Corrective Action Plans

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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
New automated financial systems have been implemented to reduce error, and management has added an additional review step for all federal reimbursement requests to verify that payroll and fringe benefit costs are accurately calculated and allocated before submission. Reimbursement requests have and ...
New automated financial systems have been implemented to reduce error, and management has added an additional review step for all federal reimbursement requests to verify that payroll and fringe benefit costs are accurately calculated and allocated before submission. Reimbursement requests have and will be reconciled to payroll reports, time records, and allocation schedules to ensure costs are not duplicated. Staff responsible for grant financial reporting have been reminded of the required review procedures, and the Finance and/or Executive Director will perform a secondary review of all reimbursement requests. These measures are intended to prevent duplicate charges and ensure compliance with federal allowable cost requirements.
2025-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed or Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. The Authority is now drawing down its CFP and is not usin...
2025-001 – ALN 14.850 – Public Housing Operating Fund – Activities Allowed or Unallowed Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. The Authority is now drawing down its CFP and is not using operating funds for CFP activities. Person Responsible for Correction of Finding: Wanda Allen, Executive Director Anticipated Completion Date: September 30, 2026
MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS – ALL FEDERAL PROGRAMS 2025-001 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the City of South St. Paul, Minnesota (the City) prepare appropriate annual financial stat...
MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS – ALL FEDERAL PROGRAMS 2025-001 Reporting Compliance Requirement Finding Summary 2 CFR § 200.510 requires that the City of South St. Paul, Minnesota (the City) prepare appropriate annual financial statements, including the Schedule of Expenditures of Federal Awards (SEFA), which must include the total federal awards expended as determined in accordance with 2 CFR § 200.502. During our audit, we noted the City did not have sufficient controls in place to ensure the accurate preparation of the SEFA in compliance with this requirement. The City’s SEFA for fiscal 2025 was overstated by $749,656 in federal expenditures, due to the inclusion of costs that were incurred in the previous fiscal year. Corrective Action Plan Actions Planned – The City has implemented new processes and procedures in 2026 which address this internal control finding to comply with the Uniform Guidance in the future. Finance department personnel will work with federal grant coordinators to assure that federal expenditures are accurately reported on the SEFA for all federal programs. Official Responsible – Clara Hilger, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Clara Hilger, will ensure the new process and procedures implemented in this area ensure future compliance with the Uniform Guidance.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION – PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION – HIGHWAY PLANNING AND CONSTRUCTION FEDERAL ALN 20.205 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements F...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION – PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION – HIGHWAY PLANNING AND CONSTRUCTION FEDERAL ALN 20.205 2025-002 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 and 2 CFR § 200.318-327 requires the City to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the Highway Planning and Construction federal program. During our audit, we noted the City did not have sufficient controls in place within this program to ensure compliance with federal requirements related to assuring that the City was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City has implemented new processes and procedures in 2026 which address this internal control finding to ensure compliance with the Uniform Guidance in the future. The procedures will include steps to assure that City personnel are following the requirements of the Uniform Guidance related to suspension and debarment, including maintaining appropriate documentation. Official Responsible – Clara Hilger, Finance Director. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Clara Hilger, will oversee the evaluation of this process, and the implementation of any procedural changes deemed necessary to ensure the City’s control procedures over suspension and debarment are performed and adequately documented in the future.
Finding 2025-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part ...
Finding 2025-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
Recommendation: The cost of additional personnel to properly segregate accounting and financial responsibilities would appear to outweigh the benefits received. However, the management and Board of Commissioner should constantly be aware of the possibility that errors or fraud could occur and contin...
Recommendation: The cost of additional personnel to properly segregate accounting and financial responsibilities would appear to outweigh the benefits received. However, the management and Board of Commissioner should constantly be aware of the possibility that errors or fraud could occur and continue current practices mitigating these possibilities and examine and implement other mitigating controls when appropriate. Action Taken: The County has assessed the benefits and costs associated with proper segregation of duties and has determined that costs would outweigh the benefits received. The County understands the inherent risks associated with improper segregation of accounting functions. Management has communicated the need for transactions to be well supported by documentation as well as seeking appropriate authorization when appropriate. The County requires reporting to the Board of Commissioner for all disbursements to ensure transactions are proper and potential errors and irregularities are identified on a timely basis. The County will continue to review accounting procedures and processes to further mitigate this internal control deficiency whenever possible and feasible.
We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements
We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Impl...
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Shenae Draughn, President.
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2...
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2025 The findings from the September 30, 2025 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2025-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Alice Marie, CFO 507-373-2040 Anticipated Completion Date: Ongoing
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to...
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to the DOR Contract Administrator and retained electronically with evidence of timely submission. Documentation may include emailed reports, delivery confirmations, or other records demonstrating compliance with reporting deadlines. Management will maintain a centralized reporting file and review quarterly reporting requirements to ensure all required reports are submitted and retained in accordance with grant requirements. Although program activity associated with the Device Lending and Demonstration Centers and Reuse Centers is currently being procured through a competitive RFP process, CFILC will submit all required quarterly reports beginning with the next reporting cycle, including reports indicating limited or no activity when applicable. Contact Person: M. Lisa Hayes, Executive Director Projected Completion Date: July 30, 2026
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Huma...
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Human Assets department will coordinate with its payroll processing vendor (UKG) to: - Review payroll configuration settings related to bonus payments. - Implement controls to ensure bonus compensation is excluded from grant-related labor distributions. 3. Monitoring and Oversight Reinforcement The VP of Government Grant Compliance will reinforce internal review procedures by: - Providing targeted guidance to the Investor Relations Grant Compliance and Fiscal teams on identifying anomalies in Wage and Hour Reports, including unusual or inflated hourly rates
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
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