Corrective Action Plans

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2025-001 Timeliness of Effort Certification Cluster: Research and Development (also applies to other major programs referenced below) Sponsoring Agency: All research and development cluster sponsoring agencies and Department of Health and Human Services (for the other major program referenced below)...
2025-001 Timeliness of Effort Certification Cluster: Research and Development (also applies to other major programs referenced below) Sponsoring Agency: All research and development cluster sponsoring agencies and Department of Health and Human Services (for the other major program referenced below) Award Names: All research and development cluster awards and Doorway for Substance Use-Related Supports and Services Award Numbers: All research and development cluster awards, Cheshire Medical Center 05-95-920510-7040000 Assistance Listing Title: All research and development cluster assistance listing titles and Opioid STR Assistance Listing Number: All research and development cluster assistance listing numbers and 93.788 Award Year: 2024-2025 Pass-through entity: All research and development cluster pass-through entities and New Hampshire Department of Health and Human Services This is a repeat finding of 2024-002 and in the prior year corrective action plan we had anticipated correcting this matter by March 31, 2025. Due to additional training needing to be administered to providers, we had to revise our date of completion to September 30, 2026. Management agrees with the finding related to the timeliness of effort certification. Management has continued to provide training and education to both operational and clinical leadership regarding timely effort certification. Dartmouth-Hitchcock currently has two effort certification systems: one used for research and one used to track other metrics. This has caused confusion among those required to certify effort for federal awards as they often believe that they had already certified their effort for research purposes . Management will provide additional education sessions and provide further clarification to the research community on the importance of timely effort certification and the differences in each effort reporting system. Individual Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: September 30, 2026
Corrective Action Plan – Single Audit Finding Entity Name: W.S. Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit finding...
Corrective Action Plan – Single Audit Finding Entity Name: W.S. Housing Development Company, Inc. Audit Period: For the year Ended September 30, 2025 Finding Reference Number: 14.157 Federal Program: Supportive Housing for the Elderly (Section 202) 1. Audit Finding Summary Describe the audit finding and the specific noncompliance identified by the auditor. In accordance with 24 CFR 891.400(e), a separate interest-bearing project fund account shall be maintained in a depository or depositories which are members of the Federal Deposit Insurance Corporation or National Credit Union Share Insurance Fund and all tenant payments, charges, income and revenues arising from project operation or ownership shall be deposited to this account. 2. Root Cause Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls. Subsequent to the initial rental assistance contract, changes to HUD regulations resulted in the requirement that the project fund account be an interest-bearing account. This change was an oversight by the Company's management. 3. Corrective Actions Action Item: Use an interest-bearing account for project funds Responsible Person: Chief Financial Officer Completion Date: TBD Status: In process 4. Monitoring Plan Describe how the implementation of corrective actions will be monitored and evaluated. Management inquired with the bank and deemed the cost outweighs the benefit due to the fees charged for an interest bearing account exceeding the interest that would be earned. 5. Contact Information Name: Aaron Hejmowski Title: Chief Financial Officer Phone: 716-884-7791 Email: ahejmowski@belmonthousingwny.org
2025-004 – COMPLIANCE AND CONTROLS OVER REPORTING Corrective Action Plan: The Organization has developed a centralized reporting calendar identifying all required report filing deadlines. Designated staff will utilize the reporting calendar to monitor and ensure the timely submission of all required...
2025-004 – COMPLIANCE AND CONTROLS OVER REPORTING Corrective Action Plan: The Organization has developed a centralized reporting calendar identifying all required report filing deadlines. Designated staff will utilize the reporting calendar to monitor and ensure the timely submission of all required reports. The reporting calendar will be incorporated into the Organization's succession planning and reviewed regularly to ensure compliance with all reporting requirements and continuity during staff transitions. Responsible Party(ies): • Executive Director • Finance Manager Anticipated Date of Completion: September 30, 2026
2025-003 INTERNAL CONTROLS OVER PAYROLL AND BENEFITS ALLOCATIONS Corrective Action Plan: The Organization has implemented a pre-payroll review process requiring supervisors to verify the accuracy of employee timesheets before submitting them to the Finance Manager. The Finance Manager will conduct a...
2025-003 INTERNAL CONTROLS OVER PAYROLL AND BENEFITS ALLOCATIONS Corrective Action Plan: The Organization has implemented a pre-payroll review process requiring supervisors to verify the accuracy of employee timesheets before submitting them to the Finance Manager. The Finance Manager will conduct a secondary review of timesheets before entering and processing payroll. In addition, the Organization has implemented a new benefits software administration system to improve the accuracy of benefit tracking and allocations. Any discrepancies identified during the review process will be corrected promptly before payroll is finalized. Responsible Party(ies): • Finance Manager Anticipated Date of Completion: September 30, 2026
New automated financial systems have been implemented to reduce error, and management has added an additional review step for all federal reimbursement requests to verify that payroll and fringe benefit costs are accurately calculated and allocated before submission. Reimbursement requests have and ...
New automated financial systems have been implemented to reduce error, and management has added an additional review step for all federal reimbursement requests to verify that payroll and fringe benefit costs are accurately calculated and allocated before submission. Reimbursement requests have and will be reconciled to payroll reports, time records, and allocation schedules to ensure costs are not duplicated. Staff responsible for grant financial reporting have been reminded of the required review procedures, and the Finance and/or Executive Director will perform a secondary review of all reimbursement requests. These measures are intended to prevent duplicate charges and ensure compliance with federal allowable cost requirements.
2025-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed or Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. The Authority is now drawing down its CFP and is not usin...
2025-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed or Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. The Authority is now drawing down its CFP and is not using operating funds for CFP activities. Person Responsible for Correction of Finding: Wanda Allen, Executive Director Anticipated Completion Date: September 30, 2026
MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS – ALL FEDERAL PROGRAMS 2025-001 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the City of South St. Paul, Minnesota (the City) prepare appropriate annual financial stat...
MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS – ALL FEDERAL PROGRAMS 2025-001 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the City of South St. Paul, Minnesota (the City) prepare appropriate annual financial statements, including the Schedule of Expenditures of Federal Awards (SEFA), which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. During our audit, we noted the City did not have sufficient controls in place to ensure the accurate preparation of the SEFA in compliance with this requirement. The City’s SEFA for fiscal 2025 was overstated by $749,656 in federal expenditures, due to the inclusion of costs that were incurred in the previous fiscal year. Corrective Action Plan Actions Planned – The City has implemented new processes and procedures in 2026 which address this internal control finding to comply with the Uniform Guidance in the future. Finance department personnel will work with federal grant coordinators to assure that federal expenditures are accurately reported on the SEFA for all federal programs. Official Responsible – Clara Hilger, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Clara Hilger, will ensure the new process and procedures implemented in this area ensure future compliance with the Uniform Guidance.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION – PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION – HIGHWAY PLANNING AND CONSTRUCTION FEDERAL ALN 20.205 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements F...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION – PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION – HIGHWAY PLANNING AND CONSTRUCTION FEDERAL ALN 20.205 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires the City to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the Highway Planning and Construction federal program. During our audit, we noted the City did not have sufficient controls in place within this program to ensure compliance with federal requirements related to assuring that the City was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City has implemented new processes and procedures in 2026 which address this internal control finding to ensure compliance with the Uniform Guidance in the future. The procedures will include steps to assure that City personnel are following the requirements of the Uniform Guidance related to suspension and debarment, including maintaining appropriate documentation. Official Responsible – Clara Hilger, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Clara Hilger, will oversee the evaluation of this process, and the implementation of any procedural changes deemed necessary to ensure the City’s control procedures over suspension and debarment are performed and adequately documented in the future.
Finding 2025-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part ...
Finding 2025-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
Recommendation: The cost of additional personnel to properly segregate accounting and financial responsibilities would appear to outweigh the benefits received. However, the management and Board of Commissioner should constantly be aware of the possibility that errors or fraud could occur and contin...
Recommendation: The cost of additional personnel to properly segregate accounting and financial responsibilities would appear to outweigh the benefits received. However, the management and Board of Commissioner should constantly be aware of the possibility that errors or fraud could occur and continue current practices mitigating these possibilities and examine and implement other mitigating controls when appropriate. Action Taken: The County has assessed the benefits and costs associated with proper segregation of duties and has determined that costs would outweigh the benefits received. The County understands the inherent risks associated with improper segregation of accounting functions. Management has communicated the need for transactions to be well supported by documentation as well as seeking appropriate authorization when appropriate. The County requires reporting to the Board of Commissioner for all disbursements to ensure transactions are proper and potential errors and irregularities are identified on a timely basis. The County will continue to review accounting procedures and processes to further mitigate this internal control deficiency whenever possible and feasible.
We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements
We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Impl...
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Shenae Draughn, President.
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2...
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2025 The findings from the September 30, 2025 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2025-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Alice Marie, CFO 507-373-2040 Anticipated Completion Date: Ongoing
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to...
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to the DOR Contract Administrator and retained electronically with evidence of timely submission. Documentation may include emailed reports, delivery confirmations, or other records demonstrating compliance with reporting deadlines. Management will maintain a centralized reporting file and review quarterly reporting requirements to ensure all required reports are submitted and retained in accordance with grant requirements. Although program activity associated with the Device Lending and Demonstration Centers and Reuse Centers is currently being procured through a competitive RFP process, CFILC will submit all required quarterly reports beginning with the next reporting cycle, including reports indicating limited or no activity when applicable. Contact Person: M. Lisa Hayes, Executive Director Projected Completion Date: July 30, 2026
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Huma...
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Human Assets department will coordinate with its payroll processing vendor (UKG) to: - Review payroll configuration settings related to bonus payments. - Implement controls to ensure bonus compensation is excluded from grant-related labor distributions. 3. Monitoring and Oversight Reinforcement The VP of Government Grant Compliance will reinforce internal review procedures by: - Providing targeted guidance to the Investor Relations Grant Compliance and Fiscal teams on identifying anomalies in Wage and Hour Reports, including unusual or inflated hourly rates
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requ...
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requirements under Uniform Guidance (2 CFR, Part 200.303) Planned Corrective Action: Road Commission is in the process of developing and implementing a written federal policies and procedure addressing the administration of federal awards to ensure compliance with Uniform Guidance (2 CFR, Part 200). The policy will address the following key compliance areas: allowable costs, cash management, procurement, and conflict of interest. The policy shall be reviewed and modified to included all the necessary items outlined in the Uniform Guidance. Contact Person responsible for corrective action: Destain Gingell, Managing Director / CHE, Kathleen Cunningham, Finance Director Anticipated Completion Date: July 30, 2026
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility f...
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility for tracking and ensuring timely submission of reports. Additionally, the Organization should conduct a root cause analysis to address any underlying issues and implement corrective actions to prevent future delays. Views of responsible officials and planned corrective actions: Management agrees with the finding and will implement processes to mitigate the risk of future late file reports. Anticipated Completion Date: June 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
Finding 1221502 (2025-003)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission...
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission of required reports". We hope that in the future, HIPS will receive the pre-requisite documentation on time. In addition, the grantors' systems are set in a chronological order and therefore even in instances where HIPS is ready to submit reports HIPS can only submit one month and wait for that month's report to be approved before HIPS can submit the next month. This system,albeit important in grant management, limits HIPS ability to fulfil "timely submission of required reports" requirements. HIPS will improve documentation on this issue.
Finding 1221501 (2025-002)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do...
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do not have the capacity to implement time tracking at this level of complexity. In FY 26, Supervisors will review and document review of proposed time allocations on the payroll allocations spreadsheets prior to month start to ensure that the allocation correctly matches the proposed schedule, and at month end to assess any changes needed based on actual time worked on various grant activities. We will also search for new software options to improve approval and entry process.
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melen...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
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