Corrective Action Plans

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August 15, 2025 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INT...
August 15, 2025 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL (Repeat) Views of Responsible Officials and Planned Corrective Actions: We concur with this finding - Management is in the process of assessing the organizational structure, capacity to provide adequate financial reporting. With Board review and approval of the Agency’s financial funding sources, the Agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and Uniform Guidance regulations. The new automated financial systems, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 2024. Concerning preparation of external reports required by various funding sources (i.e., SF-425, DHS’s reports for LIHEAP, LIHWAP, etc.), the Agency will ensure adequate training is performed to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action. Comment #2024-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START, LIHEAP, LIHWAP, CSBG, ASTHO, CACFP, and SLFRF FAL # 93.600, 93.568, 93.499, 93.569, 93.185, 10.558, 21.027 (Questioned Costs - Undetermined) Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Management and staff are in the process of assessing and updating the policies and procedures over the accounting and reporting of federal and state grants and contracts. In connection with training staff on the new and updated accounting system, we are providing ongoing training on the requirements of the Uniform Guidance and the specific requirements for each individual grant award as outlined in each applicable Compliance Supplement issued by Office of Management and Budget (OMB). We are currently reconciling all cash accounts and completing and amending, where necessary, all SF-425 reports and other external reports required by each funding source (state and federal). We anticipate completing this corrective action by December 31, 2025. See also the response to Comment #2024-001. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action.
View Audit 365128 Questioned Costs: $1
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Auditee response: The Board...
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Auditee response: The Board agrees with the finding. Corrective action planned: The Chief School Finance Officer will ensure that all accounting policies and procedures are followed to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Anticipated completion date: September 30, 2025
2024-003 Uniform Guidance Audit Valerie Vaughn, 6/30/2026 Submission Deputy City Clerk - Office Manager Corrective Action planned to be taken: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facil...
2024-003 Uniform Guidance Audit Valerie Vaughn, 6/30/2026 Submission Deputy City Clerk - Office Manager Corrective Action planned to be taken: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facilitate a timely audit submission as set forth in the Uniform Guidance.
Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.926 Healthy Start Initiative (HSI) Pass-Through Grantor: Not applicable Award Number: H4903591 Award Period: 5/1/2024-...
Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Assistance Listing: 93.926 Healthy Start Initiative (HSI) Pass-Through Grantor: Not applicable Award Number: H4903591 Award Period: 5/1/2024-3/31/2025 Summary of Finding: Three instances where the required Federal Funding Accountability and Transparency Act (FFATA) reports were not submitted in the FSRS in FY 2024. In addition, for all four FFATA reports that were submitted in FSRS in FY 2024, there was no evidence of review and approval of the reports prior to submission. Under the HSI program, there were four subrecipients that had a total of seven subaward (four new agreements and three amendments) in FY 2024. The three subaward modifications for which FFATA reports were not submitted totaled $278,805. Total subrecipient’s costs are $736,165 in FY 2024. The total federal expenditures for the HSI program for FY 2024 were $1,108,849. Corrective Action Plan: Leadership acknowledges a gap in the current FFATA reporting process specific to the submission of reports for amended subawards and review and approval of reports prior to submission. To address these deficiencies, leadership will develop a written procedure for FFATA reporting that includes specific instructions for reporting amended subawards throughout the award period. Additionally, the procedure will include review and approval of the report prior to submission. This process will be disseminated to the Office of Sponsored Programs and Research Finance teams and reviewed on a regular basis for ongoing education and compliance purposes. Individuals responsible for corrective action: Paula Schuiteman-Bishop, Vice President, Research Administration Joe Fugitt, Senior Director, Research Administration, Development and Billing Integrity Jodi Bonhorst, Director, Research Development Brandy Jurdzy, Manager, Research Sponsored Programs. Timing of corrective action: September 1, 2025, and going forward.
Finding 574705 (2024-002)
Significant Deficiency 2024
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the service...
The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with rent reasonableness requirements. Additionally, the PHA contracts the services of McCright & Associates LLC, a reputable HQS servicing company, to assist with rent reasonableness requirements. McCright now conducts all rent reasonableness comparables for all new units and staff confirm that a copy is stored in the participant file. Staff believe that with the implementation of these procedures appropriate steps have been taken to address this concern
Finding 574704 (2024-001)
Significant Deficiency 2024
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include d...
PHA staff understand that income verification is essential to ensure that only eligible participants are provided with housing assistance benefits. The housing division has conducted a thorough review of their procedures and upgraded their internal Standard Operating Procedure documents to include detailed step-by-step instructions designed to ensure compliance with EIV requirements. Additionally, staff have been in contact with their software provider about system enhancements such as the software producing a warning/error if an employee attempts to process an EIV reexamination without updating the EIV date. Such enhancements would further help to ensure compliance with federal program requirements. Staff have also been attending training to ensure sufficient knowledge of program EIV requirements. Staff believe these efforts should address this concern.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
2024-008. USDA ReConnect Program Reporting Federal AL#: 10.752 USDA ReConnect Program Award Year: 2024 Name of Contact Person(s) Responsible for the Corrective Action Plan: Grants Administrator Chief Financial Officer Financial Services Division Director Corrective Action Plan: The County is in the ...
2024-008. USDA ReConnect Program Reporting Federal AL#: 10.752 USDA ReConnect Program Award Year: 2024 Name of Contact Person(s) Responsible for the Corrective Action Plan: Grants Administrator Chief Financial Officer Financial Services Division Director Corrective Action Plan: The County is in the process of evaluating the policies, procedures, and internal controls relative to accurately reporting and reconciling the expenditures reported on the SEFA. Anticipated Completion Date: Fiscal Year 2025
Federal AL#: 21.027 State and Local Fiscal Recovery (SLFRF) Award Year: 2024 Name of Contact Person(s) Responsible for the Corrective Action Plan: Grants Administrator Chief Financial Officer Financial Services Division Director Corrective Action Plan: The County is in the process of evaluating the ...
Federal AL#: 21.027 State and Local Fiscal Recovery (SLFRF) Award Year: 2024 Name of Contact Person(s) Responsible for the Corrective Action Plan: Grants Administrator Chief Financial Officer Financial Services Division Director Corrective Action Plan: The County is in the process of evaluating the policies, procedures, and internal controls relative to accurately reporting and reconciling the expenditures reported on the SEFA. Anticipated Completion Date: Fiscal Year 2025
This finding will not completely resolve given the limited amount of financial staff and limited financial resources of the Organization. The Organization will rely on Board oversight and review of financial records.
This finding will not completely resolve given the limited amount of financial staff and limited financial resources of the Organization. The Organization will rely on Board oversight and review of financial records.
2024-005 REPORTING REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material weakness in internal controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context...
2024-005 REPORTING REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material weakness in internal controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context: Documentation was not provided to support the number of federally connected students reported on the Impact Aid application. Corrective Action: The District will establish a process to ensure proper documentation is maintained to support the Impact Aid application. Planned completion date for corrective action plan: For the period ending August 31, 2025. Name of the contact person responsible for corrective action: Laticia John, Business Coordinator
Finding 574638 (2024-005)
Material Weakness 2024
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will ha...
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2025
Finding 574636 (2024-003)
Material Weakness 2024
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Depa...
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Department head will review and document their review for all Federal Grant disbursements for applicable grant requirements and Federal regulations. Anticipated Completion Date: August 30, 2025
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: The AHA Director of Assisted Housing and the Senior Housing Inspector are conducting monthly reviews of inspection reports to identify deficiencies and ensure inspections extensions are completed on time. This program management process will continue on an ongoing basis. Additionally, we have hired an additional inspector to help meet inspection deadlines and improve overall timeliness. Anticipated Completion Date: Ongoing
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Hous...
Federal Agency Name: U.S Department of Housing and Urban Development Program Name: Housing Choice Vouchers CFDA # 14.871 Finding Summary: Significant Deficiency in Internal Control over Compliance and Immaterial Instance of Noncompliance Responsible Individuals: Celia Rivas Director of Assisted Housing Corrective Action Plan: To strengthen our compliance oversight, we now have a total of two Compliance Managers on staff. We recently filled the previously vacant Compliance Manager position, which will enhance our capacity to monitor and ensure that annual recertifications are being processed every 12 months and support staff in adhering to HUD requirements and agency procedures. We have made progress in hiring and retaining staff, which is strengthening our operational capacity and will support the timely processing of annual recertifications in compliance with HUD requirements. Anticipated Completion Date: Ongoing
Margaret McCowen: time sheet errors and discrepancies: We will review the existing time sheet policy with the Board Treasurer, and modify the policy for Board approval to include the correct internal control procedure. After the Board approval, we will schedule a mandatory training meeting with all...
Margaret McCowen: time sheet errors and discrepancies: We will review the existing time sheet policy with the Board Treasurer, and modify the policy for Board approval to include the correct internal control procedure. After the Board approval, we will schedule a mandatory training meeting with all timesheet staff to be held annually. Unsigned employment agreements: We will review the existing employment agreement policy to confirm that storage and maintenance instruction are included. We will submit the revised policy to the Board of Directors for approval and when approved, will send a copy to all hiring employees (Board president, Vice-president, Secretary and Treasurer, Executive Director). The policy will require maintenance in an electronic file and also in a paper file to be maintained by the Board President.
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur wi...
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.
FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late...
FINDING NUMBER: 2024-002 Condition: During the audit it was noted that management had difficulties providing expenditure reports for the federal grants. It was also noted that for the SLFRF grant, performance reports that are due annually, 30 days following the end of the period, were submitted late in the case of the 2024 grant. Plan: Management will monitor grant expenditure reports closely and will improve their control activities to ensure that grant performance reports are filed as required by the grant agreement. Anticipated Date of Completion: As soon as possible – before FY26 year end Name of Contact Person: Mary Ventrella, CPA - Finance Director Management Response: Since the audit, we have evaluated our monitoring procedures and control activities to ensure that grant expenditure reports are readily available and grant performance reports are filed timely.
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been com...
Finding Number: 2024-002 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Waylon Welvaert, Finance Manager Corrective Action Planned: All impacted employees have been reviewed and system adjustments in payroll have been completed. We have completed and submitted updated 2556 reports to the State on June 25, 2025, for the two quarterly reports that were affected. In addition, a review will be done at the start of every quarter to ensure that all allocations are being distributed correctly by the payroll system to ensure that reports are accurately completed. Anticipated Completion Date: We completed doing a full payroll system review on July 10, 2025 of account code classifications for the start of the 3rd quarter.
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility wo...
Finding Number: 2024-001 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: DeAnn Boney, Income and Healthcare Assistance Manager Corrective Action Planned: The results of the MA audit will be shared with all eligibility workers at a full team meeting. We will review the findings of the cases found in error and retrain workers on the expectation that the system will be updated when documentation is received on a case. The case findings will be reviewed directly with the individual workers that made the mistake on the case. They will update the case in the METS system to reflect the information in the case files. Anticipated Completion Date: Our full eligibility meeting is scheduled for July 29, 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan:...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan: The required monthly balance and the actual monthly reserve fund account balance will be presented to the board on a monthly basis for review and approval. Previously only the actual balance and a YES/NO were provided. Starting in August 2025, monthly board packets for approval will now include the required vs actual comparison with a YES/NO of meeting the requirement. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Anticipated Completion Date: August 2025
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin
View Audit 364796 Questioned Costs: $1
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A
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