Corrective Action Plans

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Management acknowledges the need to expand the current capacities of the finance team and is in the process of recruiting additional experienced and qualified personnel. To assist with immediate reporting and compliance needs, the District continues to utilize external consultants to provide assista...
Management acknowledges the need to expand the current capacities of the finance team and is in the process of recruiting additional experienced and qualified personnel. To assist with immediate reporting and compliance needs, the District continues to utilize external consultants to provide assistance with grant programs and related accounting procedures.
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
Person(s) Responsible for the Corrective Action: April Samuels, VP of Finance Corrective Action Plan: Implement monthly reconciliation between PHDC and DHCD to identify and resolve any discrepancies in real time. Anticipated Completion Date: June 30, 2026
The agency has created new policies and implemented fail saifs, including board involvement, to ensure the deadlines for all required filing are met. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024
The agency has created new policies and implemented fail saifs, including board involvement, to ensure the deadlines for all required filing are met. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024
The Organization has agreed to the recommendation that all necessary efforts be taken to ensure the timely submission of the audit, Data Collection Form, and reporting package. Sufficient internal controls will be designed and implemented to detect and prevent errors in reports and within the accoun...
The Organization has agreed to the recommendation that all necessary efforts be taken to ensure the timely submission of the audit, Data Collection Form, and reporting package. Sufficient internal controls will be designed and implemented to detect and prevent errors in reports and within the accounting system and to ensure that the audit, Data Collection form, and reports are submitted timely.
The Organization has agreed to the recommendation to maintain appropriately trained and experienced personnel and has hired a new Director of Finance. This will ensure that the accounting processes and internal controls over Federal Reporting will be functioning properly.
The Organization has agreed to the recommendation to maintain appropriately trained and experienced personnel and has hired a new Director of Finance. This will ensure that the accounting processes and internal controls over Federal Reporting will be functioning properly.
Condition: The Organization lacked sufficient internal controls to ensure sliding fee discount applications were on file and included all of the necessary information regarding family size and income to support discount determinations made. Further, controls were not sufficient to ensure the correct...
Condition: The Organization lacked sufficient internal controls to ensure sliding fee discount applications were on file and included all of the necessary information regarding family size and income to support discount determinations made. Further, controls were not sufficient to ensure the correct sliding fee discount was applied. Planned Corrective Action: The organization will implement controls to ensure sliding fee applications are maintained and sliding fee adjustments are based on correct family income and resident size. Contact person responsible for corrective action: Charles Berry (CFO) Anticipated Completion Date: 6/30/2026
As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms w...
As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms will be submitted.
Views of Responsible Officials and Planned Corrective Actions: LHCA's methodology for qualifying laboratory and affiliated organization expenses as industry in-kind contribution was developed in direct consultation with FAS program officials in June 2023. As documented in LHCA's written summary of t...
Views of Responsible Officials and Planned Corrective Actions: LHCA's methodology for qualifying laboratory and affiliated organization expenses as industry in-kind contribution was developed in direct consultation with FAS program officials in June 2023. As documented in LHCA's written summary of that meeting, transmitted to senior FAS program and operations officials including the FMD program officer and acknowledged without objection, FAS validated the eligibility of research, marketing, policy, and technical expenses funded through industry funds, focused on target markets, and connected to UES activities. LHCA was acting on direct FAS guidance, not making unsupported determinations, and that documentation is available for the auditor's review. The revenue figures that appeared in LHCA's contribution documentation served as an allocation methodology, a proportional basis for determining what share of multi-purpose expenses relates to export promotion, not as the contribution itself. The actual contribution claimed consisted of underlying expenses allocated using that methodology. LHCA acknowledges that this methodology was not clearly labeled in the documentation provided to auditors, and will revise its documentation format to clearly distinguish the allocation calculation from the contribution amount claimed, ensuring the two are not conflated in future reviews. LHCA will formalize its contribution tracking procedures with a written policy document that defines eligible activities consistent with FAS guidance, specifies the allocation methodology and its basis, and requires that all claimed contribution be supported by verifiable expense documentation consistent with the hierarchy established in FMD §1484.33(f) and the cost principles in 2 CFR Part 200 Subpart E. A documented review and approval process will be implemented to ensure contribution amounts are accurate, allowable, and properly supported prior to submission.
Reporting The College partially agrees with the finding. While the College disagrees with the auditors’ conclusions regarding the calculation of cost of attendance and Pell award amounts for the students tested, the College acknowledges the need to strengthen its review and documentation procedures ...
Reporting The College partially agrees with the finding. While the College disagrees with the auditors’ conclusions regarding the calculation of cost of attendance and Pell award amounts for the students tested, the College acknowledges the need to strengthen its review and documentation procedures over origination records and COD submissions to ensure consistency and completeness of reporting records.
Reporting The College acknowledges the finding and recognizes the need to strengthen oversight of reporting requirements. To prevent recurrence, the College will enhance its monitoring processes by developing formal reporting procedures and using the Asana Project Management system to schedule, moni...
Reporting The College acknowledges the finding and recognizes the need to strengthen oversight of reporting requirements. To prevent recurrence, the College will enhance its monitoring processes by developing formal reporting procedures and using the Asana Project Management system to schedule, monitor, and provide reminders for all federal and grant- related reporting deadlines and submissions.
Management concurs with this finding and acknowledges that this is a repeat finding from the prior year (2022-001). The Alliance takes this matter seriously and recognizes that the prior corrective action plan was insufficient in scope and specificity to prevent recurrence. To fully remediate this d...
Management concurs with this finding and acknowledges that this is a repeat finding from the prior year (2022-001). The Alliance takes this matter seriously and recognizes that the prior corrective action plan was insufficient in scope and specificity to prevent recurrence. To fully remediate this deficiency and ensure timely compliance with the reporting requirements of 2 CFR 200.512, the Alliance has implemented or will implement the following corrective actions 1. Concurrent Single Audits for FY 2023 - 2024 and FY 2024 - 2025. The Alliance will conduct concurrent audits on the currently late years to bring filing status to the current year. 2 Formal Fiscal Policy Adopted. The Alliance will adopt a formal fiscal policy governing the Single Audit process, which establishes a detailed project timeline with clearly defined milestones, responsible parties, and internal deadlines for each phase of the audit cycle — including year-end close, preparation of financial statements, auditor fieldwork, draft review, and submission of the SF-SAC Data Collection Form to the Federal Audit Clearinghouse (FAC). 3. Reverse-Engineered Timeline. The project timeline is structured to work backward from the 9-month federal deadline (March 31 for a June 30 fiscal year-end), building in a minimum 30-day buffer to ensure all deliverables — including management review of draft financial statements, resolution of auditor inquiries, and final submission — are completed well in advance of the statutory due date.4 Designated Responsible Party. The Administrative Services Officer, with regular reviews by the Executive Director, has been designated as the responsible party for monitoring progress against the timeline and escalating delays to the Executive Director and Board of Directors if any milestone is at risk of being missed.5 . Quarterly Progress Reporting. Beginning in the first quarter following fiscal year-end, the Administrative Services Officer will provide quarterly progress updates to the Executive Director on the status of the Single Audit, including any identified risks to the timeline. 6.Auditor Engagement Timeline. The Alliance will execute its audit engagement letter no later than 60 days after fiscal year-end and will provide all requested schedules and supporting documentation to the auditors within 90 days of fiscal year-end to ensure adequate time for fieldwork and report issuance. 7. Internal Controls Over Reporting. The Alliance will implement a closing checklist and internal review process to ensure that all reconciliations, adjusting entries, and supporting schedules are completed and reviewed prior to the commencement of auditor fieldwork. Estimated Completion Date: Fully implemented for the fiscal year ending June 30, 2024 audit cycle.Responsible Party: Taylor Swain, Administrative Services Officer
2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...
2023-005 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@har...
2023-004 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-6...
2023-002 CDBG Activities Allowed and Allowable Costs Significant Deficiency Corrective Action: We now have staff that can review invoices properly prior to payment. Invoices paid will have a final signoff prior to payment. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
Condition The reporting package and data collection form for the fiscal year ended September 30, 2023 were not submitted to the Federal Audit Clearinghouse by the June 30, 2024 deadline required under 2 CFR §200.512(a). This represents a repeat finding from the prior audit period. Corrective Action ...
Condition The reporting package and data collection form for the fiscal year ended September 30, 2023 were not submitted to the Federal Audit Clearinghouse by the June 30, 2024 deadline required under 2 CFR §200.512(a). This represents a repeat finding from the prior audit period. Corrective Action Plan RJI acknowledges the delayed completion and submission of the Single Audit and has implemented corrective actions designed to strengthen financial oversight, improve audit readiness, and ensure timely completion of future federal and state reporting requirements. To address the root causes identified, RJI has implemented the following corrective measures. Strengthened Financial and Grants Infrastructure RJI has expanded organizational financial capacity through dedicated finance and grants management staffing with responsibility for grant tracking, financial reconciliation, audit preparation, and compliance monitoring. Formalized Audit Preparation and Annual Compliance Calendar RJI has established a documented year-end financial close and audit readiness calendar that includes internal deadlines for monthly reconciliations, grant closeout procedures, preparation of supporting schedules, auditor request tracking, draft review periods, and Federal Audit Clearinghouse submission timelines. Enhanced Fiscal Sponsor Coordination and Governance Procedures RJI has refined communication and workflow processes with its fiscal sponsor and external financial partners by implementing recurring financial review meetings, defined responsibility matrices, and standardized documentation requirements to ensure timely access to financial records and audit support. Established Audit Continuity and Vendor Management Procedures Recognizing prior disruptions caused by auditor transitions and capacity limitations, RJI has implemented procedures to maintain continuity of audit services including earlier auditor engagement, documented deliverables and timelines, periodic status meetings, and contingency planning for audit completion. Ongoing Monitoring and Board Oversight Financial compliance status, audit progress, and reporting deadlines will be reviewed regularly by executive leadership and reported to the Board of Directors (or Finance/Audit Committee, if applicable) until all required filings are completed and sustained. Documentation and Internal Controls Enhancement RJI has strengthened record retention, reconciliation procedures, and grant documentation practices to improve the completeness and availability of records required for annual audit testing and federal reporting Anticipated Completion Date Corrective actions began implementation in November 2025 and are expected to be fully operational and incorporated into all future annual audit and federal reporting cycles beginning with FY2026 reporting requirements. Status In Progress / Partially Implemented RJI has completed staffing and process improvements and is actively implementing monitoring procedures to ensure sustained compliance with 2 CFR §200.512(a) and timely submission of future Single Audit reporting packages. Management Statement Management believes the corrective actions implemented will ensure full compliance with federal and state reporting requirements and prevent recurrence of late audit submissions. Responsible Individual Dr. Liza Chowdhury Executive Director Date: 5/26/2026
CASSE has already committed to implementing corrective measures, including: • enhanced related-party transaction review procedures; • annual conflict-of-interest disclosures; formal Board approval protocols; • legal counsel compliance training for management, key personnel and the Board; and • imple...
CASSE has already committed to implementing corrective measures, including: • enhanced related-party transaction review procedures; • annual conflict-of-interest disclosures; formal Board approval protocols; • legal counsel compliance training for management, key personnel and the Board; and • implementation of strengthened internal controls concerning procurement and federal grant compliance. CASSE will renew its cunent compliance plan with its legal counsel with a paiticular focus on ensuring compliance with the Organization's conflict of interest policy and an applicable federal grant related requirement. CA SSE remains committed to full compliance with 2 CFR Part 200 and to maintaining transparency and accountability in connection with all federal awai·ds.
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will implement procedures to ensure subrecipients are properly documented, reported, and monitored in accordance with grant requirements. Each subaward will include a formal agreement and defined scope of work, and...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will implement procedures to ensure subrecipients are properly documented, reported, and monitored in accordance with grant requirements. Each subaward will include a formal agreement and defined scope of work, and required information will be submitted within established timelines. Documentation of submissions and monitoring activities will be maintained, and a tracking process will be used to ensure compliance. The Financial Analyst will manage subrecipient monitoring, with oversight from the Executive Director, and periodic reviews will be conducted. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, March 31st, 2024
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, ...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will maintain written financial and grants management policies to support consistent operations and compliance with Uniform Guidance (2 CFR Part 200). These policies will cover key areas including allowable costs, procurement, cash management, subrecipient monitoring, reporting, record retention, and internal controls. The Financial Analyst will be responsible for maintaining and updating these policies, with oversight from the Executive Director, and policies will be reviewed at least annually and updated as needed. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst, by March 31st, 2024
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as...
Response: Management concurs with the finding. Corrective Action Plan: NewSpace Nexus will comply with federal employment eligibility requirements by ensuring a Form I-9 is completed for every employee within three business days of their start date. Employees must provide acceptable documentation as required, and completed forms will be securely maintained and retained for the required period. The Financial Analyst will periodically review personnel files to confirm compliance, and any missing or incomplete forms will be addressed promptly with documentation of corrective actions retained. Designation of Employee Position Responsible for Meeting Deadline: Financial Analyst by: January 31st, 2024
Finding: 2023-002 Agency: Lebanon County Commission on D&A Abuse Contact Person/Title: James Donmoyer, Administrator of Lebanon County Commission on D&A Abuse Finding Title/Corrective Action: Segregation of Duties over Reporting The Department was in need of additional accounting personnel and as of...
Finding: 2023-002 Agency: Lebanon County Commission on D&A Abuse Contact Person/Title: James Donmoyer, Administrator of Lebanon County Commission on D&A Abuse Finding Title/Corrective Action: Segregation of Duties over Reporting The Department was in need of additional accounting personnel and as of December 2023 a new employee was hired so adequate oversight will be corrected going forward. Anticipated Completion Date: December 2023
FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section ...
FINDING 2023-003 - Sliding Fee Discount Program MATERIAL WEAKNESS; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93.224/93 .527, Health Center Program Cluster Compliance Requirement: Special Tests & Provisions Criteria: Section 330 of the Public Health Service Act and the HRSA Health Center Program Compliance Manual require health centers to maintain and operate a board-approved Sliding Fee Discount Program that adjusts patient charges based on income and family size using the current Federal Pove1ty Guidelines, applies uniformly to all patients and all in-scope services, and is supported by adequate documentation of eligibility determinations. In addition, Uniform Guidance requires nonfederal entities to establish and maintain effective internal controls over federal programs to provide reasonable assurance of compliance with federal statutes, regulations, and award terms. Condition: During testing of the Sliding Fee Discount Program within the Health Center Cluster, the Center could not provide documentation of the appropriate sliding fee discounts for certain patients in accordance with federal requirements. Context: The condition was identified through testing of the Health Center Cluster as pa1i of the single audit, which included testing patient fee assessments and sliding fee discount application as a special test required under the program. Controls were determined to be ineffective in 2 of 40 test items. Noncompliance was noted in 2 of 25 test items. Statistical sampling was not utilized. Cause: The condition was caused by inadequate internal controls over the implementation and monitoring of the Sliding Fee Discount Program, including limited supervisory review to ensure all sliding fee applications are maintained, reviewed, and properly applied. Effect or Potential Effect: The Center's failure to maintain documentation surrounding sliding fee discounts in accordance with federal requirements increases the risk of noncompliance with Health Center Program requirements and may result in patients being charged amounts not aligned with their ability to pay. The condition also increases the risk of adverse findings during HRSA oversight or other federal monitoring activities. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is not a repeat finding. Recommendation: The Center should enhance internal controls over the Sliding Fee Discount Program by ensuring consistent documentation of income and family size, timely reassessment of eligibility in accordance with policy, consistent application of the board-approved sliding fee discount schedule to all applicable in-scope services, and periodic monitoring and supervisory review to ensure ongoingcompliance. Views of Responsible Officials: Neighborhood Medical Center has implemented quarterly SFDP internal audits and training for the intake staff to improve compliance oversight and documentation accuracy. A standardized audit tracking log documenting charts are reviewed, findings identified and corrective actions completed. An annual refresher for the staff has been implemented. A quick-reference eligibility checklist has also been developed for staff use. Person Responsible for Corrective Action: Ronica Mathis and Shenika Mathews Anticipated Completion Date for Corrective Action: This practice has already been implemented.
FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Cr...
FINDING 2023-004- Late Submission of Single Audit and FAC Data Collection Form SIGNIFICANT DEFICIENCY; NONCOMPLIANCE Identification of the Federal Program: U.S. Department of Health and Human Services; direct awards ALN: 93 .011, 93.224/93.527, 93.526, and 93.918 Compliance Requirement: Reporting Criteria: Uniform Guidance requires nonfederal entities to submit the reporting entity's Uniform Guidance reporting package, including the audit report and completed Federal Audit Clearinghouse (F AC) Data Collection Form, to the F AC within the earlier of 30 calendar days after receipt of the auditor's rep01ts or nine months after fiscal year-end (2 CFR 200. 512( a)). Timely submission of the reporting package is required to facilitate federal oversight of award compliance. Context: The condition was identified during Single Audit testing of reporting requirements applicable to the Health Center Cluster. Sampling was not utilized. Condition: The Center did not submit its required Uniform Guidance reporting package, including the reporting entity's audit report and the FAC Data Collection Form, within the required submission timeframe. Specifically, the Uniform Guidance audit and related FAC Data Collection Form were submitted after the earlier of (1) 3 0 calendar days after receipt of the auditor's reports or (2) nine months after the end of the reporting entity's fiscal year. Cause: Due to a delay in the compiling of records related to the audit, the Center was not in compliance with the reporting requirements. Effect or Potential Effect: Failure to submit the Uniform Guidance audit and F AC Data Collection Form timely increases the risk of noncompliance with Uniform Guidance reporting requirements and may result in delayed federal oversight, increased monitoring by the awarding agency, or the imposition of additional administrative conditions. Questioned Costs: No questioned costs were identified as a result of this finding. Repeat Finding: This is a repeat finding. Recommendation: The Center should strengthen internal controls over Uniform Guidance audit reporting by ·implementing procedures to track submission deadlines, assigning responsibility for timely filing of the audit report and FAC Data Collection Form, and establishing management review processes to ensure compliance with Uniform Guidance reporting requirements. View of Responsible Officials: Neighborhood's prior auditor indicated just before time to begin the audit for FY2022; they would not be able to complete the audit because of staff sho1tages. Two RFPs were issued, and it took the center a year and a half to secure a new auditor. The 2022 and 2023 audits have been completed. Engagement contract has been issued for the 2024 audit.
2023-001 REPORTING Recommendation: Reports prepared by the Executive Director should be reviewed by an independent person to ensure completeness and accuracy. Additionally, the Organization should design a control to ensure reports are submitted in a timely manner in accordance with compliance requi...
2023-001 REPORTING Recommendation: Reports prepared by the Executive Director should be reviewed by an independent person to ensure completeness and accuracy. Additionally, the Organization should design a control to ensure reports are submitted in a timely manner in accordance with compliance requirements. Corrective Action: Community of Hope recognizes that our expansion and growth have made it difficult to maintain full and timely compliance with some reporting criter+B11 ia. As such, we have created a compliance calendar that will alert staff to impending deadlines and requirements. In addition, we recently hired a staff member with compliance being a primary function. She is reviewing grant and policy compliance, making recommendations, and instituting changes to enhance compliance. Responsible party: Drew Warren, Executive Director Date Expected to be Corrected: March 1, 2026
Finding 2023-012 - Single Audit Reporting Auditee's Response and Planned Corrective Action The Town will work with the accounting department, fee accountant, and audit fmn to file the required reports timely. Planned Implementation Date of Corrective Action: January 2026 Person Responsible for Corre...
Finding 2023-012 - Single Audit Reporting Auditee's Response and Planned Corrective Action The Town will work with the accounting department, fee accountant, and audit fmn to file the required reports timely. Planned Implementation Date of Corrective Action: January 2026 Person Responsible for Corrective Action: Fred Costello, T own Supervisor
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