Corrective Action Plans

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Finding 2023-008: This is for Pohnpei Community Health Centers. 1) For 2 of 2 items tested. We noted that total expenditures reported in documentary support submitted by the State for drawdown requests do not match the initial amounts requested, approved, and received by the awarding agency. We are ...
Finding 2023-008: This is for Pohnpei Community Health Centers. 1) For 2 of 2 items tested. We noted that total expenditures reported in documentary support submitted by the State for drawdown requests do not match the initial amounts requested, approved, and received by the awarding agency. We are aware that the expenditure reports furnished to us are not the originals that would have accompanied the State’s initial request for reimbursement from the awarding agency. It does not appear that the original supporting expenditure reports were retained. 2) The State does not appear to have a policy or adopted standard methodology for monitoring 93.224 programmatic cash needs and scheduling regular drawdowns. Root Cause Analysis 1) The State’s documentary retention controls over programmatic drawdowns need improvement 2) The State has not established a policy or standard operating procedure for monitoring 93.224 programmatic cash needs and scheduling regular drawdowns. Corrective Actions 1) Strengthen its controls over documentary retention for drawdowns. Retain expenditure reports for the basis of drawdowns at the time of filing and ensure there is appropriate explanatory documentation retained for any special reconciling items. 2) Establish clear policies and procedures for monitoring cash needs, performing drawdowns, and retaining documentation of drawdowns. Responsible Parties For CAP 1, Director of DOTA and the Chief of Finance For CAP 2, Director of DOTA and the Chief of Finance Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-004: For 1 (or 1%) of 60 transactions tested, aggregating $1,187,753 out of $19,516,462 in program expenditures, the State made an advance payment using sector grant funds. No documentation was provided to evidence prior grantor agency concurrence to waive the specific special provision...
Finding 2023-004: For 1 (or 1%) of 60 transactions tested, aggregating $1,187,753 out of $19,516,462 in program expenditures, the State made an advance payment using sector grant funds. No documentation was provided to evidence prior grantor agency concurrence to waive the specific special provision. For 11 (or 23%) of 49 personnel records tested under the Compact Sector Education and Supplemental Education grants, no documentation was available to show that the annual performance evaluation had been performed. Root Cause Analysis • For advance payments, either concurrence was not obtained, or documentation was not retained; and a lack of familiarity with specific grant conditions may have contributed to the noncompliance. • For evaluations, documentation retention controls over personnel files were inadequate. Corrective Actions • For the health grants, if advance payments are necessary, the State should (a) use general fund advances with later reimbursement; (b) establish a letter of credit; or (c) obtain prior OIA concurrence. • For the Education and Supplemental Education grants, the State should strengthen controls to ensure annual evaluations are completed and retained in personnel files. Responsible Parties For bullet point one: Director of Health and his administrative officers Director of DOTA, certification and payable section For bullet point two: Director of Education and Personnel Managers Timeline Verification of Effectiveness Conduct regular assessments to ensure the effective implementation of the aforementioned action plans.
• Strengthen monitoring controls to verify period of performance, including obligation/incurrence and liquidation timelines. • Collaborate with grantors to clarify and document allowable liquidation periods for drawdowns. • Implement systematic filing of supporting documents for easy retrieval. • No...
• Strengthen monitoring controls to verify period of performance, including obligation/incurrence and liquidation timelines. • Collaborate with grantors to clarify and document allowable liquidation periods for drawdowns. • Implement systematic filing of supporting documents for easy retrieval. • Note: Drawdowns conducted in close collaboration with grantors, confirming compliance with agreed terms. 9/30/2026 Ms. Senny Phillip, Asst. Secretary of Investment & International Financing Email: senny.phillip@gov.fm
• Review all files for completeness before submission to auditors starting FY2024 audit onward. • Enhance file organization for deeper reviews and systematic access to drawdown reports, invoices, and payments. • Note: Re-review located >90% of cited "missing" documents; underlying support was availa...
• Review all files for completeness before submission to auditors starting FY2024 audit onward. • Enhance file organization for deeper reviews and systematic access to drawdown reports, invoices, and payments. • Note: Re-review located >90% of cited "missing" documents; underlying support was available. Management believed all requested files were provided. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury Email: christina.elnei@dofa.gov.fm
• Review all files for completeness before submission to auditors starting FY2024 onward. • Enhance systematic filing and accessibility of drawdown reports and supporting documentation. • Note: Re-review located >90% of cited "missing" documents; underlying support was available. Tagging is not mand...
• Review all files for completeness before submission to auditors starting FY2024 onward. • Enhance systematic filing and accessibility of drawdown reports and supporting documentation. • Note: Re-review located >90% of cited "missing" documents; underlying support was available. Tagging is not mandatory. 12/15/25 (SPAF submitted) / Ongoing 09/30/26 Ms. Christina Elnei, Asst. Secretary of National Treasury Email: christina.elnei@dofa.gov.fm
Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the fi...
Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the findings; Responsible Individual: Nicole Reinert, Public Health Director; Corrective Action Plan: Administrative staff will schedule out all required report dates in the Outlook calendar at least three weeks before the due date to keep responsible parties informed of deadlines. These set reminders will ensure timely submissions. The Department Head will review the submission process to eliminate congested workflow to ensure efficiency and identify any tasks that can be automated or improved. Regular check-ins will take place to discuss the status of ongoing reports.; Anticipated Completion Date: June 30, 2026.
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as iden...
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as identified. In addition, any project associated with outside funding has gone through or will go through a reconciliation process to evaluate its current standing, including all related receivables and payables, and will continue to do so monthly. The City is working to ensure all invoices are paid within a timely manner of the related award advances and according to application of Federal and State regulations.
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: J...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: July 1, 2022 through June 30, 2023 Type of Finding: Material Weakness in Internal Control over Compliance and Cash Management Recommendation: We recommend that management ensure that all invoices are based on actual expenses incurred and that there is a review an approval process of invoices before submission. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Aciton take in response to finding: Management has implemented a policy which requires each invoice to be based only on actual expenses incurred for the period and prohibits the use of a straight-line calculation to draw down funds. Invoices are also approved by the CFO prior to submission for reimbursement. Name of contact person responsible for corrective action: Regan Kelly, CEO of NorthEast Treatment Cetners, Inc. (215) 451-7000 Planned completion date for corrective action plan: January 31, 2024
View Audit 374235 Questioned Costs: $1
Finding 2023-007 – Payroll and Cash Management Deficiencies Responsible official: Executive Director and Accountants Corrective action planned: Management acknowledges that the same payroll and cash management deficiencies identified in the 2023 audit also occurred during 2024 and part of 2025. Spec...
Finding 2023-007 – Payroll and Cash Management Deficiencies Responsible official: Executive Director and Accountants Corrective action planned: Management acknowledges that the same payroll and cash management deficiencies identified in the 2023 audit also occurred during 2024 and part of 2025. Specifically, when federal cash balances were insufficient, payroll was paid temporarily from private funds, followed by the issuance of federal checks to employees for reimbursement purposes. During the 2025 audit, management recognized this as a recurring and systemic deficiency. A formal Cash Management and Interfund Transfer Policy is now being drafted and will be approved by the Board by February 2026. This policy will require: 1. Payroll to be processed directly from the federal account when possible. 2. Temporary transfers from private funds to be documented as interfund advances, with full repayment recorded upon reimbursement. 3. Prohibition of issuing duplicate payroll checks to employees. 4. Reconciliation of all interfund transfers within ten (10) business days after reimbursement. The organization will also implement a dual-authorization process for interfund transactions and establish a monthly reconciliation checklist to be completed by accounting staff and reviewed by the Executive Director. Monitoring: Monthly payroll and cash reconciliations will be reviewed by the Executive Director, and External Accountant. Evidence of reconciliations and approvals will be retained for audit purposes. Target completion date: March 31, 2026 Status: New finding – corrective actions in process.
Finding 2023-008: This is for Pohnpei Community Health Centers. 1) For 2 of 2 items tested. We noted that total expenditures reported in documentary support submitted by the State for drawdown requests do not match the initial amounts requested, approved, and received by the awarding agency. We are ...
Finding 2023-008: This is for Pohnpei Community Health Centers. 1) For 2 of 2 items tested. We noted that total expenditures reported in documentary support submitted by the State for drawdown requests do not match the initial amounts requested, approved, and received by the awarding agency. We are aware that the expenditure reports furnished to us are not the originals that would have accompanied the State’s initial request for reimbursement from the awarding agency. It does not appear that the original supporting expenditure reports were retained. 2) The State does not appear to have a policy or adopted standard methodology for monitoring 93.224 programmatic cash needs and scheduling regular drawdowns. Root Cause Analysis 1) The State’s documentary retention controls over programmatic drawdowns need improvement 2) The State has not established a policy or standard operating procedure for monitoring 93.224 programmatic cash needs and scheduling regular drawdowns. Corrective Actions 1) Strengthen its controls over documentary retention for drawdowns. Retain expenditure reports for the basis of drawdowns at the time of filing and ensure there is appropriate explanatory documentation retained for any special reconciling items. 2) Establish clear policies and procedures for monitoring cash needs, performing drawdowns, and retaining documentation of drawdowns. Responsible Parties For CAP 1, Director of DOTA and the Chief of Finance For CAP 2, Director of DOTA and the Chief of Finance Timeline Verification of Effectiveness Conduct regular assessments to ensure the implementation of the aforementioned action plans.
Finding 2023-004: For 1 (or 1%) of 60 transactions tested, aggregating $1,187,753 out of $19,516,462 in program expenditures, the State made an advance payment using sector grant funds. No documentation was provided to evidence prior grantor agency concurrence to waive the specific special provision...
Finding 2023-004: For 1 (or 1%) of 60 transactions tested, aggregating $1,187,753 out of $19,516,462 in program expenditures, the State made an advance payment using sector grant funds. No documentation was provided to evidence prior grantor agency concurrence to waive the specific special provision. For 11 (or 23%) of 49 personnel records tested under the Compact Sector Education and Supplemental Education grants, no documentation was available to show that the annual performance evaluation had been performed. Root Cause Analysis • For advance payments, either concurrence was not obtained, or documentation was not retained; and a lack of familiarity with specific grant conditions may have contributed to the noncompliance. • For evaluations, documentation retention controls over personnel files were inadequate. Corrective Actions • For the health grants, if advance payments are necessary, the State should (a) use general fund advances with later reimbursement; (b) establish a letter of credit; or (c) obtain prior OIA concurrence. • For the Education and Supplemental Education grants, the State should strengthen controls to ensure annual evaluations are completed and retained in personnel files. Responsible Parties For bullet point one: Director of Health and his administrative officers Director of DOTA, certification and payable section For bullet point two: Director of Education and Personnel Managers Timeline Verification of Effectiveness Conduct regular assessments to ensure the effective implementation of the aforementioned action plans.
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Certain 2023 draws were processed as advances outside grant guidelines, although these draws were properly recorded as advances payable...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Certain 2023 draws were processed as advances outside grant guidelines, although these draws were properly recorded as advances payable in the accounting records. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI considers this finding resolved. A written drawdown procedure is now in place, requiring two-tier preparation and review, and, for working-capital advances, written approval from the prime funder. When the non-compliance was identified, CUAHSI suspended all NSF draws (late March 2023) until new controls were implemented. On 15 June 2023, CUAHSI completed its first draw under the revised policy. Name of Contact Person: • Jordan S Read, Chief Executive Officer • Telephone: (339)933-4660 • Email: jread@cuahsi.org Projected Completion Date: NA; is complete
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: - States and U.S. territories - Tribal governments that are allocated more than $30 million in SLFRF funding - Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C - Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding - NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
We will review policies and procedures for disbursements to ensure that all payments have an evidenced independent review prior to payment. We plan to implement these changes January 1, 2026.
We will review policies and procedures for disbursements to ensure that all payments have an evidenced independent review prior to payment. We plan to implement these changes January 1, 2026.
Management believes that in order to ensure that the amount being drawn down are timely and more accurate to the amounts being drawn upon, management is in the process of developing a more formal policy whereby the general ledger will be formally closed on a monthly basis and all amount will be reco...
Management believes that in order to ensure that the amount being drawn down are timely and more accurate to the amounts being drawn upon, management is in the process of developing a more formal policy whereby the general ledger will be formally closed on a monthly basis and all amount will be reconciled to the ledger. Once all amounts are proven, then the drawdown amounts will be initiated with the proper documentation attached.
View Audit 371855 Questioned Costs: $1
We will ensure that meal count documents are accurate and reported correctly for reimbursement. Additionally, we will use checks and balance system using two or more people to calculate accurate and verifiable number of meals correctly, thoroughly, and efficiently. We are implementing an automation ...
We will ensure that meal count documents are accurate and reported correctly for reimbursement. Additionally, we will use checks and balance system using two or more people to calculate accurate and verifiable number of meals correctly, thoroughly, and efficiently. We are implementing an automation system that will track, record and input data for reporting purposes. The new system is called KidKare by Minute Menu to improve this process
We will ensure that meal count documents are accurate and reported correctly for reimbursement. Additionally, we will use checks and balance system using two or more people to calculate accurate and verifiable number of meals correctly, thoroughly, and efficiently. We are implementing an automation ...
We will ensure that meal count documents are accurate and reported correctly for reimbursement. Additionally, we will use checks and balance system using two or more people to calculate accurate and verifiable number of meals correctly, thoroughly, and efficiently. We are implementing an automation system that will track, record and input data for reporting purposes. The new system is called KidKare by Minute Menu to improve this process
The Accounting Department has established policies and procedures to ensure that grant billing is processed accurately and reconciled on a monthly basis. It is part of the CFO and Controller’s responsibility to verify that grant billing is reconciled each month and that there are no variances or dis...
The Accounting Department has established policies and procedures to ensure that grant billing is processed accurately and reconciled on a monthly basis. It is part of the CFO and Controller’s responsibility to verify that grant billing is reconciled each month and that there are no variances or discrepancies between the billing, drawdowns, and expenses. In addition, the CFO is working diligently to ensure that all grant billing is recorded in the same period in which the expenses are incurred.
: Management must strengthen internal controls to ensure that it meets the deadline period for making the deposit to the Residual Receipt Bank Account in the event of a surplus cash.
: Management must strengthen internal controls to ensure that it meets the deadline period for making the deposit to the Residual Receipt Bank Account in the event of a surplus cash.
Benjie Read CFO and Felecia Read Staff Accountant, will develop a policy and establish procedures to maintain federal grant funds in an interest-bearing account. This will be done within 90 days of audit completion.
Benjie Read CFO and Felecia Read Staff Accountant, will develop a policy and establish procedures to maintain federal grant funds in an interest-bearing account. This will be done within 90 days of audit completion.
Benjie Read CFO and Felecia Read Staff Accountant, will update written policies and procedures to implement the requirements of 2 CFR 200.305 to include a review and documentation of the cash draw requests prior to submission. This will be completed within 90 days of audit completion. In addition, w...
Benjie Read CFO and Felecia Read Staff Accountant, will update written policies and procedures to implement the requirements of 2 CFR 200.305 to include a review and documentation of the cash draw requests prior to submission. This will be completed within 90 days of audit completion. In addition, we no longer operate the only Federal program where cash draws were allowed.
Setting a process up for getting federal wage requirement when projects are being completed. The district will also make sure that the proper training and time will go into allowable cost.
Setting a process up for getting federal wage requirement when projects are being completed. The district will also make sure that the proper training and time will go into allowable cost.
View Audit 370309 Questioned Costs: $1
Finding 2023-006 Lack of Internal Control over Cash Management Type of Finding: Material Weaknesses Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Strengthen the payment review process: • Action: Enforce and document a stricter segregation of duties in the payment process...
Finding 2023-006 Lack of Internal Control over Cash Management Type of Finding: Material Weaknesses Name of Contact: Adela Lane, Executive Director Corrective Action Plan: 1. Strengthen the payment review process: • Action: Enforce and document a stricter segregation of duties in the payment process. This will ensure the individual requesting a payment is not the same person who authorizes the payment. • Details: All payment requests must be cross-referenced with a corresponding invoice or receipt and reviewed and approved by an authorized department head. This Department Head must not be the one who submitted the initial request. 2. Implement a two-tiered review for cash receipts: • Action: Establish a formal two-tiered cash receipts process to enhance accountability and accuracy. • Details: o Tier 1: The individual receiving and logging cash receipts will immediately perform a preliminary count and documentation. o Tier 2: A separate, authorized staff member will perform a second, independent review of the cash receipt records and verify the funds against the deposit slip before the funds are deposited. 3. Standardize training and onboarding for all staff: • Action: Develop a standardized training curriculum on financial management policies and procedures, including a dedicated section on cash management best practices. • Details: o All new permanent and staff members will undergo mandatory training on the updated policies. o Training will cover the importance of internal controls, specifically emphasizing segregation of duties in cash handling. o The Executive Director will meet with all new finance and administrative staff within their first two weeks to review proper protocols and emphasize the organization's commitment to financial controls. 4. Introduce periodic, surprise cash audits: • Action: Conduct unannounced cash counts and reconciliations to ensure compliance with procedures. • Details: An authorized, independent party will perform these surprise audits quarterly to check cash on hand and compare records against financial systems. 5. Enhance oversight and reporting: • Action: The Executive Director will provide regular updates on the implementation of these corrective actions to the Native Village of Point Hope Tribal Council. • Details: A formal report will be presented quarterly, outlining the progress of the corrective actions and any findings from the new oversight procedures. This provides a clear accountability mechanism. Proposed Completion Date: Ongoing, starting in early 2026.
View Audit 370022 Questioned Costs: $1
Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore...
Managements Corrective Action Plan Year Ending – December 31, 2023 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2023. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2023-001 – Reporting Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2024 and 2025 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings: • In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process. • During this time, we have established a grant tracking document that notates – o The reporting month o Dollar amount expected o Date submitted ▪ This date should always be within the month following the required filing o Date the funding was received o An area to document any information or changes worth noting • In 2025, the following additional items have been added to the tracking document to allow for greater oversight – o Review approval o Reporting requirements o Deadlines (monthly, quarterly, etc.) o Proof of submission
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