Corrective Action Plans

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2025-002 UNAUTHORIZED WITHDRAWAL FROM REPLACEMENT RESERVE Supportive Housing for the Elderly – Assistance Listing Number 14.155 Recommendation: CLA recommends that processes and procedures be evaluated to strengthen internal control over compliance relating to HUD-restricted accounts. Explanation of...
2025-002 UNAUTHORIZED WITHDRAWAL FROM REPLACEMENT RESERVE Supportive Housing for the Elderly – Assistance Listing Number 14.155 Recommendation: CLA recommends that processes and procedures be evaluated to strengthen internal control over compliance relating to HUD-restricted accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions Taken: Management will review compliance requirements for HUD programs related to replacement reserve withdrawals to ensure they are followed in the future. Name of the contact person(s) responsible for corrective action: Lindsey Beyer, Administrator Planned completion date for corrective action plan: September 2026
Management will review and improve controls in the patient intake process to ensure that information necessary to document sliding fee discount program eligibility is being obtained from patients and retained as determined necessary to meet the requirements health centers program.Person(s) Responsib...
Management will review and improve controls in the patient intake process to ensure that information necessary to document sliding fee discount program eligibility is being obtained from patients and retained as determined necessary to meet the requirements health centers program.Person(s) Responsible: Katrina King, CFO Timing for Implementation: December 31, 2026
Findings Relating to Financials Statement: Finding 2025-002 – Late Filing SUGGESTED CORRECTIVE ACTION PLAN ON LATE FILING Planned Corrective Actions Management will implement a formal Single Audit filing calendar that identifies all statutory deadlines for Federal Single Audit (FAC) and Florida Sing...
Findings Relating to Financials Statement: Finding 2025-002 – Late Filing SUGGESTED CORRECTIVE ACTION PLAN ON LATE FILING Planned Corrective Actions Management will implement a formal Single Audit filing calendar that identifies all statutory deadlines for Federal Single Audit (FAC) and Florida Single Audit submissions, including interim milestones for close, audit fieldwork, report issuance, and filing. The Controller will be assigned to oversee audit coordination, monitor progress against deadlines, and ensure timely submission of all required reporting packages and certifications. Management will implement a submission checklist to verify completeness of the reporting packages prior to submission and will retain documentation evidencing timely filing with both the Federal Audit Clearinghouse and the Florida Auditor General. Management will accelerate year‑end close and audit preparation to allow sufficient time for review and filing prior to statutory deadlines. In addition to the audit filing status being periodically communicated to Executive Leadership Team, the Chair of the Audit Committee and the Chair of the Finance Committee, the calendar will also be shared going forward to enhance governance to support oversight and accountability. Anticipated Completion Date: 09/15/2026 Responsible Person/Title: April Dobes, CFO Management Statement: Management believes these actions will prevent recurrence and ensure timely filing of future Federal and Florida Single Audits.
Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of C...
Material Weakness in Internal Control over Compliance 10.558 – Child and Adult Care Food Program Commonwealth of Pennsylvania, Department of Education Contract Number: 359-46-477-8 Condition: Based on the Commonwealth of Pennsylvania, Office of the Budget, Bureau of Audits (Commonwealth) review of CBS Food Program's financial accounting system, it was noted that the Food Program utilizes QuickBooks software for their accounting system. Based on inquiry with CBS Food Program management, we determined internal controls connected with their QuickBooks accounting software were insufficient in the following areas: - User Access Management: Formal written policies or procedures have not been developed and implemented related to access authorization, access monitoring, and removal of system access. Additionally, certain functions are not properly segregated as users have access to perform both input and authorization of transactions. - Input Management: Formal written policies or procedures to ensure information input into QuickBooks is appropriate and accurate have not been developed and implemented. - Change Control Management: A formal written change management policy for QuickBooks Accounting System has not been developed and implemented including requirements that system security updates are implemented timely. - Backup and Recovery: A formal written policy for regular backup and recovery testing has not been developed and implemented. Recommendation: We recommend that CBS Food Program develop and implement comprehensive written internal control policies and procedures connected with their QuickBooks Accounting System. This should include: - Development and utilization of an Accounting Manual which includes an outline of CBS Food Program's accounting rules, procedures, and guidelines. - Access control policies and procedures to ensure that user access to QuickBooks is appropriate, regularly reviewed and promptly revoked upon termination or when otherwise merited. - A formal written change management policy for QuickBooks should be developed and implemented including requirements that systems security updates are implemented timely. - A disaster recovery plan and procedures to perform periodic testing to ensure that plans are functional and mitigate the risk of extended downtime. This process should also include regular review of backup records to ensure they are appropriately created and maintained. Repeat Finding: Yes Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. Action taken in response to finding: CBS Food Program will review all users of its new QuickBooks Online platform, document each user, and assign access based on job responsibilities and established best practices. Written procedures will address the timely removal or reassignment of access following terminations or role changes and will be incorporated into the applicable human resources checklists. CBS Food Program will also coordinate with QuickBooks support to identify security updates that may affect financial processes and establish procedures and defined timelines for implementing those updates. In addition, CBS Food Program will develop a disaster recovery plan and procedures for testing backups at least annually, or every 180 days if deemed appropriate, to confirm that backup records are created accurately and maintained properly. Community Benefit Solutions will also develop an accounting manual documenting standard practices for all accounting functions. Planned completion date for corrective action plan: June 30, 2026
Evaluate the outstanding checks and deposits and close them out.
Evaluate the outstanding checks and deposits and close them out.
Finding 1239802 (2025-007)
Material Weakness 2025
FINDING 2025-007 Finding Subject: COVID-19 - State and Local Fiscal Recovery Funds - Subrecipient Monitoring Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the fi...
FINDING 2025-007 Finding Subject: COVID-19 - State and Local Fiscal Recovery Funds - Subrecipient Monitoring Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The identified material weakness of SUBRECECIPIENT MONITORING has been recognized, confirmed, and accepted. The form of reporting contains language that formed differing thoughts as the County documented the Subrecipient report to the County Commissioners via a Public meeting, however, SBOA’s evaluation was to strengthen internal controls to ensure financial and performance reports are timely and accurate complying with the requirement of the Treasury. All Subrecipient awards from the Dept. of Treasury have been distributed in 2025, however, the Corrective Action Plan by the County is to ensure Compliance with each and every detail of Federal Awards in the future, by obtaining necessary subrecipient financial and/or performance reports and including a secondary review of the documents by someone other than the person who obtained the reports. Anticipated Completion Date: The anticipated completion date of the Corrective Action Plan identified above will occur September 30, 2026 reporting as the exposure of this finding-material weakness, is being addressed.
Finding 1239801 (2025-006)
Material Weakness 2025
FINDING 2025-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the find...
FINDING 2025-006 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The corrective action plan provided in FY 2025 was enacted and reviews did occur as committed to in FY 2024 Audit review and Corrective Action Plan. As stated in 2025 Corrective Action Plan for Audit Year 2024, the review was not effective in detecting and correcting previously enacted errors or misreported values in submitted reports. These previous reports have been “locked” from modifications and cannot be amended in future periods. The Commissioners did appoint the Chief Operations Officer and Chief Financial Officer to review future reporting for compliance. This move became effective in August 2025. The internal controls process has been strengthened with both positions collaborating on and reviewing for accuracy and required timely reporting. The final step of the internal control process is to have the President of the Commissioners review and submit the final quarterly reports. The Quarter III & IV FY 2025 is identified in the finding with 3 project errors $21,693. The CAUSE as identified on the Audit Report states “The County’s oversight process for filing the P&E reports did not detect errors. The errors were the result of including expenditures from the incorrect time periods.” The strengthened internal controls (The Chief Operations Officer and Chief Financial Officer will independently review the reporting and documentation and each will sign off on signifying their review and approval of submissions) are to ensure that all values presented to the Dept of Treasury are accurately reported and vetted with the local County reports thru the County Auditor’s Office. The P&E reports are reflective of the time period of payment, to ensure the Auditor records agree with the Treasury reporting and not timed to the completion/submission of the payment requests. All future efforts will be directed to compliance with the recommendations and requirements of the Treasury reporting. Floyd County agrees with the RECOMMENDATION as provided within the Audit Report – Strengthening the County’s system of internal controls to provide for segregation of duties in the preparation and review of federal reports and providing the Treasury with complete and accurate information for the P&E reports. Anticipated Completion Date: The anticipated completion date of the Corrective Action Plan identified above will occur September 30, 2026 reporting as the exposure of this finding-weakness, is being addressed.
Finding 1239799 (2025-004)
Material Weakness 2025
FINDING 2025-004 Finding Subject: Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corre...
FINDING 2025-004 Finding Subject: Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Stan Heil Contact Phone Number and Email Address: 812-542-0506-sheil@floydcounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corrective Action Plan for this identified material weakness is first to recognize that strengthened internal controls will reduce/eliminate non-compliance submissions. Thereby resulting in potential loss of Federal awards to the County of Floyd. All Highway Planning Construction procurement procedures comply with State Statute. Floyd County will issue Request for Proposals are required and directed by Statute, requirements and deadlines are reviewed by Chief Operations Officer, reviewed by legal counsel and Commissioners, submitted for advertisement, sealed bids are receivedpresented to the Commissioners, opened and recorded in a Commissioner public meeting, taken under review and decisions are announced at a later Commissioner public meeting. Award letters are issued. Compliance to federal award reimbursements are completed and submitted to INDOT for processing. Floyd County has and will continue to comply with all Federal Award compliance requirements and embrace the recommendations of State Board of Accounts Internal Controls review by having the prepared documentation to INDOT reviewed by the Commissioners Chief Financial Officer and signed off on. Moving forward with the strengthened internal controls, the LPA Selection Checklist will be completed by the Chief Operations Officer – reviewed and authorized (signature) by the Chief Financial Officer prior to submission. Anticipated Completion Date: The anticipated completion date of the Corrective Action Plan identified above will occur September 30, 2026 reporting as the exposure of this finding-weakness, is being addressed.
Plan: Implement internal controls in the Department for matching to be updated monthly in order to evaluate matching level. Director of prevention will work with the accounting team to keep records up to date in order for accounting to make appropriate matching JEs as the grant year progresses. Impl...
Plan: Implement internal controls in the Department for matching to be updated monthly in order to evaluate matching level. Director of prevention will work with the accounting team to keep records up to date in order for accounting to make appropriate matching JEs as the grant year progresses. Implementation Date: Beginning of Fiscal Year 27- October 2026 Responsible Party: Director of Prevention will oversee the staff report of Matching for the grant and ensure that these internal controls are taking place and report to the accounting department as necessary.
Plan: Procedures implemented to ensure that all necessary reports for the program are filed in a timely manner. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensur...
Plan: Procedures implemented to ensure that all necessary reports for the program are filed in a timely manner. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure reports are on time.
Plan: Implement a policy to ensure appropriate review by management of program is in place to ensure all grant costs are approved by management and on to higher leadership for final review. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reent...
Plan: Implement a policy to ensure appropriate review by management of program is in place to ensure all grant costs are approved by management and on to higher leadership for final review. Implementation Date: Beginning of Fiscal Year 26- July 1, 2025 Responsible Party: Melissa Goodman, VP of Reentry Services will oversee the manager of the Work for Success program and ensure that these internal controls are taking place.
Plan: The accounting team will implement processes to review and reconcile investment account quarterly. Implementation Date: Beginning of Fiscal Year 27- July 1, 2026 Responsible Party: Staff accountant will reconcile, and provide reconciliations to Shelby Turner, CFO for review.
Plan: The accounting team will implement processes to review and reconcile investment account quarterly. Implementation Date: Beginning of Fiscal Year 27- July 1, 2026 Responsible Party: Staff accountant will reconcile, and provide reconciliations to Shelby Turner, CFO for review.
Corrective Action Plan Year Ended December 31, 2025 The following is the corrective action plan for Section III - Federal Award Findings and Questioned Costs: Finding 2025-002 Summary of Finding: The USDA requires multiple reports to be submitted each fiscal year. During the current year, certain re...
Corrective Action Plan Year Ended December 31, 2025 The following is the corrective action plan for Section III - Federal Award Findings and Questioned Costs: Finding 2025-002 Summary of Finding: The USDA requires multiple reports to be submitted each fiscal year. During the current year, certain reports were not submitted to the USDA until after the due date. Corrective Action Plan: Effective immediately, the Nursing Home Administrator will maintain a calendar reminder to ensure notifications are sent after the close of each quarter when the required report is due for submission. Contact Person: Caitlin Delbridge, NHA Westward Heights Care Center Administrator
Reporting – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement a policy to record and retain review of all reports, and to retain proof of submission to verify timeliness of submission of required reports. Explanation of disagreement with audit find...
Reporting – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement a policy to record and retain review of all reports, and to retain proof of submission to verify timeliness of submission of required reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies to record and retain review of all reports, and to retain proof of submission to verify timeliness of submission of required reports. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies to retain proof of amounts requested for reimbursement. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
2025-001 Federal Awards Internal Control CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Commission will review policies and procedures to ensure compliance with the Uniform Gui...
2025-001 Federal Awards Internal Control CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Commission will review policies and procedures to ensure compliance with the Uniform Guidance. Official Responsible for Ensuring CAP: Jessica Beyer, Deputy Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: June 30, 2026 Plan to Monitor Completion of CAP: The Board of Directors will be monitoring this corrective action plan. Jessica Beyer Deputy Director
Auditee Response The Commission will review their internal control policies for compliance with HCVP Housing Choice Voucher Program tenants to ensure compliance with the program. Management's Response - The Commission will review their internal control policies for compliance with HCVP Housing Choic...
Auditee Response The Commission will review their internal control policies for compliance with HCVP Housing Choice Voucher Program tenants to ensure compliance with the program. Management's Response - The Commission will review their internal control policies for compliance with HCVP Housing Choice Voucher Program tenants to ensure compliance with the program. Action Plan — The commission's management continues to review and update file deficiencies and has hired an outside firm to assist in this matter. We expect this process to be completed by June 30, 2026.
SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding No.: Compliance and Internal Control over Compliance Findings 2025-001 Level of Effort - Changes in Program Plans - Significant Deficiency in Internal Control over Compliance and Noncompliance Recommendation: We recommend that INPEACE...
SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding No.: Compliance and Internal Control over Compliance Findings 2025-001 Level of Effort - Changes in Program Plans - Significant Deficiency in Internal Control over Compliance and Noncompliance Recommendation: We recommend that INPEACE implement procedures to regularly monitor the level of effort of key personnel against the requirements of each federal award, and to identify changes that require prior written approval from the awarding agency before those changes occur. We also recommend that INPEACE promptly request approval from the U.S. Department of Education for any current changes in level of effort that have not been approved. View of Responsible Officials: INPEACE concurs with the finding. Corrective Action: INPEACE will submit a written request to the U.S. Department of Education to obtain approval for the current change in the Project Director’s level of effort for the Keiki Steps program. Going forward, INPEACE will implement procedures to monitor the level of effort of key personnel against the requirements outlined in each federal award. At the beginning of each grant period, the Finance and Grants/Development departments will review the Grant Award Notification and applicable award terms to identify key personnel and required levels of effort. Any proposed changes to the duties, assignment, or level of effort of key personnel will be reviewed by the appropriate Program Director, CFO, and CPO and/or CEO prior to the change taking effect. The review will determine whether prior written approval from the federal awarding agency is required under the applicable federal regulations and award terms. When required, INPEACE will obtain and document the approval before implementing the change. INPEACE will also incorporate a review of key personnel level of effort into its periodic grant monitoring procedures. Time and effort reports and personnel allocations will be reviewed to identify significant variances from the level of effort required by the award. Any identified variance requiring prior approval will be promptly addressed with the applicable federal awarding agency. These procedures will help ensure that INPEACE remains in compliance with federal award requirements and that changes in key personnel responsibilities or level of effort are properly reviewed, approved, and documented. Contact Person Responsible for Action: Sanoe Marfil, CEO and Marissa Pico, CFO Anticipated Completion Date: October 31, 2026
Finding 1239653 (2025-002)
Material Weakness 2025
Federal Agency Name: Corporation for National and Community Service Federal Financial Assistance Listing #94.012 Program Name: September 11th National Day of Service and Remembrance Grants Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance and Material Noncom...
Federal Agency Name: Corporation for National and Community Service Federal Financial Assistance Listing #94.012 Program Name: September 11th National Day of Service and Remembrance Grants Procurement, Suspension and Debarment Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: The organization’s procurement policy is missing required provisions in accordance with 2 CFR 200.318. For each of the 3 vendors selected for testing there was no documentation retained to support the rationale for the method of procurement. Additionally, the Organization did not retain supporting documentation to substantiate whether consideration was taken whether the vendor was suspended or debarred from doing business with the federal government prior to entering the covered transaction for each of the 3 vendors selected for testing. Corrective Action Plan: Management agrees with the finding and has revised its procurement policies and procedures to strengthen compliance with federal procurement requirements. The organization's Procurement Policy has been updated to incorporate applicable requirements of 2 CFR Part 200, including requirements governing procurement methods, noncompetitive procurements, conflicts of interest, contractor oversight, and suspension and debarment. Management has also implemented a standardized Sole Source Justification and Procurement Record for noncompetitive procurements. The record requires identification of the applicable basis for noncompetitive procurement under 2 CFR §200.320(c), documentation of the programmatic need and procurement rationale, consideration of available alternatives and applicable market research, documentation supporting cost or price reasonableness, suspension and debarment verification when applicable, and required internal approvals. Supporting documentation will be retained with the procurement record. For covered transactions subject to federal suspension and debarment requirements, management will verify the prospective contractor's exclusion status prior to entering into the transaction and retain dated evidence of the verification. Procurement documentation and required compliance reviews will be completed and retained prior to contract execution.
Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871 & 14.879 Noncompliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Defi...
Finding 2025-002 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Federal Assistance Listing Numbers: 14.871 & 14.879 Noncompliance - E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 1,225 units Housing Voucher Cluster units. Of a sample size of twenty-five (25) tenant files, the following information was unavailable for examination at the time of audit: • Original application was missing in one (1) file • Citizenship declaration was missing in one (1) file • HUD-9887 form was missing in one (1) file • Lead based paint forms were missing or not signed by the lessee in eight (8) files • Verification of income and assets was missing in one (1) file Our sample size is statistically valid. Known Questioned Costs: $13,908* *Represents HAP attributable to one (1) tenant file for which the Authority could not demonstrate compliance with eligibility requirements. The questioned costs do not represent amounts determined to be ineligible but rather costs associated with HAP that the Authority could not substantiate since there were no supporting documents on file. Cause: There is a significant deficiency in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster is in non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend that the Authority implement a process whereby Authority personnel are properly trained on tenant recertification processes to ensure compliance with the Uniform Guidance and the compliance supplement. Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Melena Nelson, Director of Finance, will be responsible to implement this corrective action by December 31, 2026.
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2025 Financial Statement Findings: Finding 2025-001 During the audit, we identified deficiencies in internal control over financial reporting related to the Foundation's accounting for its Recovery Housing Programs funding. Specifically, the Fou...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2025 Financial Statement Findings: Finding 2025-001 During the audit, we identified deficiencies in internal control over financial reporting related to the Foundation's accounting for its Recovery Housing Programs funding. Specifically, the Foundation initially recorded federal funding from housing grants received in FY24 and FY25 as revenue rather than as forgivable mortgage liabilities in accordance with the terms of the grant agreements. The Foundation also did not record federal grants receivable for allowable expenditures incurred before year-end that had not yet been requested for reimbursement. Material audit adjustments (proposed by the auditor) were required to reclassify federal funding from revenue to liabilities and to properly record grants receivables. The total proposed/adjustment related to these errors was approximately $1.234 million. Corrective Action Plan: Upon review of the grant amendments and contracts for 29 E. Mill Rd and 1207 McClellan residences, specified federal funding agency of Department of Housing and Urban Development was represented. The amendment identifies the New Jersey Department of Community Affairs as the administering agency, alongside the HUD federal program. This was the first year in which a Single Audit was performed, where the organization had spent $1 million or more in funding for the purpose of establishing new sober living for those dealing with addiction. Going forward, we will work with our Director of Housing to ensure appropriate involvement and communication up front between state representatives of DCA and our internal finance leadership. The goal will be to ensure the organization fully understands its obligations, requirements, and commitments under contract.This will help ensure that the appropriate financial oversight and compliance considerations are addressed throughout the term of the agreement. Finding 2025-002 During the audit, it was noted that the Foundation does not maintain documentary evidence of the review and approval of adjusting and other journal entries. The Foundation's process provides that entries are recorded by the Staff Accountant or Accounting Manager and reviewed by the Controller and/or Chief Financial Officer. While this review is performed, evidence identifying the reviewer, the date of review, and the scope of the review was not retained. Corrective Action Plan: Please be aware that the Hansen Foundation accounting team will create and adopt a journal entry log sheet with corresponding NetSuite Journal Entry audit reports. The log sheet will show who initially reviewed the reports and on what date this was performed. The Accounting Manager and/or Controller will perform initial monthly review and forward to myself for final review. The journal entry log and NetSuite backup reports can then be provided to the Armanino team as part of the year end analysis moving forward. Name of person responsible: Michael Hansen, CFO & Treasurer Anticipated Completion Date: September 30, 2026 DATE: 9/24/2026
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records ar...
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records are reviewed and supported by appropriate documentation. Management should also implement monitoring procedures to verify that participant counts and listings are complete, accurate, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: Sound Generations is updating procedures to strengthen controls over recording participant information, including participant profiles and meal services. Administrative staff will conduct regular site visits to train and monitor site staff and volunteers on these procedures. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2027.
Special Programs for the Aging, Title III, Part C, Nutrition Services Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate pro...
Special Programs for the Aging, Title III, Part C, Nutrition Services Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate processes and controls to ensure program income is recorded correctly for Federal programs, based on the underlying supporting documentation. Management should also continue to reinforce review procedures over program income reporting to help ensure recording errors are detected and corrected on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations is reviewing and revising our control structure using our new software and new staff with the appropriate experience. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: major initiative to be completed in 2027.
Finding 1239546 (2025-003)
Material Weakness 2025
Upmc
PA
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Rya...
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Ryan White, Part D) Condition: Ryan White, Part C and Part D require the use of program income under the additive method, which requires program income earned from a federally funded program is added to the federal award amount and used to further program objectives. Under the method, allowable expenditures of program income are included on the SEFA. UPMC’s SEFA did not include expenditures related to program income, which were allowable. UPMC’s preliminary SEFA did not include these expenditures, which resulted in the incorrect identification of major programs. The SEFA was subsequently corrected. Corrective action plan: UPMC has remediated the control deficiency as of the period ending December 31, 2025, and has appropriately revised its processes and internal controls to expenditures of program income in the SEFA for impacted programs. Completion: September 2026
Finding 2025-006 United States Environmental Protection Agency Federal Financial Assistance Listing #66.458/66.468 Capitalization Grants for Clean Water State Revolving Funds Material Weakness in Internal Control over Compliance Finding Summary: In our testing of procurement, suspension, and debarme...
Finding 2025-006 United States Environmental Protection Agency Federal Financial Assistance Listing #66.458/66.468 Capitalization Grants for Clean Water State Revolving Funds Material Weakness in Internal Control over Compliance Finding Summary: In our testing of procurement, suspension, and debarment it was identified that the City’s written policy did not address the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Sarah Hellekson, City Administrator Corrective Action Plan: Management will establish a written policy that is in compliance with all of the procurement requirements for federal programs as identified in 2 CFR sections 200.318 through 200.326 and maintain adequate supporting documentation and records to document history and methods of procurement and the procedures performed to comply with these CFR sections. Anticipated Completion Date: December 31, 2026
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