Corrective Action Plans

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Corrective Action Planned: Management will strengthen procedures over the Sliding Fee Discount Program to ensure each patient’s discount is accurately determined based on documented annual income and family size and correctly applied to patient charges. Procedures will include documented supervisory...
Corrective Action Planned: Management will strengthen procedures over the Sliding Fee Discount Program to ensure each patient’s discount is accurately determined based on documented annual income and family size and correctly applied to patient charges. Procedures will include documented supervisory review of income determinations and verification that the approved sliding-fee discount is accurately reflected in the patient billing process. Management will also provide appropriate staff training and incorporate periodic monitoring to identify and correct discrepancies timely. Management’s Response: Management agrees with the finding. The exceptions identified resulted from approved sliding fee discounts being incorrectly applied to patient accounts. Management has enhanced review and monitoring procedures to ensure discount determinations are accurately reflected in the billing process and that supporting review is appropriately documented. These improvements are intended to strengthen compliance and prevent similar errors in the future.
The College has continued to develop a system of internal controls over the financial close and reporting process to mitigate the risk of misstatement in accordance with GAAP as set by the GASB. Developments include regular reconciliations between cash draws on grants, revenues recorded, and expendi...
The College has continued to develop a system of internal controls over the financial close and reporting process to mitigate the risk of misstatement in accordance with GAAP as set by the GASB. Developments include regular reconciliations between cash draws on grants, revenues recorded, and expenditures incurred.
Management concurs with the finding and recommendation. The Organization recognizes the importance of maintaining complete and accurate documentation supporting expenditures reported under federal awards and ensuring that amounts reported to the grantor reconcile to the underlying accounting records...
Management concurs with the finding and recommendation. The Organization recognizes the importance of maintaining complete and accurate documentation supporting expenditures reported under federal awards and ensuring that amounts reported to the grantor reconcile to the underlying accounting records. Management has strengthened its procedures for preparing and reviewing ARPA and other grant-related financial reports. The Partnership corrected the reporting discrepancy through its March 2024 Q1 report to the City of College Park, with all subsequent reports reflecting the correction. The final report to the City, submitted on May 16, 2025, as part of the grant closeout, provided a complete accounting of the grant funds expended and their intended purposes, together with bank statements and supporting documentation. The City did not identify any additional concerns with the corrected or subsequent reports following the December 2023 Q4 report. The Partnership has also implemented broader improvements including a redesigned chart of accounts, grant specific project records within QuickBooks, a centralized grant tracker, reorganized electronic files centered on individual grant awards, and a regular review meeting between the Partnership and TCG. These improvements provide clearer grant level accounting, reporting, deadline tracking, and supporting documentation. In addition, since the period under audit, the Partnership has already implemented adjustments to grant reporting. Management maintains a reconciliation between cumulative expenditures reported to the grantor and cumulative expenditures recorded in the general ledger. Management is finalizing written grant administration and reporting policies and procedures as part of the financial policies and procedures updates – outlining requiring grant specific reconciliations to the general ledger and supporting documentation, documented explanations for adjustments and corrections, management review and approval before submission,complete grant reporting files, and period review of reporting and closeout requirements by grantor. Management anticipates competing and formally implementing these policies and procedures by November 30, 2026. Once established, the Finance Committee will receive periodic updates on grant reporting controls and the status of related corrective actions. The Partnership will retain the reports and supporting documentation associated with the $3,86 identified by the auditors and will provide additional information if requested by the City or the federal awarding agency. If a management decision requires additional action, the Partnership will respond withing the timeframe identified in that decision.
The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also...
The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also consider providing the SEFA and supporting expenditure information to its external engineering consultants for review to help ensure all grant activity administered on behalf of the Village is properly identified and reported.
We will establish written procedures reconciling patient billing reports to the general ledger for receivables, pharmacy, dental and medical revenues, contractual adjustments, and cash collections, as applicable. Complete cross training using written procedures, demonstrations, and supervised perfor...
We will establish written procedures reconciling patient billing reports to the general ledger for receivables, pharmacy, dental and medical revenues, contractual adjustments, and cash collections, as applicable. Complete cross training using written procedures, demonstrations, and supervised performance. After implementation, complete reconciliations monthly, target close within 45 days after month end, and provide financial results and unresolved exceptions to management and the governing board or its designated committee. Escalate staffing gaps and overdue reconciliations promptly. Reconcile federal award reporting to the accounting records and track audit deliverables and applicable reporting deadlines.
Management will approve and implement a procedure covering journal entries, including revenue, payroll allocations, grant billings, receivables, and account reconciliations. Each entry will identiry its preparer, purpose, accounts, amounts, and supporting records. We will implement documented approv...
Management will approve and implement a procedure covering journal entries, including revenue, payroll allocations, grant billings, receivables, and account reconciliations. Each entry will identiry its preparer, purpose, accounts, amounts, and supporting records. We will implement documented approval by an authorized person other than the preparer. The reviewer will verify support, coding, period, and calculations and record the review date and approval. The policy will prohibit self-approval.
Finding 1241295 (2024-002)
Material Weakness 2024
Gardeneers concurs with the finding and is strengthening its procedures for obtaining, reviewing, retaining, and maintaining supporting documentation for expenditures charged to federal awards. Gardeneers will implement the following corrective actions: 1. Documentation Requirement. Gardeneers will ...
Gardeneers concurs with the finding and is strengthening its procedures for obtaining, reviewing, retaining, and maintaining supporting documentation for expenditures charged to federal awards. Gardeneers will implement the following corrective actions: 1. Documentation Requirement. Gardeneers will require appropriate supporting documentation, such as itemized receipts, invoices, contracts, or other records sufficient to substantiate the expenditure, before costs are charged to a federal award or included in a reimbursement request. 2. Pre-Reimbursement Review. Gardeneers will establish a review checkpoint before submission of federal reimbursement requests to confirm that required supporting documentation is complete and maintained in the organization’s records. 3. Centralized Record Retention. Gardeneers will strengthen its process for maintaining grant-related financial documentation in an organized and accessible manner so that supporting records can be readily produced for monitoring, audit, or grantor review. 4. Staff Training and Accountability. Staff responsible for purchasing, expense submission, grant administration, and financial review will receive guidance regarding documentation requirements for federally funded expenditures and their responsibilities for timely submission and retention of supporting records. 5. Ongoing Monitoring. Management will periodically review a sample of federally funded expenditures and reimbursement documentation to confirm adherence to the revised procedures and identify any needed corrective follow-up.
Audit Finding Number 2024-004 Audit Finding Title Reporting Planned Corrective Action Effective October 2026, the 2023, 2024, 2025 FFATA reporting requirements have been completed. Going forward, once the NOA is confirmed and the subgrantees have submitted workplans and signed agreements, the FFATA ...
Audit Finding Number 2024-004 Audit Finding Title Reporting Planned Corrective Action Effective October 2026, the 2023, 2024, 2025 FFATA reporting requirements have been completed. Going forward, once the NOA is confirmed and the subgrantees have submitted workplans and signed agreements, the FFATA will be completed in the Federal Subaward Reporting System. This item is still pending for 2026 because those agreements have not been signed. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting
Audit Finding Number 2024-003 Audit Finding Title Cash Management Planned Corrective Action Effective September 2026, each drawdown will be prepared by Kim Cockerham, Sr. Director of Finance and Accounting and then reviewed by a separate employee before submission. Preparation and review are time st...
Audit Finding Number 2024-003 Audit Finding Title Cash Management Planned Corrective Action Effective September 2026, each drawdown will be prepared by Kim Cockerham, Sr. Director of Finance and Accounting and then reviewed by a separate employee before submission. Preparation and review are time stamped and documented in the CDC payment system. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting
Audit Finding Number 2024-002 Audit Finding Title Activities Allowed or Unallowed, Allowable Costs/Cost Principles Planned Corrective Action Other than Personnel Services: In April of 2025, we discontinued the previous credit card usage processes and began using Ramp for all credit card purchases. T...
Audit Finding Number 2024-002 Audit Finding Title Activities Allowed or Unallowed, Allowable Costs/Cost Principles Planned Corrective Action Other than Personnel Services: In April of 2025, we discontinued the previous credit card usage processes and began using Ramp for all credit card purchases. The Ramp system requires employees to upload an itemized receipt, document the business reason for the expense, and select the grant that expense should be coded to. Each transaction is approved by the employee’s manager and reviewed by the AP staff before it is synched over to the general ledger. If a transaction cannot be properly documented the system will notify the employee of the need for repayment. The repayment is drafted from the employee’s personal bank account, and the expense is reversed in the general ledger. Indirect Costs: In Year 1 $200,000 was deemed unallowable because while there was a provisional indirect rate agreement in place for 28.50%, the CDC did not adjust the NOA to reflect the update. Going forward, when there are any approved changes to the NOA, BWHI will ensure that those changes are reflected in an updated NOA. In addition, in 2025, the new accounting team is charging indirect costs as a percentage of direct expenses incurred during the period of draw down. Each drawdown will be prepared and then reviewed by a separate employee before submission. Preparation and review are time stamped and documented in the CDC payment system. Personnel Services: In July 2026, we formalized our review process for all payroll transactions. Each payroll is reviewed for completeness and reasonableness and is reconciled on each payroll run before posting to the general ledger. We are currently working on our employee training that will require employees to document their weekly time and charge hours to grants using actual timesheets. Those timesheets will be reviewed and approved by their manager before the payroll run. This process will be in place effective in December 2026. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting Desarae Kirtz, Sr. Director HR (personnel services)
Views of Responsible Officials The Town acknowledges the finding and notes that the issues identified relate to reporting activities performed during FY2024. During and following that period, the Town experienced substantial turnover among personnel responsible for grant administration, financial re...
Views of Responsible Officials The Town acknowledges the finding and notes that the issues identified relate to reporting activities performed during FY2024. During and following that period, the Town experienced substantial turnover among personnel responsible for grant administration, financial reporting, and ARPA compliance activities. Since the audit period, the Town has established improved oversight of federal grant compliance responsibilities and has assigned reporting responsibilities to designated staff. Procedures are being implemented to ensure that all federal reporting deadlines are identified and monitored, reports are reviewed by supervisory personnel prior to submission, and documentation supporting submitted reports is retained in a centralized manner.Additionally, the Town has improved its grant accounting and tracking procedures to better distinguish direct expenditures from pass-through expenditures and to maintain supporting documentation sufficient to support federal reporting requirements. Management believes these actions will significantly improve compliance with federal reporting standards going fonvard. Responsible Official: Finance Directorffown Accountant
Finding 2024-001 Criteria The Project must make the required monthly reserve for replacements deposits according to the Regulatory Agreement with HUD. Statement of Condition The reserve for replacements account was under funded by $14,759 as of December 31, 2024, due to deposits not being made in a ...
Finding 2024-001 Criteria The Project must make the required monthly reserve for replacements deposits according to the Regulatory Agreement with HUD. Statement of Condition The reserve for replacements account was under funded by $14,759 as of December 31, 2024, due to deposits not being made in a timely manner. Effect or Potential Effect The Project is in non-compliance with the reserve for replacements compliance requirement of the Section 202 Capital Advance Program. Cause Internal controls are not in place to ensure that reserve for replacements deposits are funded in the appropriate amount and in a timely manner. Recommendation We recommend that the Project establish internal controls to ensure reserve for replacements deposits are made in the appropriate amounts and in a timely manner. Views of Responsible Officials and Planned Corrective Action The Auditee has recognized the deficiency and made an additional deposit to the reserve for replacements. Proper controls were put in place to ensure that reserve for replacements deposits are funded in the appropriate amount and in a timely manner. If the U.S. Department of Housing and Urban Development has any questions regarding this plan, please call Darryl Yorkman, Controller at 856-486-1990.
The Organization’s Board of Directors will continue to rely on its direct knowledge of daily operations and direct contact with employees to control and safeguard assets.
The Organization’s Board of Directors will continue to rely on its direct knowledge of daily operations and direct contact with employees to control and safeguard assets.
We partially agree with this Finding which cited certain teachers who had only official transcripts on file and no diplomas. Before the JEMCO resolution came out, we were not required to file diplomas in our personnel files, so most of our teachers do not have diplomas on file. We had sought concurr...
We partially agree with this Finding which cited certain teachers who had only official transcripts on file and no diplomas. Before the JEMCO resolution came out, we were not required to file diplomas in our personnel files, so most of our teachers do not have diplomas on file. We had sought concurrence from our grant manager on whether we could use official transcripts in lieu of proof of degrees for existing teachers without degrees and for new hires to get them on board sooner. Our pool of personnel to select teachers from is limited, and it is challenging to get quality teachers with degrees. He concurred that we use transcripts as long as they are the official ones from the institutions and clearly state that the students have been awarded the required degrees and that the students’ names are written clearly on them. In the meantime, each student/teacher will continue to provide a copy of the required degree so we can have it on file. I think this is the process we are still using and if it is not correct, please let us know.
We agree with this Finding. We have updated our Sliding fee scale using the US Federal poverty guideline for year 2026, it has been approved by our board of directors as of 04/10/26. This new sliding fee scale is applied in the new ECW Electronic Health Records system that we are currently in the pr...
We agree with this Finding. We have updated our Sliding fee scale using the US Federal poverty guideline for year 2026, it has been approved by our board of directors as of 04/10/26. This new sliding fee scale is applied in the new ECW Electronic Health Records system that we are currently in the process of completing and instituting into our health centers. This new system is presumed to go live in September 2026 and will be able to accommodate our need to capture accurate demographic data that is needed to determine whether a patient is eligible for the discount or not, it will be able to automatically place each individual patient under the different sliding fee scale categories that they fall under based on their income once they register to see a doctor. So to correct our finding for 2023 and 2024, this is what we have been working on to improve our health center and build a system in place that will be able to capture the data we need, we will also be updating our sliding fee scale in the system every year based on the yearly US federal poverty guideline.
IMPLEMENT SEFA RECONCILIATION CONTROL MATRIX DOCUMENTATION, MONITORING AND TRAINNING
IMPLEMENT SEFA RECONCILIATION CONTROL MATRIX DOCUMENTATION, MONITORING AND TRAINNING
Corrective Action Plan: Management acknowledges the deficiency regarding the timely return of tenant security deposits and will strengthen its internal controls to ensure that security deposits are processed and returned within the required timeframe. The following corrective actions will be impleme...
Corrective Action Plan: Management acknowledges the deficiency regarding the timely return of tenant security deposits and will strengthen its internal controls to ensure that security deposits are processed and returned within the required timeframe. The following corrective actions will be implemented: 1. Move-Out Tracking: Management will maintain a tracking process for all tenant move-outs, including the move-out date, security deposit balance, applicable deductions, and required refund date. 2. Timely Processing of Security Deposits: Upon notification of a tenant move-out, responsible staff will promptly review the tenant account, determine any allowable deductions, and process the remaining security deposit for return within the applicable required timeframe. 3. Management Review and Monitoring: A designated supervisory employee will periodically review outstanding tenant security deposits and the move-out tracking report to identify deposits approaching their required return date and ensure timely processing. 4. Documentation and Record Retention: Documentation supporting the calculation, deductions, refund, and date of return of each security deposit will be maintained in the tenant's records to demonstrate compliance with applicable requirements.
Contact Person – Katie Greenwood, Deputy Finance Director Corrective Action Plan – Project management staff has been made aware of this requirement and will document vendor checks for federal projects going forward. Completion Date – December 31, 2025
Contact Person – Katie Greenwood, Deputy Finance Director Corrective Action Plan – Project management staff has been made aware of this requirement and will document vendor checks for federal projects going forward. Completion Date – December 31, 2025
2024-010 Material Weakness in Internal Control and Compliance over Major Programs Management Response: Head Start has established monthly meetings with the Board President, CFO, Controller, and Executive Director. Both the Board President and Executive Director completed additional training in Augus...
2024-010 Material Weakness in Internal Control and Compliance over Major Programs Management Response: Head Start has established monthly meetings with the Board President, CFO, Controller, and Executive Director. Both the Board President and Executive Director completed additional training in August 2026 to support compliance with Head Start requirements. Additional training is scheduled through December 2026. The Board is in the final stage of confirming the Finance/Audit Committee Chair, with an expected completion date of October 31, 2026. Staff responsible: Executive Director Anthony Ives aives@kcr.org and CFO Irmgard Davis irmgardd@kcr.org.
2024-008 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions, to addr...
2024-008 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions, to address the specific finding, to prevent further incidents KCR is requiring that anytime a change is made on an employee a new PAF is required from the program, the current PAF form will updated and completion date 11/30/2026. Staff responsible: CFO Irmgard Davis irmgardd@kcr.org.
2024-07 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is in the process of implementing electronic timesheets by 10/1/2026, that will eliminate the risk of unsigned and unapproved timesheets prior to payroll processing. KCR will be using elect...
2024-07 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is in the process of implementing electronic timesheets by 10/1/2026, that will eliminate the risk of unsigned and unapproved timesheets prior to payroll processing. KCR will be using electronic timesheets through MIP. Supervisors and managers will need to electronically approve timesheets prior to payroll being processed. Staff responsible: CFO Irmgard Davis irmgardd@kcr.org.
Finding 2024-008 Single Audit Reporting Deadline Responsible Individuals: Chief Financial Officer, Comptroller Corrective Action Plan: The County agrees with the finding and will take the following actions: - Catch up schedule. The County is working on an aggressive schedule to catch up on their aud...
Finding 2024-008 Single Audit Reporting Deadline Responsible Individuals: Chief Financial Officer, Comptroller Corrective Action Plan: The County agrees with the finding and will take the following actions: - Catch up schedule. The County is working on an aggressive schedule to catch up on their audits with a goal of being caught up in FY2028. The County is completing the FY2024 audit in the beginning of FY 2027. The FY2025 audit is scheduled to be completed in the second half of FY 2027, and the FY 2026 audit is planned for completion in early FY 2028. - Year-end close calendar. Beginning with the close of FY 2027, the County will follow a close calendar with these milestones: year-end close in the first week of August, reconciliations and journal entries posted by October 1, and the audit opinion issued by March 31. - Timely submission. For each catch-up year, the County will submit the reporting package and data collection form to the Federal Audit Clearinghouse within 30 days of receiving the auditor's reports. Anticipated Completion Date: The County expects to fully meet the nine-month deadline beginning with the timely completion of the FY 2027 single audit, due March 31, 2028. Catch-up submissions for audits FY 2025 and FY 2026 will be made within 30 days of each auditor's report.
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial and performance reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the a...
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial and performance reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review each agreement to confirm the reporting requirements, deadlines, and any specific formats or templates that must be followed. A designated team member will be responsible for preparing, reviewing, and submitting the required reports. We will to track submission deadlines and ensure that reports are submitted on time. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026
The County will develop a formal process for tracking all federal expenditures and take steps to learn when those expenditures trigger additional audit requirements.
The County will develop a formal process for tracking all federal expenditures and take steps to learn when those expenditures trigger additional audit requirements.
The Institute will adopt written procurement policies and procedures that conform to the Uniform Guidance procurement standards, present them to the Board of Directors for approval, and train the personnel responsible for procurement on their use. Anticipated completion date: December 31, 2026. Resp...
The Institute will adopt written procurement policies and procedures that conform to the Uniform Guidance procurement standards, present them to the Board of Directors for approval, and train the personnel responsible for procurement on their use. Anticipated completion date: December 31, 2026. Responsible contact person: Kathy Walker, Executive Director.
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