Corrective Action Plans

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To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. These advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unawa...
To Whom it May Concern, Orlando Rehabilitation Group, Inc. has a $2.7 million dollar advance on their balance sheet. These advances were made to unaffiliated not-for-profit healthcare organizations. These advances are to be repaid by these organizations. Orlando Rehabilitation Group, Inc., was unaware that such an advance was not permitted to be made. Kane Financial Services was also unaware. The plan to correct it includes the following action steps:  Seeking approval from HUD for the $2.7M advance.  If the advance is not approved, then the repayment will occur by the organizations over an 18 month period beginning in October 2025. It is understood that such advances will not be made going forward without prior HUD approval. The contact information for oversight of the plan is: Susan Shain Executive Vice President of Finance, Kane Financial Services Email: SShain@kanefs.com Phone: 561-223-4161
Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, st...
Management has reviewed the audit finding and acknowledges the allegation related to improper administration of the applicant wait list. The former project manager is no longer with the Project, and management responsibilities have been reassigned. Management plans to review wait list procedures, strengthen oversight and documentation requirements, and implement additional controls to ensure applicants are processed in accordance with established policies and applicable program requirements.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the gr...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has updated the grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. As part of this update management has reassigned responsibilities for various grants to ensure the process is followed.
Federal Award Finding 2025-005 - Material Weakness, Material Non-Compliance - Special Tests and Provisions, Surplus Cash and Distributions to Owners or Affiliates Finding: During the fiscal year ended December 31, 2025, project management did not prepare or document a surplus cash calculation in acc...
Federal Award Finding 2025-005 - Material Weakness, Material Non-Compliance - Special Tests and Provisions, Surplus Cash and Distributions to Owners or Affiliates Finding: During the fiscal year ended December 31, 2025, project management did not prepare or document a surplus cash calculation in accordance with HUD requirements, nor did management implement controls to review, approve, or retain documentation supporting the required calculation. Recommendation: Management should establish and implement formal policies and procedures to ensure that surplus cash is independently calculated in accordance with HUD requirements and the applicable HUD Regulatory Agreement. Such procedures should include preparation of a documented surplus cash calculation at each required reporting period using HUD-prescribed criteria; Independent review and approval of the surplus cash calculation by appropriate management personnel or, where applicable, the court-appointed receiver; and retention of supporting documentation sufficient to demonstrate compliance with HUD restrictions on the use and distribution of project funds. Management should coordinate with the court-appointed receiver and HUD to ensure that surplus cash determinations are performed consistently and in compliance with program requirements going forward. Action Taken: Management acknowledges the finding related to the absence of an independently prepared and documented surplus cash calculation. During the fiscal year ended December 31, 2025, the Organization operated in an environment of financial distress, limited staffing resources, and evolving oversight responsibilities, which contributed to informal and undocumented procedures related to surplus cash determinations. As disclosed in the financial statements, the Organization became subject to a court-appointed receivership. Following the appointment of the receiver, responsibility for financial oversight, including compliance with HUD cash flow and surplus cash requirements, has transitioned to the receiver in coordination with HUD. The receiver and management are evaluating HUD requirements related to surplus cash calculation. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: Not started
Federal Award Finding 2025-004 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Cash Receipts Finding: The Organization maintained cash balances in excess of federally insured limits in financial institutions that did not meet HUD's minimum GNMA rating requirements. Recomm...
Federal Award Finding 2025-004 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Cash Receipts Finding: The Organization maintained cash balances in excess of federally insured limits in financial institutions that did not meet HUD's minimum GNMA rating requirements. Recommendation: The Organization should transfer excess cash balances to financial institutions that meet HUD's GNMA rating requirements or otherwise structure its cash holdings to ensure compliance with federal insurance limits and HUD custodial requirements. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevin's mission in the community. Given Nevins’ current financial struggles, the balance in the bank seldom exceeds the $250,000 threshold. In addition, the receiver established its own account with East West Bank and was in the process of fully transitioning the operating account to East West Bank at the end of the fiscal year. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: Not started
Federal Award Finding 2025-003 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Reserve Fund, Equipment Replacement Reserve Fund, and Special Escrows Finding: During the audit period, Henry C. Nevins Home, Inc. did not make all required deposits into the reserve f...
Federal Award Finding 2025-003 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Reserve Fund, Equipment Replacement Reserve Fund, and Special Escrows Finding: During the audit period, Henry C. Nevins Home, Inc. did not make all required deposits into the reserve for replacement fund in accordance with the terms of the applicable HUD Regulatory Agreement. The required monthly reserve deposits were either not made or were made in amounts less than those required. Recommendation: We recommend that Henry C. Nevins Home, Inc., in coordination with the court-appointed receiver and HUD, establish procedures to ensure that reserve for replacement deposits are made timely and in accordance with the HUD Regulatory Agreement, or that appropriate waivers or modifications are obtained from HUD where compliance is not currently feasible. Action Taken: Management acknowledges the audit finding related to the failure to make required deposits into the reserve for replacement fund in accordance with the HUD Regulatory Agreement. As disclosed in the notes to the financial statements, during the audit period the Organization was subject to a court-appointed receivership effective September 12, 2025 and is in default under its HUD-insured mortgages. As part of the receivership, control over substantially all cash management and financial decision-making activities was assumed by the court-appointed receiver. Management believes that the conditions giving rise to this finding are directly related to liquidity constraints. Given the complexities of the receivership and regulatory environment, a specific timeline for remediation is not able to be determined. As a result of the loan default, the mortgage was assigned to the U.S. Department of Housing and Urban Development. Since the appointment of the Receiver, responsibility for cash management, financial oversight, and debt service planning has transitioned to the Receiver. The Receiver and the Organization are actively evaluating available options to address the loan default which includes marketing the Organization for a sale. Interim corrective actions include enhanced cashflow monitoring, prioritization of expenses required to continue operations, and ongoing communication with HUD regarding the sale process. Management believes that these actions will address the conditions identified and result in the satisfaction of the HUD loan. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: In process
Federal Award Finding 2025-002 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Status and Reserve for Replacements Finding: During the fiscal year, the Organization experienced ongoing financial distress and declining liquidity, which adversely affected its abili...
Federal Award Finding 2025-002 - Material Weakness, Material Noncompliance - Special Tests and Provisions, Mortgage Status and Reserve for Replacements Finding: During the fiscal year, the Organization experienced ongoing financial distress and declining liquidity, which adversely affected its ability to meet financial obligations as they became due. As a result, mortgage payments, including required principal, interest, mortgage insurance premiums, and escrow deposits, were not made in accordance with the loan and regulatory agreements. As of December 31, 2025, delinquent amounts totaled approximately $978 thousand. Recommendation: The Receiver and the Organization should work with HUD to develop and implement a formal workout or resolution plan, including enhanced cash-flow monitoring and debt service planning, to address the loan default and restore compliance with HUD debt service requirements. Action Taken: Management acknowledges the finding related to the failure to make required debt service payments under the HUD Section 232 and Section 241(a) insured mortgage loan agreements. The Organization experienced significant financial distress and constrained liquidity during the fiscal year, which limited its ability to remit required principal, interest, mortgage insurance premium, and escrow payments as they became due. As a result of the loan default, the mortgage was assigned to the U.S. Department of Housing and Urban Development. With the appointment of a Receiver over the Organization, responsibility for cash management, financial oversight, and debt service planning has transitioned to the Receiver. The Receiver is marketing the facility towards a sale in order to satisfy the outstanding loan balance with HUD. Interim corrective actions include enhanced cash-flow monitoring, prioritization of operational suppliers, and ongoing communication with HUD regarding the project's financial condition and sale status. Management believes that these actions will support progress towards stabilization and marketability of the Organization. Responsible Person: Paul Valentine, Receiver Target Completion Date: September 30, 2026 Status: In process
Management has provided a template, which was reviewed and approved by the CFO in April 2026, to the AP Clerk without any roundings of the allocation percentages. Management will review the calculations between January 1 and April 2026 that were used for allocations and will correct any allocations ...
Management has provided a template, which was reviewed and approved by the CFO in April 2026, to the AP Clerk without any roundings of the allocation percentages. Management will review the calculations between January 1 and April 2026 that were used for allocations and will correct any allocations as necessary. Management will ensure the review of expenses include all calculations supporting the expense amounts. All these actions are effective January 1, 2026, and will be managed by the Chief Financial Officer.
Management has implemented enhanced procedures to strengthen the tracking, reconciliation, and reporting of recipient share (matching) contributions associated with federal awards under ALN 14.265, Rural Capacity Building for Community Development and Affordable Housing Grants. Actions include: 1. U...
Management has implemented enhanced procedures to strengthen the tracking, reconciliation, and reporting of recipient share (matching) contributions associated with federal awards under ALN 14.265, Rural Capacity Building for Community Development and Affordable Housing Grants. Actions include: 1. Updating the internal matching contribution tracking system to improve documentation and cumulative tracking of recipient share contributions by grant and reporting period. 2. Establishing a formal reconciliation process between supporting documentation, grant records, and amounts reported on the SF-425 to ensure both federal expenditures and applicable recipient share amounts are accurately reflected. 3. Implementing a pre-submission review checklist and control requiring verification that recipient share (matching) information has been evaluated, reconciled, and included on the SF-425, when applicable, prior to submission to the awarding agency. 4. Requiring supervisory review and approval of the completed SF-425 to confirm completeness, accuracy, and compliance with reporting requirements under 2 CFR §200.328 before certification and filing. 5. Updating internal grant reporting procedures and providing additional guidance to staff responsible for federal financial reporting regarding SF-425 reporting requirements and recipient share reporting expectations. Management will evaluate the SF-425 reports submitted during the audit period to determine whether amendments are necessary. If required, amended SF-425 reports will be submitted to accurately reflect recipient share (matching) contributions. Anticipated Completion Date: The enhanced controls were implemented during 2026 and will be operational for the preparation, review, and certification of the SF-425 for the reporting period ending June 30, 2026, and all future reporting periods. For the reports submitted before June 30, 2026, management will confirm with HUD by July 20 if they would like an amended report. If HUD request one, the amended report will be submitted by August 15. Responsible Contact: Lakia Goodman, Controller (preparation and reconciliation of recipient share reporting) Chris Perry Authorized SF-425 Signer/Certifying Official (final review and certification)
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued prog...
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued progress in strengthening internal controls. The Office of Child Care remains committed to enhancing eligibility determination processes and related internal controls, including ensuring that required eligibility documentation is consistently maintained in the electronic case record. Corrective actions to address the remaining findings, along with the anticipated completion dates, are outlined below. [See Corrective Action Plans for table.] In addition to the corrective actions outlined above, the Department is strengthening supervisory oversight through implementation of routine pre-authorization quality reviews and standardized supervisory monitoring practices. Supervisors will utilize these tools as part of ongoing quality assurance activities to verify that required eligibility documentation is complete prior to authorization, identify recurring error trends, and provide targeted coaching, training, and process improvements to strengthen program integrity and reduce future eligibility errors. Management agrees with the recommendation to evaluate modifications to the existing eligibility system to support eligibility determinations under the CCAP Child Care Staff program. The Department previously assessed the feasibility of modifying RIBridges to accommodate eligibility determinations for the CCAP Child Care Educators and Child Care Staff pilot program. At that time, implementation was not feasible due to competing system development priorities, limited vendor development capacity, and the pilot status of the program. Since the period covered by the audit, the Department has implemented a requirement that participants in the pilot program also apply for the traditional CCAP program. This change has strengthened documentation requirements and helped mitigate risks associated with incomplete eligibility documentation. While these interim measures have improved program administration, the Department recognizes that administering eligibility determinations outside of the primary eligibility system is not a sustainable long-term approach. Accordingly, the Department is reassessing the future administration of the pilot program and evaluating options to incorporate eligibility determinations into RIBridges or, alternatively, to develop the functionality within RISES and integrate it with RIBridges. The Department will determine the most appropriate path forward based on program needs, system capabilities, and available resources to ensure a sustainable and well-controlled eligibility process. Additionally, the Department has strengthened controls over provider payments for the CCAP Child Care Staff pilot program since the audit period. Prior to each payment, the CCAP program team reviews the copayment workbook to identify and resolve discrepancies between pilot program payments and traditional CCAP benefits. In addition, the CCAP Finance team performs a formal review of each payment workbook before payments are processed. The vendor supporting the pilot has also enhanced its payment file process by implementing an additional level of financial review by the project team prior to submission and incorporating safeguards to identify attendance records that may have been previously paid, reducing the risk of duplicate payments. The Department has established procedures to recover identified overpayments, including both one-time recoveries through withholding from future pilot payments, where appropriate, and a formal recoupment process for providers who are no longer participating in the pilot program. These enhanced controls are intended to strengthen payment accuracy and support effective stewardship of program funds. Anticipated Completion Dates: See table above Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
Although the Department remained in compliance with applicable CCDF earmarking requirements, DHS will strengthen its review procedures to ensure that only expenditures applicable to the reporting period are included in quarterly earmarking calculations. These procedures will include verification tha...
Although the Department remained in compliance with applicable CCDF earmarking requirements, DHS will strengthen its review procedures to ensure that only expenditures applicable to the reporting period are included in quarterly earmarking calculations. These procedures will include verification that expenditures are reported within the appropriate reporting period, reconciliation of source expenditure reports to supporting accounting records, documented supervisory review of quarterly earmarking calculations to verify the accuracy, completeness, and appropriateness of expenditures included in the calculation prior to finalization, and formal approval prior to finalization. In addition, DHS will update written procedures and provide training to staff responsible for preparing and reviewing quarterly earmarking calculations to ensure the enhanced controls are consistently applied. The corrective actions implemented in response to Finding 2025-051 will further strengthen the reliability of the expenditure data used in quarterly earmarking calculations and support effective monitoring of compliance with CCDF earmarking requirements. These enhancements will strengthen the reliability of quarterly compliance calculations, improve management oversight, and provide greater assurance that CCDF earmarking requirements continue to be accurately monitored and documented. Anticipated Completion Date: June 30, 2027 Contact Person: Eileen Asselin, Assistant Director, Financial and Contract Management, Department of Human Services eileen.asselin@dhs.ri.gov
The Department is developing standardized written procedures for the preparation, reconciliation, review, and submission of required federal financial reports. The procedures will include reconciliation of reported expenditures to the State accounting system, identification of applicable appropriati...
The Department is developing standardized written procedures for the preparation, reconciliation, review, and submission of required federal financial reports. The procedures will include reconciliation of reported expenditures to the State accounting system, identification of applicable appropriation accounts, reporting thresholds, required documentation, submission deadlines, and documented supervisory review and approval prior to submission. The Department will also review previously identified reporting discrepancies and amend reports, as appropriate, to ensure compliance with federal reporting requirements. Development of these standardized procedures was temporarily delayed due to implementation of the State's Enterprise Resource Planning (ERP) system. DHS anticipates resuming this work during State Fiscal Year 2027 and incorporating lessons learned from the ERP implementation into its reporting procedures to strengthen financial reporting controls. Anticipated Completion Date: June 30, 2027 Contact Person: Ben Quattrucci, Assistant Director, Financial Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov
The Department has worked with the ACF Data Unit and the system vendor to identify the required coding corrections and implement updates consistent with current ACF reporting guidance. System enhancements are underway to address the identified coding issues. The Department will also implement a docu...
The Department has worked with the ACF Data Unit and the system vendor to identify the required coding corrections and implement updates consistent with current ACF reporting guidance. System enhancements are underway to address the identified coding issues. The Department will also implement a documented quality assurance review process for each quarterly ACF-199 submission. Prior to submission, designated staff will validate report data against RIBridges case information, verify compliance with current ACF reporting guidance, and document supervisory review and approval. DHS has incorporated updated ACF reporting guidance into its reporting procedures and will provide training and technical assistance to staff responsible for preparing and reviewing ACF-199 reports to ensure consistent application of federal reporting requirements. The Department will also obtain documentation on a quality assurance review for the quarterly 199 reports. Anticipated Completion Date: Ongoing Contact Person: Nikolaos Petropoulos, Data Analyst III, Office of Performance Analytics & Continuous Improvement, Department of Human Services nikolaos.petropoulos@dhs.ri.gov
The Department updated Policy (218-RICR-20-002) to reflect 45 CFR 205.55, including procedures for using IEVS interfaces and incorporating the resulting information into eligibility determinations. The updated policy will be sent to OMB 7/1/26. Additionally, the updated policy will be discussed at m...
The Department updated Policy (218-RICR-20-002) to reflect 45 CFR 205.55, including procedures for using IEVS interfaces and incorporating the resulting information into eligibility determinations. The updated policy will be sent to OMB 7/1/26. Additionally, the updated policy will be discussed at meetings (Office Hours, Training consultations, and Quarterlies). System interfaces will run on a quarterly basis consistent with the language in 45 CFR §205.55 regarding all applicants. This process is being tracked and prioritized in BRR-141767 which is the ticket number used to communicate with the vendor. In addition, DHS is strengthening operational controls to ensure required IEVS interfaces are executed, reviewed, and acted upon within required federal timeframes. Supervisors will monitor outstanding interface matches and timeliness of case actions as part of routine quality assurance activities to ensure interface information is appropriately evaluated, documented within the electronic case record, and incorporated into eligibility determinations. These actions will be supported by the Department's broader supervisory quality assurance and pre-authorization review initiatives to improve verification accuracy, ensure timely processing of electronic data matches, and reduce future eligibility errors. The Department also notes that a portion of the untimely processing identified during the audit occurred during the RIBridges cybersecurity incident, when staff were operating under documented Business Continuity Plan (BCP) procedures to restore critical operations and address processing backlogs. While these circumstances contributed to delays during the audit period, the Department recognizes the need to strengthen routine controls and has implemented the corrective actions described above. Information security enhancements are further addressed in response to Finding 2025-032. Anticipated Completion Date: Ongoing – The process of posting updated policy and then the public comment period historically takes about 6 months. Disseminating information to staff regarding the policy updates will begin July 2026 and continue until saturation. Contact Person: Donna Rook, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov
FINDINGS 2025-003 Contact person responsible for Corrective Action: Christi McElhaney, City Clerk Treasurer Contact phone number: 260-356-1400 x2016 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City continues to implement controls when contrac...
FINDINGS 2025-003 Contact person responsible for Corrective Action: Christi McElhaney, City Clerk Treasurer Contact phone number: 260-356-1400 x2016 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The City continues to implement controls when contracted consultants are assisting with projects, to ensure grant reports are properly reviewed and approved by a designated City employee before being submitted. Anticipated completion date: July 31, 2026
Name of Auditee: Town of Huntington, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2025 CAP Prepared by: Sabrina Mastroianni, Deputy Comptroller Phone: (631) 351-3346 (1) Audit Finding 2025-001 - The Town did not submit its audited financial...
Name of Auditee: Town of Huntington, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2025 CAP Prepared by: Sabrina Mastroianni, Deputy Comptroller Phone: (631) 351-3346 (1) Audit Finding 2025-001 - The Town did not submit its audited financial information for the year ended December 31, 2024, to the FAC by the required deadlines. (a) Implementation Plan of Actions - The Town will submit required reports to the FAC within nine months after the end of the audit period. (b) Implementation Date - This will be implemented for the year ending December 31, 2026. (c) Persons Responsible for Implementation - The Comptroller and the Town Board.
Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will...
Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will prepare the monthly SNP Claim for Reimbursement Summary report and compile all supporting meal count documentation. 2. Prior to submission, the Administrative Assistant to the Director of Food Services or another designated individual independent of the preparation process will: a. Review the claim for mathematical accuracy; b. Verify meal counts against supporting documentation; c. Confirm claims are submitted within required timelines; and 3. Evidence of the review and approval will be documented through: a. Signature or electronic approval on the reimbursement summary report; and b. Retention of supporting documentation in accordance with federal and state record retention requirements. 4. A written standard operating procedure (SOP) outlining these review and approval responsibilities will be developed and communicated to applicable personnel. The Business Manager will periodically monitor compliance with the procedure to ensure controls remain effective.
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient ...
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient to support compensation costs charged to the Community Development Financial Institutions Program in accordance with 2 CFR § 200.430. The Organization's methodology relied on management-established allocation percentages based on employee responsibilities and anticipated level of effort supporting CDFI Fund activities. While management believes the costs charged to the award were incurred in support of eligible program activities, the Organization recognizes that documentation supporting the allocation methodology did not meet the standards required under Uniform Guidance. Planned Corrective Action: Beginning July 1, 2026, the Organization will implement formal time and effort reporting procedures for all personnel whose compensation is charged, in whole or in part, to federal awards. Specifically, the Organization will: 1.The CFO will establish a cost allocation plan which includes a methodology to support salary, wage, and fringe benefit charges, and other applicable costs, to the federal award and to support allocation among cost objectives. 2. The CFO will implement a documented process for personnel activity reporting and/or periodic certifications (or other equivalent documentation) that reasonably reflects actual work performed and supports the allocation of compensation costs to eligible activities. 3. CFO will reconfigure the current workforce management system to ensure projects, departments, and contextual details are logged at the source. 4. The COO will review existing timesheet submission and review policy to ensure compliance with federal requirements. The policy will require supervisory review and approval of personnel activity documentation/ certifications consistent with the payroll cadence and retain documentation in the grant file and/or payroll file. The CFO will review and enforce compliance with timesheet submission requirements. 5. The CFO will implement a dynamic allocations module within Sage Intacct to facilitate automated allocation of time and fringe benefits to federal and other programs. 6. The CFO will ensure that the systems established perform periodic reconciliation and after-thefact review of payroll and fringe benefit allocations. The CFO will make timely adjustments when actual activity differs from budget estimates or planned allocations. 7. The CFO, COO, and other personnel working on federal programs will receive training on the documentation standards in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 8. The CFO and COO will provide training to program and finance personnel on the documentation standards. in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 9. The CFO will, as part of the monthly close process, review compensation charged to federal awards to ensure all costs are appropriate and supported prior to requesting reimbursement. Management believes these actions will strengthen internal controls over compensation costs charged to federal awards and ensure compliance with Uniform Guidance requirements going forward. Responsible Official: Julia Gazizova, Chief Financial Officer Anticipated Completion Date: September 30, 2026.
The Airport plans to complete a credit memo for all the amounts drawn down on the 2025 grants and reissue a pay request for the remaining federal share on the eligible expenses to be in accordance with the match in the grant agreements.
The Airport plans to complete a credit memo for all the amounts drawn down on the 2025 grants and reissue a pay request for the remaining federal share on the eligible expenses to be in accordance with the match in the grant agreements.
Management Response: Management agrees with the finding. The reporting package and Data Collection Form were not submitted by the required deadline. While the delay was primarily the result of significant staffing shortages within the Finance Department during the reporting period, management recogn...
Management Response: Management agrees with the finding. The reporting package and Data Collection Form were not submitted by the required deadline. While the delay was primarily the result of significant staffing shortages within the Finance Department during the reporting period, management recognizes that it remained the City's responsibility to ensure timely compliance with federal reporting requirements. To address this issue, the City will implement a formal tracking process for all federal reporting requirements, maintain a compliance calendar, clearly assign responsibility for monitoring submission deadlines, and require management review prior to submission. These procedures are expected to strengthen internal controls, improve oversight of compliance deadlines, and ensure timely submission of future reporting packages in accordance with Uniform Guidance requirements. Anticipated Completion Date: 06/30/2026 Responsible Person: Mandy Kellogg, Administrative Services Director
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully t...
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebecca Holden Planned completion date for corrective action plan: 6/30/2026
Corrective Action Plan: The NCHA has implemented CFP drawdown procedures to ensure that all eLOCCS requests are supported by eligible expenditures, properly documented, and submitted in accordance with applicable federal cash management requirements and HUD Capital Fund Program regulations. Effectiv...
Corrective Action Plan: The NCHA has implemented CFP drawdown procedures to ensure that all eLOCCS requests are supported by eligible expenditures, properly documented, and submitted in accordance with applicable federal cash management requirements and HUD Capital Fund Program regulations. Effective immediately, the Authority has established the following corrective actions:  CFP Drawdown Review and Approval Process  All CFP drawdown requests are now reviewed by Finance staff before submission to verify that requested amounts are supported by eligible CFP expenditures, available obligations, and approved Capital Fund budgets.  A Management approval requirement has been implemented for all eLOCCS draw requests before submission.  Supporting documentation, including invoices, purchase orders, contracts, payroll allocations, and other eligible expenditure support, is maintained with each draw request.  Monthly eLOCCS-to-Expenditure Reconciliation  Finance staff perform a monthly reconciliation of CFP eLOCCS drawdowns to actual expenditures recorded in the accounting system.  The reconciliation process confirms that: o Drawdowns do not exceed eligible costs incurred; o Funds are properly recorded for the appropriate Capital Fund grant year and project; o Outstanding balances and remaining grant funds are accurately monitored; and o Any discrepancies are identified and corrected on time through appropriate accounting adjustments.  Improved Cash Management Controls  NCHA revised its CFP cash management procedures to align drawdown timing with actual cash needs and incurred eligible costs.  Draw requests are limited to amounts necessary to reimburse expenditures and avoid excessive cash balances.  Finance staff have been trained in federal cash management requirements, CFP eligible cost principles, and proper eLOCCS drawdown procedures.  Documentation and Record Retention  NCHA implemented a CFP Drawdown Checklist to document: o Grant availability; o Eligible expenditures supporting the draw; o Required approvals; o Reconciliation completion; and o Supporting documentation retention.  CFP financial records are maintained in accordance with federal record retention requirements and are available for HUD review.  Ongoing Monitoring and Quality Control  The CFO or designee conducts periodic quality control reviews of CFP drawdowns and related reconciliations to ensure continued compliance.  Any identified exceptions are documented, corrected, and incorporated into ongoing staff training and process improvements. Responsible Official: CFO, Sr. Staff Accountant with oversight by Executive Director/CEO Responsible for implementation, monitoring, and continued compliance with CFP drawdown procedures. Expected Completion Date: Implemented July 2026; Ongoing monitoring and monthly reconciliation procedures will continue as part of the Authority’s standard financial management practices
Finding 1224495 (2025-002)
Material Weakness 2025
Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed ...
Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that supervisors will properly follow up with staff during casefile review and will retain documentation supporting that evaluation. Name of the contact person responsible for corrective action: Steven Jones Planned completion date for corrective action plan: December 31, 2026
KHDA will hire a CPA to oversee this process.
KHDA will hire a CPA to oversee this process.
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