Corrective Action Plans

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Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and institut...
Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and instituted the following corrective actions: • Updated Internal Signature Policy: We have drafted a strict internal policy requiring the primary case manager-and any other staff actively working on a case-to sign and date all required enrollment documents. This explicitly includes signing intake forms and completing the interpreter sections, where applicable. This policy ensures there is never any ambiguity regarding who is handling the case. • Mandatory Supervisory Review: To enforce this new standard, our internal policy now requires Program Managers and Directors to systematically review each individual case file. Leadership must verify that all required staff signatures, interpreter sign-offs, and eligibility approvals are fully documented before a client's enrollment is considered complete. • Standardized Case Coversheet: To immediately resolve the issue of identifying case handlers, we are implementing a standardized enrollment coversheet for all new files. This document clearly assigns the primary case manager on day one and requires a final supervisory signature to formally authorize the eligibility review. • Targeted Training and Spot-Checks: We are conducting immediate refresher training for all program staff to clarify exactly which signatures are required on each document. Furthermore, leadership will conduct routine, random spot-checks of active case files each month to verify that staff are consistently adhering to this policy in real-time. By formalizing our signature requirements and mandating director-level reviews, we are confident this updated workflow establishes clear accountability and fully resolves the finding.
Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. F...
Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. Furthermore, the delayed receipt of the FY23 audit-delivered post-FY24-precluded the implementation of procedural adjustments during the audited timeframe. To address our operational realities and ensure strict, ongoing adherence to 2 CFR § 200.430, the agency immediately instituted systemic enhancements for FY25. The Organization has transitioned all time tracking to a streamlined, system-driven process within our UKG platform: • Integrated UKG Time Tracking and Approvals: All employees are now required to punch in and out directly through the UKG system, efficiently assigning their actual hours worked to specific program and grant codes to generate functional, after-the-fact timesheets. To further streamline this documentation, the Organization is gradually transitioning our existing supervisory reviews into UKG’s electronic sign-off workflow, which will centralize our approval records and ensure accurate distribution across federal awards.
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorpor...
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.
Recommendation We recommend that Management enhance its internal control structure, to include milestones for submitting the Single Audit Reporting Package. Management Response Corrective Action Corrective Action: DNA will comply with the recommendation. DNA will ensure processes are in place to com...
Recommendation We recommend that Management enhance its internal control structure, to include milestones for submitting the Single Audit Reporting Package. Management Response Corrective Action Corrective Action: DNA will comply with the recommendation. DNA will ensure processes are in place to comply with the due date of nine months after year end. Due Date of Completion: September 30, 2026. Responsible Party(ies) Chief Financial Officer
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: • DNA prov...
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: • DNA provide the Board a redline copy of the changes for each revised policy, • correlate each revised policy to each finding in the OIG report and • provide the Board each related policy section guidance in the LSC Financial Guide. Management Response Corrective Action As of January 15, 2026, our accounting department is short one person and we are supporting accounting staff training needs As of January 15, 2026, management has drafted updates and received acceptance by the OIG to all but one of the policies and procedures referenced in the OIG report. Updated policies, including a revised Accounting Manual and an updated Personnel Manual presented to the Board, the Board Budget & Audit Committee and the Board Executive Committee prior to the June 2, 2025 OIG response deadline. Management acknowledges that during the 2024 audit period the Legal Services Corporation Office of Inspector General (OIG) issued a final report on December 2, 2024 noting inadequate accounting policies, practices, and oversight for the period of January 1, 2022 through April 30, 2023. Also, while many of the policies noted in the OIG report have been updated, the policies mentioned in the OIG report have not been reviewed or adopted by the Board. Three primary causes contributed to the deficiencies noted during the period under review by the OIG (January 1, 2022 through April 30, 2023), and before the issuance of the final LSC OIG report in December 2024: • Staffing shortages. For most of the January 1, 2022 to April 30, 2023 review period DNA had three vacancies in our five-person accounting operation. Additionally, our Chief Financial Officer was hired during the middle of the period under review, and even though he has extensive legal services accounting experience, he just started learning about DNA’s organizational structure and accounting practices, and refamiliarizing himself with LSC accounting policies and financial guidelines. • A change in LSC accounting standards applicable to nonprofit LSC funded organizations was implemented during the period under review which made some of our policies and procedures outdated. • Management made a strategic decision to wait for the issuance of the final OIG report to ensure that updates to policies and practices would fully align with the OIG's expectations, rather than implementing piecemeal or interim measures that might have required further revision. Due Date of Completion: February 28, 2026. Responsible Person(s) Executive Director and Chief Financial Officer
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colora...
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colorado Department of Education, for the fiscal year ended June 30, 2024. Specifically, the District lacked adequate segregation of duties over payroll and human resources processes, both of which were performed by a single employee without a secondary review. In addition, the District did not maintain adequate reimbursement request documentation or regularly reconcile ESSER grant expenditures to reimbursement requests, as required under 2 CFR 200.303. These conditions resulted in material audit 60 adjustments, significant audit delays, and the engagement of a third-party accounting firm to reconstruct grant records. Notwithstanding these control deficiencies, the District was in compliance with allowable activities, allowable costs, and cash management requirements, as allowable costs exceeded the amounts requested for reimbursement. Current management has improved procedures related to the oversight of federal grant compliance and payroll processes. The District has engaged a third-party accounting firm and hired new staff to assist with grants reconciliation, reimbursement request preparation, and internal controls over federal awards. A secondary review process has been established for payroll and human resources transactions to ensure that no single employee has unchecked control over these functions. Grant reconciliation responsibilities have been reassigned to incorporate segregation of duties, and a defined schedule for monthly ESSER reconciliations and reimbursement submissions has been implemented. We plan to have all ESSER grant activity fully reconciled, reimbursement documentation complete and available for review, and monthly reconciliation and secondary review procedures operational and documented for all applicable federal grant programs prior to the start of the audit process. Estimated date of implementation of the corrective action plan: June 30, 2026 Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood
Controls Over Reporting for SMT Program Management acknowledges that encounter notes were not entered on a timely basis and that an inactive participant remained on the program listing during the audit period. The Organization will implement a supervisory review process requiring that encounter note...
Controls Over Reporting for SMT Program Management acknowledges that encounter notes were not entered on a timely basis and that an inactive participant remained on the program listing during the audit period. The Organization will implement a supervisory review process requiring that encounter notes are entered within a defined timeframe following each program interaction and reviewed by a supervisor for completeness and accuracy. The participant listing will be reconciled monthly to ensure that inactive individuals are promptly flagged and removed. Monthly reports will be documented as reviewed and dated at the time of submission to maintain an auditable record of timely reporting. This process has already taken place in late 2025 and the CFO and Controller will oversee the process.
Vaccine Education Grant Reporting Management acknowledges the repeat finding that quarterly reports required under the NYS OMH Vaccine Education Block Grant were not submitted as required by the contract. The Organization will designate a staff member responsible for tracking all grant reporting dea...
Vaccine Education Grant Reporting Management acknowledges the repeat finding that quarterly reports required under the NYS OMH Vaccine Education Block Grant were not submitted as required by the contract. The Organization will designate a staff member responsible for tracking all grant reporting deadlines and will implement a reporting calendar that captures submission requirements for each active grant contract. Grant contracts will be reviewed in full prior to execution so that all reporting obligations are understood and built into operational workflows. Management will also establish an internal review and approval process for all grant reports prior to submission to ensure completeness and timeliness. This will be overseen by the Controller in FY26.
2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...
2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2024-003 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@har...
2024-003 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555 Recommendation: We recommend the School District implement a documented review and approval process over reporting, including defined roles and responsibilities, required evidence of review, and retention of supporting documentation. Ex...
Child Nutrition Cluster – Assistance Listing No. 10.553, 10.555 Recommendation: We recommend the School District implement a documented review and approval process over reporting, including defined roles and responsibilities, required evidence of review, and retention of supporting documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We concur with the findings regarding the Child Nutrition Cluster and will implement the necessary actions. Name(s) of the contact person(s) responsible for corrective action: Jennifer Gannon/ Dea Popovski Planned completion date for corrective action plan: December 2026.
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
To ensure the audit is submitted in a timely manner, and on time, we will begin at the beginning of the year.
U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional ...
U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional training over fiduciary responsibilities under the CSBG Act. The Neighborhood Service Center, Inc. should adhere to the board composition and vacancy reporting requirements. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Executive Director and Deputy Director of the Neighborhood Service Center are actively recruiting individuals to join the Board. The Deputy Director, or their designee, will provide information to the Maryland Department of Housing and Community Development on the Board composition and vacancies on a monthly basis. Name of the contact persons responsible for corrective action: E. Yvette Robinson, Deputy Director Planned completion date for corrective action plan: For immediate implementation and ongoing.
Management is strengthening internal controls surrounding transaction support, financial documentation, reconciliation procedures, and record retention practices. Existing fiscal policies and procedures will be revised to ensure supporting documentation is consistently maintained for all transaction...
Management is strengthening internal controls surrounding transaction support, financial documentation, reconciliation procedures, and record retention practices. Existing fiscal policies and procedures will be revised to ensure supporting documentation is consistently maintained for all transactions recorded in the accounting system, including personnel and non-personnel transactions. Additional supervisory review procedures, centralized documentation practices, and monitoring activities are being implemented to improve the accuracy, accessibility, and retention of financial records and audit support documentation.
Finding 2024-002, Transaction Support Condition: The Organization internal controls did not require all transactions to be properly documented and maintained. As a consequence, we noted the Organization was not readily able to document support for accounts receivable and investments holdings at Octo...
Finding 2024-002, Transaction Support Condition: The Organization internal controls did not require all transactions to be properly documented and maintained. As a consequence, we noted the Organization was not readily able to document support for accounts receivable and investments holdings at October 31, 2024. In addition, the source and support for some revenue items selected for testing could not initially be explained or provided to the auditor to verify the reasonableness of the amount reported. Although once the Organization’s CEO became aware of the revenue testing issue she was able to identify the source documentation required to meet our audit requirements. Cause: There has been a high amount of turnover in the financial management side of the organization’s operation. Additionally, there were periods of time when accounting staff was not available because of a leave of absence. Other accounting staff tried to assist us in our request but due to the person’s limited time in the position it was difficult for them to identify the necessary support required. Effect: The Statements on Auditing Standards requires the independent auditor to review sufficient and adequate audit evidence in order to opine on the financial information. We were able to apply sufficient alternative procedures related to revenues selections. Additionally, we were able to have the Organization obtain subsequent documentation to verify the existence of the investment as of October 31, 2024. Result: It was difficult to obtain sufficient supporting documentation as required by auditing standards for all transactions subjected to audit verification.
All employment agreements are currently in compliance and will be regularly reviewed by the Organization for completeness.
All employment agreements are currently in compliance and will be regularly reviewed by the Organization for completeness.
Corrective Action Plan: Management concurs with the auditor's recommendations. Management will submit the necessary documentation to the U.S. Department of Housing and Urban Development (HUD) to request retroactive approval for the $4,700 withdrawal from the Residual Receipts Account made during the...
Corrective Action Plan: Management concurs with the auditor's recommendations. Management will submit the necessary documentation to the U.S. Department of Housing and Urban Development (HUD) to request retroactive approval for the $4,700 withdrawal from the Residual Receipts Account made during the year ended December 31, 2024. To prevent recurrence, management has implemented additional internal controls to ensure that all future withdrawals from restricted accounts receive the required prior written HUD authorization. These controls include a formal review and approval process by the Property Manager and Corporate Accounting before any disbursements are made from restricted accounts. In addition, management has scheduled staff training on HUD regulatory requirements governing restricted accounts to reinforce understanding of program compliance and documentation standards. Management is committed to maintaining full compliance with HUD regulations and ensuring that all account activity is properly reviewed, authorized, and documented.
Management Response / Corrective Action: The City acknowledges the finding. Federal reporting deadlines will be incorporated into the City's annual compliance calendar, and management will coordinate earlier completion of audit deliverables and required submissions. For the FY2024 Single Audit repor...
Management Response / Corrective Action: The City acknowledges the finding. Federal reporting deadlines will be incorporated into the City's annual compliance calendar, and management will coordinate earlier completion of audit deliverables and required submissions. For the FY2024 Single Audit reporting package, the City will complete the Data Collection Form and Federal Audit Clearinghouse submission upon final issuance/receipt of the auditor's reports and retain evidence of submission. For future single audits, the City will monitor the Uniform Guidance deadline and submit the Data Collection Form and reporting package by the earlier of 30 calendar days after receipt of the auditor's reports or nine months after year-end.
The City acknowledges the finding. The City will develop and maintain written policies and procedures appropriate to its federal award activity and the terms and conditions of its federal awards, including internal controls, record-keeping, reporting responsibilities, allowable costs, procurement an...
The City acknowledges the finding. The City will develop and maintain written policies and procedures appropriate to its federal award activity and the terms and conditions of its federal awards, including internal controls, record-keeping, reporting responsibilities, allowable costs, procurement and conflict-of-interest requirements where applicable, and compliance monitoring.
Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the a...
Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness. Name of the contact person responsible for corrective action: Lyn Elliot, CEO Planned completion date for corrective action plan: 7/1/2026
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING NO. 2024-004 Assistance Listing Number 14.181: Section 811 Supportive Housing for Persons with Disabilities See the details of this finding for segregation of duties and other designs of internal controls in 2024-001 above.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING NO. 2024-004 Assistance Listing Number 14.181: Section 811 Supportive Housing for Persons with Disabilities See the details of this finding for segregation of duties and other designs of internal controls in 2024-001 above.
Finding 2024-001, Significant Deficiency in Internal Control over Financial Reporting. Condition: The design of the Project’s internal controls precludes certain segregation of duties and other designs of internal controls. Criteria: Proper design of the Project’s internal controls to include segreg...
Finding 2024-001, Significant Deficiency in Internal Control over Financial Reporting. Condition: The design of the Project’s internal controls precludes certain segregation of duties and other designs of internal controls. Criteria: Proper design of the Project’s internal controls to include segregation of duties and other designs of internal controls. Cause: The size of The Project’s accounting and administrative staff precludes certain segregation of duties and other designs of internal controls that would be preferred if the office staff were larger. Effect: The segregation of duties and other designs of internal controls are limited. Recommendation: The auditor recommended that management and Project governance review their procedures and develop processes to address deficiencies in the segregation of duties and other designs of internal controls. Increased involvement of the Board of Directors in the financial affairs of the Project would provide oversight and independent review functions, thereby lessening the severity of the deficiencies. Responsible Person: Brittany Colson, Manager Planned Action: The Project agrees with the finding and the auditor’s recommendations will be adopted. Anticipated completion date: The recommendation will be applied in fiscal year ending June 30, 2025.
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management overrid...
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management override, Cayuga Centers has implemented standardized procedures to ensure grant expenditures are properly classified in our financial system. Each transaction are supported by detailed documentation, including invoices, receipts, and grant-specific identifiers. Individuals responsible for grant oversight will undergo mandatory training to deepen their understanding of grant requirements, allowable costs, and reporting obligations. Additionally, Cayuga Centers is working to ensure open communication between staff and the Board. Under new leadership, the agency continues to enforce its Non-Retaliation Policy (Whistleblower). The Acting President’s office is establishing quarterly “Grant Compliance Forums” for employees to raise concerns related to grant administration.
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors...
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors will be adjusted each period to ensure that account and ledger totals are properly maintained and recorded. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over bank reconciliations, accounts payable and grants receivable. Controls and the policies and procedures have been reviewed with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely reconciliations. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended December 31, 2024, management did not properly accrue federal grant expenditures that were incurred during the fourth quarter of fiscal year 2024. As a result, federal grant expenses on...
Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended December 31, 2024, management did not properly accrue federal grant expenditures that were incurred during the fourth quarter of fiscal year 2024. As a result, federal grant expenses on cost reimbursement grants and related revenues were understated as of December 31, 2024, and required year end audit adjustments to properly reflect expenditures incurred but not invoiced or recorded as of year end. Recommendation We recommend that individuals overseeing the accounting and finance department continue to review the Organization’s current accounting policies and update existing policies or implement new policies, as needed, to ensure that federal grant expenditures are accrued for and recorded in the proper period and reconciliations between incurred expenditures, invoices submitted and amounts recorded in the general ledger are completed and reviewed monthly or quarterly, as appropriate. Management’s Corrective Action Plan Management is working to improve the timeliness of reconciliations and has implemented procedures to identify and accrue grant expenditures incurred but not yet invoiced at period end, as needed. Management will perform periodic reconciliations between incurred expenditures, invoices submitted to grantors, and amounts recorded in the general ledger, and will ensure such reconciliations are reviewed and approved by the appropriate personnel. Management is confident that the issues that have been noted have been rectified. Contact Person: Patricha Paul, Finance Director Anticipated Completion Date: June 30, 2026
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