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Corrective Action Plans

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Finding 1222697 (2022-005)
Material Weakness 2022
Veterans Transition Center of California
CA
Subrecipient Monitoring Allowable Costs / Cost Principles Cash Management § 200.307
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be ...
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA5, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years, including the establishment of policies and procedures to ensure that program income is tracked by contract and expended in accordance with applicable federal requirements.
View Audit 406305
Finding 1222695 (2022-003)
Material Weakness 2022
Veterans Transition Center of California
CA
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.403 § 200.405 § 200.430
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be ...
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA3, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. Unallowable costs will be identified and documented in the Accounting Policies and Procedures Manual and communicated to the Finance Department and the Organization’s employees. The CFO will regularly communicate these requirements to directors and staff through weekly and monthly meetings to ensure a clear understanding of allowable versus unallowable costs. In addition, quarterly budget-to-actual analyses will be prepared and reviewed to monitor expenditure and ensure costs remain within approved budget limitations.
View Audit 406305
Finding 1222694 (2022-002)
Material Weakness 2022
Veterans Transition Center of California
CA
Subrecipient Monitoring Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303
Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fisca...
Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA2, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. CFDA numbers for new federal awards will be identified, along with the applicable compliance requirements in accordance with the OMB Compliance Supplement (Matrix of Federal Compliance Requirements). Policies and procedures will be established for each applicable compliance requirement and will be communicated to employees responsible for monitoring and ensuring compliance.
View Audit 406305
Finding 1222693 (2022-001)
Material Weakness 2022
Veterans Transition Center of California
CA
Reporting Internal Control / Segregation of Duties
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA1, management agrees with the finding. Corrective actions will be ...
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SA1, management agrees with the finding. Corrective actions will be implemented in subsequent fiscal years. ALN numbers and federal expenditures will be tracked by contract and reported on the Schedule of Expenditures of Federal Awards (SEFA) for each fiscal year and reconciled to the general ledger. Separate classes will be utilized to track activity for individual federally funded contracts and grants.
View Audit 406305
Finding 1216696 (2022-004)
Material Weakness 2022
Rhode Island Disaster Medical Assistance Team, Inc.
RI
Reporting Internal Control / Segregation of Duties § 200.512
Strengthen internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implement a detailed closing schedule and tracking process to monitor deadlines, beginning with monthl...
Strengthen internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implement a detailed closing schedule and tracking process to monitor deadlines, beginning with monthly financial close procedures and year-end close preparation by March 31, 2026. Ensure adequate staffing or external support during the financial statement preparation and audit process, including retention of qualified accounting consultant by April 30, 2026. Conduct periodic reviews to confirm compliance with federal Single Audit submission deadlines, with Executive Director oversight of audit progress reports by May 31, 2026. Prioritize completion of outstanding audit reports for fiscal years 2023-2024 with aggressive timeline: 2023 audit by September 30, 2026; 2024 audit by December 31, 2026. Establish year-round audit preparation procedures, including monthly reconciliations, quarterly financial reviews, and ongoing documentation organization to prevent delays.
View Audit 403130
Finding 1216695 (2022-003)
Material Weakness 2022
Rhode Island Disaster Medical Assistance Team, Inc.
RI
Internal Control / Segregation of Duties § 200.334
Strengthen record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implement procedures to maintain institutional knowledge during employee turnover...
Strengthen record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implement procedures to maintain institutional knowledge during employee turnover, including documented policies, cross-training, centralized recordkeeping, and formal transition protocols by March 31, 2026. Consider extending retention periods for documents supporting high-risk federal programs or key internal control activities beyond minimum requirements by April 30, 2026. Establish a centralized electronic filing system with version control and backup procedures for all federal award documentation by May 31, 2026. Create detailed internal control documentation templates and ensure all control activities are evidenced in writing by June 30, 2026.
View Audit 403130
Finding 1216177 (2022-004)
Material Weakness 2022
Mental Health Kokua
HI
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.512
Mental Health Kokua will ensure compliance with the FAC requirement of submitting the Single Audit Package and data collection report no later than 30 days after receipt of the audit. The CFO of Mental Health Kokua will be responsible for ensuring this compliance is met.
Mental Health Kokua will ensure compliance with the FAC requirement of submitting the Single Audit Package and data collection report no later than 30 days after receipt of the audit. The CFO of Mental Health Kokua will be responsible for ensuring this compliance is met.
View Audit 402656
Finding 1216173 (2022-010)
Material Weakness 2022
Virgin Islands Port Authority
VI
Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303
The Authority will retain emails between preparers and reviewers for forms that cannot be signed.
The Authority will retain emails between preparers and reviewers for forms that cannot be signed.
View Audit 402648
Finding 1216172 (2022-009)
Material Weakness 2022
Virgin Islands Port Authority
VI
Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303
The Authority will continue to make progress in meeting required review processes and submission timelines. For the reports where the submission requirement is unclear, the Authority will consult with its federal partner to obtain a determination.
The Authority will continue to make progress in meeting required review processes and submission timelines. For the reports where the submission requirement is unclear, the Authority will consult with its federal partner to obtain a determination.
View Audit 402648
Finding 1216171 (2022-008)
Material Weakness 2022
Virgin Islands Port Authority
VI
Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303
The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filin...
The Director of Engineering will sign reports submitted to the FAA to confirm that the items have been reviewed. The Senior Compliance Officer serves as the recordkeeper for documents filed between the Authority, the FAA, and other institutions, ensuring that the Authority submits the required filings and maintains a working spreadsheet of items sent. In addition, Accounting has implemented a tickler system to remind staff to submit financial reports to Engineering or the grantor.
View Audit 402648
Finding 1216167 (2022-006)
Material Weakness 2022
Virgin Islands Port Authority
VI
Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303
The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.
The Authority will ensure that when a federal report is prepared by Director, it will be reviewed by another Director or member of the management team.
View Audit 402648
Finding 1214370 (2022-006)
Material Weakness 2022
St. Croix Chippewa Housing Authority
CA
Subrecipient Monitoring Material Weakness Internal Control / Segregation of Duties
2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the a...
2022-006 Minutes/Resolutions Material Weakness Recommendation: Written minutes should be prepared for each council meeting along with any approved resolutions/recommendations. The minutes and resolutions should be centrally filed, maintained by the Council’s Secretary, and easily accessible to the auditor. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report.
View Audit 401032
Finding 1214365 (2022-001)
Material Weakness 2022
St. Croix Chippewa Housing Authority
CA
Internal Control / Segregation of Duties Subrecipient Monitoring Significant Deficiency
2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...
2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.
View Audit 401032
Finding 1214251 (2022-002)
Material Weakness 2022
Urban Partnerships Community Development Corporation
TX
Internal Control / Segregation of Duties Subrecipient Monitoring Reporting
This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management ...
This issue was brought on this year due to the quick acceleration of the Organization and Affiliates' activities, while management was in the process of implementing internal control policies and procedures, including the transition of third-party bookkeepers engaged by the Organization. Management will implement proper policies and procedures to ensure the Organization and Affiliates' activities are properly recognized. In addition, management will reconcile the activities of the Organization and Affiliates quarterly against the financial system and ensure activities are recognized properly at year-end.
View Audit 400976
Finding 1213892 (2022-005)
Material Weakness 2022
Town of Livermore Falls
ME
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303
CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-005) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board will take the following actions to address finding 2022-005 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. The Select Board will review this draft at their meeting in January 2024, edits will be made and then it will be sent to legal for final review before adoption. Additionally, Department Heads are required to turn in no later than Thursday by noon, invoices to be paid on that week’s warrant. The Treasurer has been given authority by the Town Manager to contact Department Heads and request that they come to the office weekly to turn in invoices. All invoices must have the appropriate expense code and be signed by the Department Head. Anticipated Completion Date: The processing of invoices for the warrant has been corrected as of December 2023. The Procurement Policy was approved and implemented by the Select Board on January 23, 204.
View Audit 400731
Finding 1213890 (2022-006)
Material Weakness 2022
Town of Livermore Falls
ME
Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303
CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2022-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and is drafting a new Internal Controls Policy that will address this deficiency. The Select Board will review this draft at their meeting in February or March 2024, edits will be made and then it will be sent to legal for final review before adoption. This policy will include sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: It is anticipated that the Internal Controls Policies and Procedures will be approved and adopted by June 2024 by the Select Board. Implementation will be July 1, 2025 with the new chart of accounts.
View Audit 400731
Finding 1211144 (2022-005)
Material Weakness 2022
Carestl Health
MO
Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Procurement, Suspension & Debarment § 200.303 § 200.328 § 200.329
Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...
Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.
View Audit 400353
Finding 1211143 (2022-004)
Material Weakness 2022
Carestl Health
MO
Cash Management Internal Control / Segregation of Duties § 200.305
We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to e...
We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to ensure funds are drawn and disbursed promptly ▪ Develop and enforce policies consistent with the Prompt Payment Act, including defined payment timelines ▪ Perform periodic reviews of cash flow and payment cycles to ensure compliance ▪ Assign oversight responsibility to ensure timely processing and documentation of payments Strengthening cash management practices will improve compliance with federal requirements and enhance overall financial control.
View Audit 400353
Finding 1211141 (2022-002)
Material Weakness 2022
Carestl Health
MO
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Eligibility § 200.302 § 200.303
Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Per...
Recommendation We recommend that management: ▪ Implement formal procedures to ensure complete documentation of all program activities ▪ Maintain records demonstrating that activities are authorized and aligned with program objectives ▪ Establish centralized recordkeeping and retention policies ▪ Perform ongoing monitoring and review of program activities ▪ Train staff on federal compliance requirements and documentation expectations
View Audit 400353
Finding 1211140 (2022-001)
Material Weakness 2022
Carestl Health
MO
Internal Control / Segregation of Duties Cash Management Material Weakness
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.
View Audit 400353
Finding 1211101 (2022-003)
Material Weakness 2022
El Paso Alliance, Inc.
TX
Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.212 § 200.318
U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the...
U.S Department of Health and Human Services 2022-003 - Suspension and Debarment - Assistance Listing No. 93.243 Recommendation: We recommend the Organization retain documentation that SAM.gov was used to verify that vendors are not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will update procurement procedures to require documented SAM.gov verification for vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Ben Bass, CEO Planned completion date for corrective action plan: May 2026
View Audit 400343
Finding 1211100 (2022-002)
Material Weakness 2022
El Paso Alliance, Inc.
TX
Procurement, Suspension & Debarment Internal Control / Segregation of Duties § 200.320
U.S Department of Health and Human Services 2022-002 - Procurement - Assistance Listing No. 93.243 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement util...
U.S Department of Health and Human Services 2022-002 - Procurement - Assistance Listing No. 93.243 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/services and then utilizing an approved vendors list. Explanation of disagreement with the audit finding: There is no disagreement with the audit finding. Action take in response to finding: Management will ensure the Organization follows the Procurement policy for any future acquistions over the threshold of $15,000 enumerated in the policy and obtain bids and document the selection process. Name(s) of the contact person(s) responsible for corrective action: Manuel Burrola, Accountant Planned completion date for corrective action plan: May 2026
View Audit 400343
Finding 1208815 (2022-004)
Material Weakness 2022
Sheridan Community Hospital
MI
Reporting Internal Control / Segregation of Duties § 200.512
In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of ...
In FY 2020 through FY 2022, the hospital was going through a transition due to financial constraints, hence several internal operations were affected. Even though we have internal policy to schedule Annual Financial audits 90 days after close of every Fiscal year, we fell behind and for a period of two years were unable to schedule annual financial audits timely. At the time when the FY 2022 single Audit was due, we had not even completed our FY2020 Audit hence the delay. Currently, the hospital is working toward getting caught up with the annual financial audits to get back on track with our policy. We just completed FY 2023 and are working on FY 2024. We hope to be done with FY 2025 and FY 2026 in the Fall of calendar year 2026.
View Audit 399700
Finding 1205802 (2022-001)
Material Weakness 2022
Reimagining Justice, Inc.
NJ
Reporting Internal Control / Segregation of Duties § 200.512
Reimagining Justice Inc. Corrective Action Plan Federal Single Audit Finding Auditors’ Recommendation Reimagining Justice Inc. should ensure that financial records, reconciliations, and reporting documentation are completed in a timely manner so that the Single Audit can be performed and finalized o...
Reimagining Justice Inc. Corrective Action Plan Federal Single Audit Finding Auditors’ Recommendation Reimagining Justice Inc. should ensure that financial records, reconciliations, and reporting documentation are completed in a timely manner so that the Single Audit can be performed and finalized on schedule and required reporting can be submitted before applicable deadlines. Corrective Action Plan Management acknowledges that the Single Audit reporting package and Data Collection Forms for the 2022 audit were not submitted by the required deadlines. To correct this issue and prevent recurrence, the organization has implemented the following actions:• Enhanced monitoring and tracking• Hired an internal accountant to strengthen financial oversight and reconciliation processes.• Assignment of oversight responsibility.• Staff Training.• Formalized workflows and fiscal coordination protocols with St. Joseph’s University Medical Center (fiscal sponsor) including submission timelines, approval processes, and reporting requirements.• Established external filing deadlines. Anticipated Completion Date These corrective actions were initiated in autumn 2025, and will be fully in place for the audit of the fiscal year ended September 30, 2025, ensuring timely submission by June 30, 2026. 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: March 17, 2026
View Audit 397546
Finding 1205534 (2022-003)
Material Weakness 2022
Kanawha Valley Collective Inc.
WV
Reporting Internal Control / Segregation of Duties § 200.512
Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Antici...
Planned Corrective Action: The Kanawha Valley Collective, Inc. will develop internal policies and procedures designed to ensure a timely annual financial statement closing which will allow the required single audit to be completed in a timelier manner. Name of Contact Person: Traci Strickland Anticipated completion date: June 30, 2026
View Audit 397204
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