Corrective Action Plans

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Finding No. 2025-005: Matching Compliance Controls Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2026
Finding No. 2025-005: Matching Compliance Controls Responsible Individuals: Carrie Watts, Fiscal and Grant Manager Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2026
Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and C...
Description of Finding: Criteria or Specific Requirement: The lead agencies, who are subrecipients under the Federal Awards, are required to have clients sign the Form 502045-A CSFP Sub-Agency Monthly Participant Sign-in Sheet to self-declare program eligibility before food is disbursed. Issue and Cause: There were two instances out of 40 distributions tested where this signoff was not completed. Due to the hectic environment at the lead agencies during food distribution day, oversights have occurred when obtaining the required client signoff. Statement of Concurrence or Nonconcurrence: PARF management has reviewed the 2025-001 finding and concurs with the recommendations as stated. Corrective Action: PARF has an extensive training process in place for lead agencies, in relation to grant award compliance requirements, which includes the provision of training manuals and monthly phone calls to review matters. In addition, PARF provides updates to the lead agencies as new or amended requirements are enacted. Further, PARF does periodic reviews of the lead agencies and completes the biennial review Form 502035 CSFP Management Evaluation. PARF will continue to reiterate the required signoff process with the lead agencies during phone calls, training session and reviews. In addition for FY 2026 PARF will be conducting a mandatory webinar to ensure all the lead agencies are understanding the procedure and why it is important for 100 percent accuracies -https://docs.google.com/presentation/d/1YZgcq7SY4DmvhYrKZE8sp-NDhpuzn827PZDZ0xAKDw/edit?usp=sharing
2025-002: Reporting – Submission of the Data Collection Form Information on Federal Programs Federal Emergency Management Agency Assistance Listing Number: 97.036 Assistance Listing Name: Disaster Grants - Public Assistance passed through Florida Division of Emergency Management U.S. Department of H...
2025-002: Reporting – Submission of the Data Collection Form Information on Federal Programs Federal Emergency Management Agency Assistance Listing Number: 97.036 Assistance Listing Name: Disaster Grants - Public Assistance passed through Florida Division of Emergency Management U.S. Department of Health and Human Services Assistance Listing Number: 93.778 Assistance Listing Name: Medicaid Cluster – Medical Assistance Program Management will implement and maintain the following corrective actions:  Management has added a validation step with a secondary review by another team member to validate that all steps relating to submission have been clearly completed.  Management has also added this to our reporting checklist that is part of the Single Audit Process Narrative. Responsible Party: Controller, under the oversight of the Vice President of Financial Services/Chief Financial Officer, in coordination with the Grants function. Completion date: June 30, 2026
The Community Services Department (CSD) acknowledges the untimely submission of the October 2024 report. As indicated in the finding letter, this matter was an isolated event and not a systemic or programmatic concern. The delay resulted from temporary staffing shortages and leadership transitions d...
The Community Services Department (CSD) acknowledges the untimely submission of the October 2024 report. As indicated in the finding letter, this matter was an isolated event and not a systemic or programmatic concern. The delay resulted from temporary staffing shortages and leadership transitions during a high-demand fiscal period, rather than from deficiencies in internal controls. The Department maintains appropriate internal controls, clearly assigned responsibilities, and supervisory review processes. With stabilized leadership and strengthened monitoring procedures in place, the County is confident that timely grant reporting will continue moving forward. Although the County’s internal control structure remains sound and responsibilities are clearly assigned, the following measures have been reinforced to ensure continuity during future staffing transitions or high-volume periods: 1. Affirmation of Existing Internal Controls o Confirmed that established internal controls over grant reporting remain appropriate and effective. o Reaffirmed clearly designated staff responsible for preparation, review, and submission of grant reports. 2. Enhanced Deadline Monitoring o Strengthened use of a centralized tracking log 3. Backup Coverage and Cross-Training o Identified backup personnel to ensure continuity during staff vacancies or absences. 4. Strengthened Management Oversight o With the new Fiscal Division Director in place, oversight and monitoring of grant reporting timelines have been reinforced. Management now conducts proactive check-ins during peak workload periods, including Fiscal Close-Out. Responsible Parties: Fiscal Division Director, Fiscal Unit Management, Assigned Accountant 3 and 2. Implementation and Completion Date: Corrective actions began in November 2024 following stabilization of leadership positions. Enhanced monitoring and oversight procedures are consistently reviewed, evaluated, and refined throughout the year to increase operational efficiency, strengthen internal controls, and ensure continued compliance with all grant reporting requirements.
VIEWS OF RESPONSIBLE OFFICIALS The Puerto Rico Department of Education (PRDE) accepts the finding identified by the auditors regarding the incorrect coding of five (5) reimbursement payments for equipment purchases in account E6170 (Donations and Contributions to Private Entities), rather than in th...
VIEWS OF RESPONSIBLE OFFICIALS The Puerto Rico Department of Education (PRDE) accepts the finding identified by the auditors regarding the incorrect coding of five (5) reimbursement payments for equipment purchases in account E6170 (Donations and Contributions to Private Entities), rather than in the appropriate E5000-series accounts, and the omission of said assets from the institutional property register. The PRDE has initiated the necessary corrective actions to address this deficiency. Specifically, all assets included within the affected reimbursement transactions have been identified, and a detailed inventory is being prepared in which each asset is classified according to the capitalization criteria established in the Restart Program Fiscal Process Guide (unit cost equal to or greater than $500.00 and useful life greater than two (2) years). This inventory distinguishes between capitalizable equipment (E5000 series) and non-capitalizable equipment (E4414), in accordance with applicable regulatory requirements. Once finalized, the inventory file will be submitted to the PRDE’s Office of Property for review and mass upload into the institutional property register, ensuring that all assets acquired with Restart Program funds are properly recorded under PRDE ownership, in compliance with Section 102(h)(3) of the 2018 Hurricane Relief Act and the requirements of 2 CFR §200.302(b)(3)(4). IMPLEMENTATION DATE Fiscal Year 2026-2027 RESPONSIBLE PERSON Edgar Delgado Serrano Interim Director of Federal Affairs Office
Recommendation: We recommend the Organization review its cash policies and procedures to develop a system of requiring management approval of all expenditures of federal funds and documenting this approval. Action Taken: Management will establish a process for properly approving all expenses and mai...
Recommendation: We recommend the Organization review its cash policies and procedures to develop a system of requiring management approval of all expenditures of federal funds and documenting this approval. Action Taken: Management will establish a process for properly approving all expenses and maintaining documentation of approvals before the end of the next fiscal year.
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2025-005: Major Programs: Capital Advance Program, Federal Assistance Listing Number 14.U01 and Section 8 New Construction and Substantial Rehabilitation, Federal Assistance Listing Number 14.182 - Mate...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2025-005: Major Programs: Capital Advance Program, Federal Assistance Listing Number 14.U01 and Section 8 New Construction and Substantial Rehabilitation, Federal Assistance Listing Number 14.182 - Material Weakness RECOMMENDATION The auditor recommends the Project and management review and attend training on the HUD Handbook. In addition, the auditor recommends the Project and management review its internal control policies and procedures. ACTION TAKEN Carrasquillo Management LLC acknowledges the significant deficiency noted and is committed to improving internal controls to ensure full compliance with all HUD program requirements. 1. Policy and Procedure Review Management has initiated a comprehensive review of internal control policies and procedures to identify gaps and align practices with the HUD Handbook 4350.3 and related program regulations. Updates will be made to strengthen compliance checkpoints and clearly define staff responsibilities for each stage of tenant file processing, income verification, certifications, and documentation retention. 2. Training and Capacity Building Carrasquillo Management LLC has committed to ongoing staff development by enrolling relevant personnel in HUD-compliant training programs focused on regulatory requirements, internal controls, and compliance best practices. All staff involved in leasing, recertifications, and program compliance will be required to complete refresher trainings at least annually. 3. Internal Audit and Quality Control A quarterly internal audit process has been established to monitor the effectiveness of internal controls and ensure consistent application across all major program functions. Findings from these audits will be reviewed by senior management, and corrective actions will be taken immediately when deficiencies are identified. 4. Oversight and Accountability Management will assign a dedicated compliance coordinator responsible for overseeing adherence to HUD regulations and internal policies, providing regular updates to leadership, and ensuring follow-through on all audit-related corrective actions. Carrasquillo Management LLC is committed to fostering a culture of compliance and accountability and will take all necessary steps to prevent future deficiencies and ensure the Project remains in good standing with HUD program requirements.
Finding 2025-010: Reporting – FFATA Subawards Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will establish sufficient procedures or oversight controls to identify first-tier subawards subject to FFATA reporting requireme...
Finding 2025-010: Reporting – FFATA Subawards Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will establish sufficient procedures or oversight controls to identify first-tier subawards subject to FFATA reporting requirements and ensure the required subaward information was submitted timely. Additionally, personnel responsible for grant administration were not sufficiently aware of the applicable FFATA reporting requirements Implementation dates: July 31, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
Finding 2025-009: Reporting – Semi-Annual Performance Report Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will establish a formal review and approval procedure requiring independent supervisory review of SAFER performan...
Finding 2025-009: Reporting – Semi-Annual Performance Report Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will establish a formal review and approval procedure requiring independent supervisory review of SAFER performance reports prior to submission. Implementation dates: July 31, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
Finding 2025-008: Special Tests and Provisions – Revenue Diversion Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will draft and maintain a formal written policy or documented procedure to ensure airport-generated revenue...
Finding 2025-008: Special Tests and Provisions – Revenue Diversion Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will draft and maintain a formal written policy or documented procedure to ensure airport-generated revenues are used only for allowable airport-related purposes in accordance with federal revenue-use restrictions. Implementation dates: July 31, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
Finding 2025-007: Reporting – FAA Form 5100-127 Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will enhance its existing reconciliation and review procedures by requiring documented tie-outs of FAA Form 5100-127 amounts t...
Finding 2025-007: Reporting – FAA Form 5100-127 Airport Improvement Program View of responsible officials: The City agrees with the finding. Corrective action plan: The City will enhance its existing reconciliation and review procedures by requiring documented tie-outs of FAA Form 5100-127 amounts to the general ledger, retention of supporting documentation for all reported amounts, and evidence of supervisory review prior to submission. Implementation dates: September 30, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
The Organization has been working on improving controls over interim financial reports including review of related reconciliations and financial statements by the board and management since this finding was originally reported. Improvements have been made but continuing work is being done to complet...
The Organization has been working on improving controls over interim financial reports including review of related reconciliations and financial statements by the board and management since this finding was originally reported. Improvements have been made but continuing work is being done to complete this. These additional controls are expected to be fully implemented for the fiscal year ending September 30, 2026.
Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approv...
Management has issued written policies and required training of all employees that handle financial transactions and will continually evaluate processes to find ways to segregate duties where possible. Management and the board of directors will continue to oversee operations closely requiring approvals for all transactions.
Audit Firm: CohnReznick Period Covered by Audit October 1, 2024 - September 30, 2025 Corrective Action Plan Prepared By: Name: Nancy Thomas Position Chief Financial Officer and Executive Vice President Telephone Number: 336-917-6066 Finding No. 2025-002; Eligibility - Material Weakness PUBLIC HOUSIN...
Audit Firm: CohnReznick Period Covered by Audit October 1, 2024 - September 30, 2025 Corrective Action Plan Prepared By: Name: Nancy Thomas Position Chief Financial Officer and Executive Vice President Telephone Number: 336-917-6066 Finding No. 2025-002; Eligibility - Material Weakness PUBLIC HOUSING Name of Federal Agency: Department of Housing and Urban Development Federal Program Name: Public Housing Operating Fund Assistance Listing Number: 14.850 Federal Award Identification Number and Year: NC012-00000325D; NC012-00000625D; NC012-00000825D; NC012-00000925D; NC012-00001225D; NC012-00002125D; NC012-00002225D; NC012-00003025D; NC012-00003125D; NC012-00003225D; NC012-00034325D; NC012-00003525D; NC012-00003625D; NC012-00003725D; NC012-00003825D; NC012-00004025D; NC012-00004125D Criteria: In accordance with Uniform Guidance, internal controls are required to be in place to ensure compliance with federal requirements and to maintain complete and accurate participant files as noted in 24 CFR 5.233. Condition and Context: Our testing of 40 participant files noted the following: • No electronic income verification was done within the required time period for 20 of 40 participant selections. Effect or Potential Effect: The Housing Authority of the City of Winston-Salem (“ASPIRE”) is not in compliance with federal requirements regarding Eligibility. Cause: Tenant lease files were not maintained, and tenant eligibility was not determined in accordance with Uniform Guidance. Questioned Costs: Unknown Identification as a Repeat Finding: This finding is not a repeat finding. Recommendation: ASPIRE should maintain complete and accurate participant files to ensure compliance with federal requirements. Views of Responsible Official(s) and Planned Corrective Actions: ASPIRE will improve internal controls to maintain complete and accurate participant files to ensure compliance with federal requirements. CORRECTIVE ACTION TO BE TAKEN: 1. No electronic income verification was done within the required time period for 20 of 40 participant selections. Response: Electronic Income Verification (EIV) reports were not completed within the required timeframe for 20 of the 40 public housing tenant files selected for review. The delays were the result of staff oversight and a lack of adequate monitoring to ensure EIV reviews were completed and documented within HUD-required timeframes. To address this issue, Public Housing staff have been retrained on EIV requirements, including HUD-required review and documentation deadlines. Management has reinforced expectations regarding the timely completion of EIV reviews and implemented additional monitoring procedures to ensure compliance. The Assistant Director has also established a tracking system and compliance calendar to assist staff in monitoring and completing required EIV reviews within the prescribed deadlines. In addition, the Assistant Director of Compliance conducts monthly reviews of a random sample of tenant files to verify compliance with EIV requirements and identify any deficiencies including the 120-day move in EIV reports and requires corrective action. Any findings are addressed through staff coaching, corrective action, and additional training as necessary. These measures are intended to strengthen internal controls, improve compliance monitoring, and ensure EIV reviews are completed in accordance with HUD requirements.
2025-001 – Management Review and Approval Auditor Description of Condition and Effect: During our testing of 40 payroll disbursements, we noted certain internal control processes were not consistently performed or documented. This included an instance identified during a payroll conversion in which ...
2025-001 – Management Review and Approval Auditor Description of Condition and Effect: During our testing of 40 payroll disbursements, we noted certain internal control processes were not consistently performed or documented. This included an instance identified during a payroll conversion in which an individual was compensated using an incorrect pay rate. In addition, timesheet review and approval procedures were informal in nature and not consistently documented, including 30 out of 40 instances where timesheets were approved through verbal communication and where there was no evidence of independent review for certain personnel. As a result, there is an increased risk that payroll transactions may be processed using inaccurate rates or unsupported hours and that errors or irregularities may not be detected in a timely manner. Additionally, the absence of documented review reduces accountability and transparency over payroll activities. Auditor Recommendation: We recommend that the Commission enhance formal procedures to ensure payroll reports are reviewed for accuracy of pay rates and hours prior to processing and that all timesheets are subject to documented review and approval, including independent review where appropriate. Corrective Action: Management will develop and implement formal procedures to strengthen controls over payroll processing and timesheet approvals, including requiring documented evidence of review and ensuring independent oversight where appropriate Responsible Person: Jim Snell Executive Director, Sydney Sheaks Finance Manager Anticipated Completion Date: 9/30/2026
2025-002 – Journal Entries and Disbursement Approval Controls Auditors Description of Condition and Effect: During our testing of journal entries and accounts payable disbursements, we noted certain internal control processes were not consistently performed or documented. This included 5 out of 40 i...
2025-002 – Journal Entries and Disbursement Approval Controls Auditors Description of Condition and Effect: During our testing of journal entries and accounts payable disbursements, we noted certain internal control processes were not consistently performed or documented. This included 5 out of 40 instances where supporting documentation was not readily available for journal entries and 19 out of 40 instances where invoices were not consistently reviewed and approved by an individual independent of the preparer in accordance with Commission policy. These conditions are attributable to insufficiently formalized procedures and enforcement of controls governing journal entry support and disbursement review and approval. As a result, there is an increased risk that unsupported or inappropriate transactions could be recorded and that disbursements may be processed without proper authorization, increasing the risk of errors or irregularities not being detected in a timely manner. Auditor Recommendation: We recommend that the Commission strengthen procedures to ensure that all journal entries are supported by appropriate documentation and that all disbursements are reviewed and approved in accordance with established policies, with evidence of such review maintained. Corrective Action: Management will implement procedures to ensure all journal entries are adequately supported and that invoice approvals are documented in accordance with policy requirements. Responsible Person: Jim Snell Executive Director, Sydney Sheaks Finance Manager Anticipated Completion Date: 9/30/2026
In its 2025 Compliance Report, auditors made the following finding: Finding 2025‐001: Reporting – Significant deficiency in internal controls over compliance and compliance finding. Criteria: Under this grant program, the Foundation is required to complete semi‐annual performance reports in the Disa...
In its 2025 Compliance Report, auditors made the following finding: Finding 2025‐001: Reporting – Significant deficiency in internal controls over compliance and compliance finding. Criteria: Under this grant program, the Foundation is required to complete semi‐annual performance reports in the Disaster Recovery Grant Reporting (DRGR) system. Condition: During reporting testing, it was noted that the Foundation had not completed or submitted the required performance reports during the year. Cause: The Foundation didn’t implement an effective control for ensuring the required reporting under the grant was completed and submitted timely. Effect: Internal control was not properly designed to identify the required reporting and prevent noncompliance, and the Foundation was not in compliance with the reporting requirement. Recommendation: The Foundation should implement internal controls over the reporting process that ensures the required reporting is submitted in a timely manner. In addition, the Foundation should ensure grant agreements are reviewed in detail so no required reporting is overlooked. In response, Southern Gateway Public Green Foundation commits to the following Corrective Action Plan:  Remedy: In order to remedy this violation, staff will take immediate action to file missing semiannual reports in cooperation with general contractor.  Responsibility for Implementing Remedy: Reports will be filed by Anne Hagan, VP of Strategic Initiatives.  Verification of Remedy: Reports will be reviewed by April Allen, President and CEO, and filing of reports will also be confirmed by April Allen, President and CEO  Deadline for Remedy: As soon as possible but no later than 7/31/26.  Consequences in the event remedy is not undertaken: Failure to file reports could result in request for reimbursement of grant revenue.  Training to Prevent future violations: Reporting requirements and grant agreements will be reviewed by Anne Hagan.  Statement on Consequences of Repeated Violations: If future reports are late or missed, already reimbursed grant payments may have to be repaid and SGPGF may not be eligible for future grant payments.
Finding ref number: 2025-002 Finding caption: The Housing Authority did not have adequate internal controls for ensuring compliance with Housing Quality Standard inspection requirements. Name, address, and telephone of Housing Authority contact person: Wendy Westby 600 Park Avenue Bremerton, WA 9833...
Finding ref number: 2025-002 Finding caption: The Housing Authority did not have adequate internal controls for ensuring compliance with Housing Quality Standard inspection requirements. Name, address, and telephone of Housing Authority contact person: Wendy Westby 600 Park Avenue Bremerton, WA 98337 (360) 616-7111 Corrective action the auditee plans to take in response to the finding: BHA agrees with the finding. BHA acknowledges that certain biennial HQS inspections were not completed within required timeframes due to a Yardi notification and scheduling issue, staffing limitations, and reliance on outdated guidance when determining inspection deadlines. BHA has taken and will continue to take corrective action to strengthen internal controls over HQS inspection scheduling, monitoring, and completion. Corrective actions include resolving the primary Yardi scheduling issue, completing additional system refinements and testing, updating procedures for determining biennial inspection due dates, training staff on current HQS inspection requirements and BHA policy, hiring an additional Housing Inspector I, using an additional contract inspector, and using temporary administrative support to assist with inspection scheduling and communication. During fiscal year 2026, BHA will use manual monitoring and quality-control supervisory review to track upcoming, completed, and overdue inspections while the backlog is being cleared. BHA will review inspection reports regularly to monitor progress and ensure inspections are scheduled and completed at least biennially in accordance with federal requirements and BHA policy. Anticipated date to complete the corrective action: BHA expects to complete the inspection backlog and have inspections current by September 30, 2026. BHA expects to return to normal inspection operations effective October 1, 2026.
SCEC contracts with a third-party payroll provider to process our payroll. Upon discovery of this error, we reviewed all pay periods again, but found no other error regarding sick time overpayment, or any other time paid incorrectly. The payroll provider had merged companies in a prior year and had ...
SCEC contracts with a third-party payroll provider to process our payroll. Upon discovery of this error, we reviewed all pay periods again, but found no other error regarding sick time overpayment, or any other time paid incorrectly. The payroll provider had merged companies in a prior year and had several system updates that caused this error. SCEC had other issues with this provider’s system. SCEC cancelled our contract with this payroll provider and contracted with a new payroll provider by the end of the 2025 fiscal year. Payroll is reviewed extensively before it is processed to ensure staff are being paid at their correct rates and other elements of payroll are correct.
Finding 2025-005: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: December 31, 2026 Recommendation: It was recommended Sessions Village 202 implement internal controls to ensure that the audited financial...
Finding 2025-005: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: December 31, 2026 Recommendation: It was recommended Sessions Village 202 implement internal controls to ensure that the audited financial statements are filed in accordance with the regulatory agreement. Action Taken: On February 8, 2025, the audit was submitted to HUD through REAC. The Executive Director/Administrator and Accountant at the management agent will review the process and procedures in place for the audit, and implement internal controls to ensure that the audited financial statements are filed in accordance with the regulatory agreement going forward.
Finding 2025-002: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: November 13, 2025 Recommendation: It was recommended Sessions Village 202 deposit the underfunded amount into the account. In addition, it...
Finding 2025-002: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: November 13, 2025 Recommendation: It was recommended Sessions Village 202 deposit the underfunded amount into the account. In addition, it was recommended management of Sessions Village 202 review their internal controls over the reserve for replacements deposit process with the necessary individuals involved in the process to ensure the implementation of general ledger account coding on cash disbursements is consistently performed going forward. In addition, it was recommended management review their monitoring controls to ensure a secondary review is conducted at least quarterly to ensure the appropriate deposits were made. Action Taken: In November 13, 2025, the amount was deposited into the account. The Executive Director/Administrator and Accountant at the management agent reviewed the process and procedures in place with the new accounts payable clerk, and implemented controls to ensure the appropriate deposits are made going forward.
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
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