: Management agrees with the finding and will implement a formal review and approval process for all federal drawdowns. All draw requests will be reviewed and approved by the Director of Finance or another designated member of management prior to submission through the federal payment system. Documentation of the review will be retained with the supporting drawdown records. Anticipated Completion Date July 2026
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found three instances of reimbursement by the grantor totaling approximately $9,600 received approximately three to five months before payments were made to the vendors. R...
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Condition and context: In a sample of 30 vendor payments, we found three instances of reimbursement by the grantor totaling approximately $9,600 received approximately three to five months before payments were made to the vendors. Repeat of finding #2024-004. Recommendation: Strengthen controls to ensure that invoices are paid in a timely manner to ensure federal reimbursements are not being held for an excess period of time. Planned corrective action: As part of our enhanced review of government transactions, we will be on the alert to disburse federal funds received in a timely/reasonable manner. Accounts payable report will be reviewed with a heightened priority to quickly disbursing federal funds received. Responsible officer: Amber Newman, CEO. Estimated completion date: October 1, 2026.
2025-001 – Cash Management and Period-of-Performance Corrective Action The Authority will monitor modernization activity against grant funding availability dates regularly. Additionally, the Authority will execute procedures requiring each Capital Fund grant funding request to be supported by immedi...
2025-001 – Cash Management and Period-of-Performance Corrective Action The Authority will monitor modernization activity against grant funding availability dates regularly. Additionally, the Authority will execute procedures requiring each Capital Fund grant funding request to be supported by immediate, documented, and eligible expenditures in accordance with HUD’s requirements. Jeremy Hayes, Executive Director has assumed the responsibility of executing this corrective action as of September 18, 2026
Noncompliance with Period of Performance (Public Housing Capital Fund ALN # 14.872) The Authority’s staff will attend trainings to ensure that the Authority is in compliance with all CFP reporting requirements. Date of completion: Ongoing
Noncompliance with Period of Performance (Public Housing Capital Fund ALN # 14.872) The Authority’s staff will attend trainings to ensure that the Authority is in compliance with all CFP reporting requirements. Date of completion: Ongoing
Noncompliance with Cash Management (Public Housing Capital Fund ALN # 14.872) We will implement controls to ensure all future eligible Capital Fund draws are made within 3 business days of expenditures. Date of completion: Ongoing
Noncompliance with Cash Management (Public Housing Capital Fund ALN # 14.872) We will implement controls to ensure all future eligible Capital Fund draws are made within 3 business days of expenditures. Date of completion: Ongoing
Athens Land Trust has implemented an updated grant reporting and reimbursement process to ensure required expenditure reports and supporting documentation are complete and submitted within established deadlines. The Finance Director and Housing Director coordinate the tracking of expenditures and co...
Athens Land Trust has implemented an updated grant reporting and reimbursement process to ensure required expenditure reports and supporting documentation are complete and submitted within established deadlines. The Finance Director and Housing Director coordinate the tracking of expenditures and collection of supporting documentation, with the Development Coordinator assisting with reimbursement tracking and drawdown documentation. Multiple staff members are also being cross-trained on reporting procedures to ensure continuity and reduce reliance on any single employee. Grant reporting and reimbursement status is periodically reviewed during biweekly directors’ meetings, providing additional oversight by the Executive Director and helping prevent recurrence of late filings.
Finding 1236918 (2025-004)
Material Weakness 2025
RANDOM MOMENT STUDY (RMS) EMPLOYEES LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through A...
RANDOM MOMENT STUDY (RMS) EMPLOYEES LISTING Federal Agency: U.S. Department of Health and Human Services Federal Program Title: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Federal Award Identification Number and Year: 2505MN5ADM and 2505MN5MAP, 2025 Pass-Through Agency: Minnesota Department of Human Services Pass-Through Numbers: 2505MN5ADM and 2505MN5MAP Award Period: Year-Ended December 31, 2025 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: It is recommended the County review the RMS listings and employees within the department and account codes to ensure the proper employees are included on the listing and general ledger accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County has implemented procedures and policies to have a person ensure account coding is made to the correct accounts. Name of the contact person responsible for corrective action plan: Anne Broskoff, Human Services Director Planned completion date for corrective action plan: December 31, 2026
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