Corrective Action Plans

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In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals w...
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals with adequate training and subject matter knowledge to perform assigned functions in accordance with appropriate standards and expectations. We are always receptive to positive constructive criticism in our effort to improve upon compliance and financial reporting. Sincerely yours, Rufus Wofford– Acting Chief Executive Officer
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.
Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts tha...
Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts that exceed $2,000. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the future all construction contracts will be reviewed on an monthly basis to determine what contracts total $2,000.00 or over to make sure we have a certified payroll for these contracts. Name(s) of the contact person(s) responsible for corrective action: Jamie Navenma, Executive Director and Cheryl Mullins, Controller Planned completion date for corrective action plan: December 1, 2025
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There ...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: Th...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: A monthly review checklist and variance analysis template will be adopted. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The internal audit function will conduct semiannual reviews to confirm adherence to established review procedures.
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Assistance Listing 93.354 Public Health Emergency Response Program Views of the Responsible Officials and...
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Assistance Listing 93.354 Public Health Emergency Response Program Views of the Responsible Officials and Corrective Action Plan: ALN 93.136 – Injury Prevention and Control Research and State/Community Based Programs PDPH acknowledges that Federal Funding Accountability and Transparency Act (FFATA) reporting requirements were not consistently met during the audit period due to limited staff capacity and lack of clearly defined procedures for subaward reporting. In response, SUPHR will establish procedures to ensure timely and accurate FFATA reporting in accordance with federal requirements. These procedures include designating responsible staff, assigning appropriate SAM.gov access roles, and providing orientation and training on subaward reporting processes. Standardized documentation and retention practices will also be implemented to ensure proper recordkeeping and verification of all submissions. SUPHR is committed to maintaining compliance with FFATA requirements going forward and will continue to monitor adherence through routine oversight by the grants management team. Initial implementation of corrective measures will begin upon receipt of an approved Year 3 budget from the Centers of Disease Control. ALN 93.323 – Epidemiology and Lab Capacity Program PDPH acknowledges the error that occurred with FFATA reporting with respect to its incomplete reporting. This grant had previously been connected in the FSRS.gov system to a PDPH division that was created during the COVID pandemic that no longer exists. Although the grant was listed under the Division of Disease Control by FY24, the FFATA was overlooked and not completed. The Division of Disease Control will work toward implementing additional internal controls to support accurate and timely FFATA reporting going forward. ALN 93.354 – Public Health Emergency Response PDPH acknowledges that errors occurred with FFATA reporting with respect to both the timing of the reporting and the amounts of subawards reported. The Division of Disease Control will work toward implementing additional internal controls to support accurate and timely FFATA reporting going forward. Contact Persons: Daniel Teixeira da Silva, Director, Division of Substance Use Prevention and Harm Reduction (SUPHR), 267-760-0307 Jessica Caum, Public Health Preparedness Program Manager, Philadelphia Department of Public Health, 215-685-6731
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delay in liquidating obligations resulted from internal control procedures that appropriately identified a potenti...
Assistance Listing 14.231 Emergency Solutions Grants Program Views of the Responsible Officials and Corrective Action Plan: The Office of Homeless Services acknowledges the finding. The delay in liquidating obligations resulted from internal control procedures that appropriately identified a potential contract concern involving the Resources for Human Development. In accordance with established financial oversight protocols, the Finance Department placed a temporary hold on related payments pending further review. Once the review was concluded, the payments were released. Additionally, limitations within the FAMIS system, specifically its inability to retain original voucher creation dates after rejection and resubmission, contributed to the appearance of delayed liquidation. To prevent recurrence, the Office of Homeless Services will strengthen its closeout procedures to ensure timely review and liquidation of all obligations in accordance with 2 CFR § 200.344. The Office will also initiate earlier coordination with the Finance Department when payment holds arise and reinforce staff training on grant closeout and escalation protocols. These corrective actions will enhance compliance and reduce the likelihood of future delays. Contact Person: Jerome Hill, Director of Compliance, OHS, 215-686-0371
Corrective Action Plan: The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts. Anticipated Completion Date: Fiscal Year 2025
Corrective Action Plan: The City of Charleston will implement internal controls and procedures to ensure all required reports are prepared, reviewed, and submitted within the program’s required timeframes, and with the correct amounts. Anticipated Completion Date: Fiscal Year 2025
The Child Care and Development Division is working towards compliance with federal requirements for license-exempt health and safety monitoring with an anticipated completion date of July 1, 2029, assuming additional resources are secured. This plan has been outlined in Appendix A of the Federal Fis...
The Child Care and Development Division is working towards compliance with federal requirements for license-exempt health and safety monitoring with an anticipated completion date of July 1, 2029, assuming additional resources are secured. This plan has been outlined in Appendix A of the Federal Fiscal Year 2025-27 State Plan for California with Administration of Children and Families (State Plan). The State Plan can be provided upon request. Estimated Implementation Date: July 1, 2029 Contact: • Jeff Fowler, Child Care Administration Bureau Chief • Central Operations Branch • Child Care and Development Division • California Department of Social Services
CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including s...
CHCQ will address the audit findings by increasing outreach to local District Office management and by providing ongoing oversight to frontline staff. CHCQ will emphasize the importance of completing CMS 1539 forms with proper documentation and signatures for all recertification surveys, including surveys conducted by Accrediting Organizations. CHCQ has already taken steps by reiterating this requirement at a recent statewide management meeting. CHCQ will continue reminding staff of expectations at appropriate meetings and provide additional training as needed to ensure all offices follow consistent procedures when completing the required CMS 1539 forms. Headquarters management will provide oversight and conduct periodic audits to ensure staff complete and sign all CMS 1539 forms according to expectations. Estimated Implementation Date: Fiscal Year 2025-26 Contact: Nate Gilmore, State Surveyors Branch Chief, CHCQ
Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County p...
Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance, DHCS will resume monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Through the reinstatement of county performance standards and Focused Reviews, DHCS can identify and address eligibility concerns, such as the proper use of aid codes, and work with counties through the corrective action plan process to address staff training to ensure correct eligibility determinations for all Medi-Cal programs, including pregnancy programs. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief
Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County p...
Effective June 1, 2024, DHCS reinstated county performance standards and reintroduced Focused Reviews. As outlined in All County Welfare Directors Letter (ACWDL) 24-17—Enhancing County Medi-Cal Eligibility Performance. DHCS has resumed monitoring county performance and timeliness standards. County performance standards measure the timeliness of county actions, while Focused Reviews evaluate both timeliness and accuracy of county determinations related to Medi-Cal applications, redeterminations, and Medi-Cal Eligibility Data System (MEDS) Alert processing. All counties will participate in a Focused Review on a biennial, rotating basis. Additionally, DHCS resumed the Aid Code Cleanup effort in September 2025, as outlined in MEDIL I 25-19. The purpose of the aid code cleanup effort is to assist counties in identifying records that require eligibility re-evaluation to either transition individuals to the correct Medi-Cal aid code or appropriately discontinue coverage. Through these initiatives, DHCS can identify and address eligibility concerns, such as processing timeliness and proper aid code usage. Estimated Implementation Date: Fully Implemented Contact: Sarah Crow, Medi-Cal Eligibility Division, Division Chief Harold Higgins, Medi-Cal Eligibility Division, Branch Chief Amy Halim, Medi-Cal Eligibility Division, Section Chief
SWRCB Program Manager acknowledges and understands the recommendation. During the December 2023 period, the SWRCB Program Manager held a meeting with staff and reviewed the information prior to approving the information being inputted into the CDOF Portal. Information being submitted to the CDOF Por...
SWRCB Program Manager acknowledges and understands the recommendation. During the December 2023 period, the SWRCB Program Manager held a meeting with staff and reviewed the information prior to approving the information being inputted into the CDOF Portal. Information being submitted to the CDOF Portal aligns with the FI$Cal KK Report per the direction of CDOF. For information provided by the SWRCB for the CDOF Quarterly Reporting, the SWRCB started formally documenting the approval of information starting the quarter after the December 2023 period. Corrective action plan: SWRCB Program Manager has implemented a process for the recommendation provided. As of the quarter following December 2023 period, a formal process that documents the information and approval of that information for CDOF portal updates is being used. The information submitted to the CDOF Portal aligns with the FI$Cal KK Report per the direction of CDOF. Estimated Implementation Date: March 2024 Contact: Selica Potter
The HQ Budgets OFR will update FPFT guidance and development documentation to include specific references to a new required secondary data validation for the more complex funding scenarios. A set of core FPFT standard templates will be modified to include an automated requirement for secondary data ...
The HQ Budgets OFR will update FPFT guidance and development documentation to include specific references to a new required secondary data validation for the more complex funding scenarios. A set of core FPFT standard templates will be modified to include an automated requirement for secondary data validation for any project that includes complex funding scenarios, including cooperative agreements, multiple funding priorities, multiple federal program codes, multiple state funding programs, and funding earmarks. Calculated data cells for federal reimbursement ratios will be added, as well as an automated check for the total sum of funding line percentages to ensure any rounding errors are eliminated. Consistent training will be provided for key HQ Budgets OFR staff on a regular basis, including live sessions for practical FPFT case reviews and FPFT development during monthly team meetings. Estimated Implementation Date: • Updated FPFT guidance documentation: 11/25/2025 • Updated FPFT template (automated secondary validation): 12/01/2025 • Monthly live training sessions (1st Thursday each month): 12/04/2025 Contact: • Raul Lerma, Chief, Program and Project Management Branch, Office of Federal Resources, HQ Division of Budgets • Keith Duncan, Division Chief, HQ Division of Budgets
Corrective Action Plan Management acknowledges the importance of timely submission of the Single Audit reporting package and data collection form to the Federal Audit Clearinghouse (FAC) as required by 2 CFR 200.512(a). In this instance, the delay was due to the auditor not completing the audit and ...
Corrective Action Plan Management acknowledges the importance of timely submission of the Single Audit reporting package and data collection form to the Federal Audit Clearinghouse (FAC) as required by 2 CFR 200.512(a). In this instance, the delay was due to the auditor not completing the audit and issuing the reports by the required deadline, despite the auditee providing all necessary information in a timely manner. To prevent recurrence, management will establish a timeline for the Single Audit process, including key milestones and deadlines for both internal preparation and auditor deliverables; along with regular status meetings with the audit firm during the audit period to monitor progress and address any issues promptly. Completion Date September 30, 2026
Views of Responsible Officials and Planned Corrective Action We are giving instructions to the Finance Department, the Federal Program Office, and all other departments to submit, in a timely manner, all the required financial information, to our financial consultant and the external auditors, to co...
Views of Responsible Officials and Planned Corrective Action We are giving instructions to the Finance Department, the Federal Program Office, and all other departments to submit, in a timely manner, all the required financial information, to our financial consultant and the external auditors, to comply with the deadline for the submission of the Single Audit Report for the fiscal year ended June 30, 2025, which is March 31, 2026. Responsible Official: Mrs. Irma M. Vargas Aguirre, Finance and Budget Director Implementation Date: March 31, 2026
Views of Responsible Officials and Planned Corrective Action We will give instructions to the accounting staff in charge of the preparation of the quarterly progress reports of the Program, in order to comply with the FEMA reporting requirements. Responsible Official: Mrs. Irma M. Vargas Aguirre, Fi...
Views of Responsible Officials and Planned Corrective Action We will give instructions to the accounting staff in charge of the preparation of the quarterly progress reports of the Program, in order to comply with the FEMA reporting requirements. Responsible Official: Mrs. Irma M. Vargas Aguirre, Finance and Budget Director Implementation Date: December 31, 2025
Views of Responsible Officials and Planned Corrective Action The necessary instructions were given to the accounting staff in order to comply with the reporting requirements established by each federal grant that the Municipality currently manages. Responsible Official: Mrs. Irma M. Vargas Aguirre, ...
Views of Responsible Officials and Planned Corrective Action The necessary instructions were given to the accounting staff in order to comply with the reporting requirements established by each federal grant that the Municipality currently manages. Responsible Official: Mrs. Irma M. Vargas Aguirre, Finance and Budget Director Implementation Date: December 31, 2025
Finance Director Rice will review the current internal controls related to the compliance requirements of federal award, to ensure transactions are properly recorded and that all documentation is readily available and accessible for audit and review.
Finance Director Rice will review the current internal controls related to the compliance requirements of federal award, to ensure transactions are properly recorded and that all documentation is readily available and accessible for audit and review.
Develop and Implement Comprhensive Written Policies and Procedures. We will revise and formalize internal controls that address all major federal compliance area, Including: -Allowable/unallowable costs - Time and Effort reporting-Payroll allocations-Prior Approvals-Subrecipeint Monitoring -Grant Cl...
Develop and Implement Comprhensive Written Policies and Procedures. We will revise and formalize internal controls that address all major federal compliance area, Including: -Allowable/unallowable costs - Time and Effort reporting-Payroll allocations-Prior Approvals-Subrecipeint Monitoring -Grant Closeout. Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, B2.4 Personnel Costs, which states that even though costs of overtime/bounsus are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section.
Untimely Single Audit Filing - Auditor’s Recommendations: The Authority should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. ...
Untimely Single Audit Filing - Auditor’s Recommendations: The Authority should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Authority’s Response: Eldred Borough Water Authority was unable to contract a CPA to perform the single audit. The Authority has since contracted with a CPA firm to perform the single audit and do not anticipate it being delayed in submission in future years.
Segregation of Duties - Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the b...
Segregation of Duties - Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Authority’s Response: The board reviews the reports monthly. A printed payroll report and checks written from meeting to meeting are provided and are approved and initialed. Also provided is a report of the bank statements for the board to review what has been received and what has been paid. Before any bills are paid they are approved at the meeting. If an error is made when inputting a deposit received into C/A, the correction is printed and initialed approving the correction.
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements - Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Authority should continue to review and accept both proposed adjusting journa...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements - Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Authority should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. Authority’s Response: The Authority has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the Authority believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the Authority considers such assistance provided by the auditors to be the most cost-effective manner to prepare such information. The Authority will also ensure that in the future all transactions will be properly reflected in the accounting software.
Untimely Single Audit Filing - Auditor’s Recommendations: The Authority should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. ...
Untimely Single Audit Filing - Auditor’s Recommendations: The Authority should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Authority’s Response: Eldred Borough Water Authority was unable to contract a CPA to perform the single audit. The Authority has since contracted with a CPA firm to perform the single audit and do not anticipate it being delayed in submission in future years.
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