Corrective Action Plans

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VIDE acknowledges the audit finding regarding the Child Nutrition Cluster Period of Performance and concurs with the recommendation. We recognize that while the cost was incurred during the valid period, the liquidation payment occurred 18 days past the allowable deadline. To prevent recurrence, VID...
VIDE acknowledges the audit finding regarding the Child Nutrition Cluster Period of Performance and concurs with the recommendation. We recognize that while the cost was incurred during the valid period, the liquidation payment occurred 18 days past the allowable deadline. To prevent recurrence, VIDE will enforce strict protocols for grant closeout and liquidation. To achieve this, VIDE will establish an internal hard stop deadline for invoice submission, requiring that all invoices for expiring grants be submitted to the Fiscal Office no later than 45 days prior to the federal liquidation deadline to provide a necessary buffer to resolve vendor disputes and process payments before the federal cutoff. Additionally, the State Director of Special Nutrition Programs will implement a scheduled notification system to issue closeout alerts to relevant program staff and fiscal support personnel at 90, 60, and 30 days prior to the liquidation deadline, which will trigger the immediate review of open encumbrances and the expediting of pending invoices to ensure the internal hard stop deadline is met. Furthermore, for any valid expenditures remaining unpaid within 30 days of the liquidation deadline, the Fiscal Office will generate a priority payment list and transmit it to the Department of Finance with a high-priority flag to ensure these specific vouchers are processed before the grant period closes. Finally, the Federal Grants Director and the Deputy Commissioner of Fiscal and Administrative Services will review the Grant Expiration Report monthly to identify grants approaching their liquidation deadline and ensure the internal cut-off dates are being adhered to.
While the ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a ...
While the ERP provides an overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. Lastly, a Director of Audit and Compliance has been onboarded. Once the audit team is developed, support and compliance monitoring will be provided to ensure compliance.
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.
SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.
SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.
SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.
SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do n...
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that ...
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to special tests and provisions – reasonable rental rates are consistently implemented including maintaining documentation of the verification of rental reasonableness in the program participant's file. Corrective Action: In response to the findings from the 2023 audit regarding the annual requirement for rent reasonableness, we developed the following action plan to ensure compliance with HUD regulations: 1. Annual Schedule: We established that annual rent reasonableness assessments for Temenos TCDC would be conducted each January, as required by HUD. This included comprehensive assessments for all scatter site properties. 2. Staff Reminders: A systematic reminder protocol was implemented for all staff involved in the rent reasonableness process. This included: 1. Calendar alerts 2. Email notifications 3. Regular team meetings to discuss timelines and responsibilities 3. Monitoring and Compliance: The Executive Director (ED) and Director of Operations closely monitored the compliance process to ensure assessments were completed accurately and on time. By implementing this action plan, Temenos TCDC aimed to address the 2023 audit findings effectively and ensure compliance with HUD's annual rent reasonableness requirements, including assessments for all TCDC site properties. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Implemented in January of 2025
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are c...
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025
2023-004 Compliance and Internal Controls over Earmarking (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program Contract No. TX0425L6E002106 Recommendation: The Organization should establish procedures to ensure that controls related to earmarki...
2023-004 Compliance and Internal Controls over Earmarking (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program Contract No. TX0425L6E002106 Recommendation: The Organization should establish procedures to ensure that controls related to earmarking are consistently implemented which should include reconciling the administrative costs to all drawn funds on individual grants. Corrective Action: In response to the findings from the 2023 audit, we are implementing several corrective actions to enhance our financial management processes, ensuring compliance and preventing future discrepancies. 1. Monthly Reporting: The Director of Operations is required to send monthly ELLOC (HUD account balances) reports to both Your Part Time Controller (YPTC) and the Executive Director (ED). This ensures transparent tracking of funds. 2. Expenditure Budgets: Monthly expenditure budgets have been established for each grant to maximize the use of grant funds and prevent shortages in administrative expenditures. 3. Regular Reviews: Balances are reviewed monthly in conjunction with drawdown preparations. YPTC will provide recommendations for any necessary adjustments to expenditures, which will be communicated to the ED during monthly drawdown closeouts. 4. Budget Adjustments: For the 2025 NOFO budgets, adjustments will be made to align with the grant history from the past three years. This historical analysis highlights areas of both funding shortages and overages, allowing for more accurate future budgeting. 5. HUD Notification: Notifications for adjustments to the 2024 NOFO will be sent to HUD to prevent the recurrence of findings in the upcoming 2024 audit. Through these measures, we aim to strengthen our financial oversight and ensure compliance with HUD requirements. Responsible Parties: Sandra Robicheaux – ED Madelyn Wages – Director of Operations Tyler Starkel - YPTC Date to be Corrected: 1. Implementation of drawdown process began 06/01/2024 2. HUD budget adjustment to be submitted by 01/31/2026
2023-003 Compliance and Internal Controls over Matching (Material Weakness) Internal Controls over Period of Performance and Earmarking (Material Weakness) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: We recommend that part of the r...
2023-003 Compliance and Internal Controls over Matching (Material Weakness) Internal Controls over Period of Performance and Earmarking (Material Weakness) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: We recommend that part of the review process for payroll include verification that the cost charged to the grant does not exceed the grant hours reported on employee timesheet. Corrective Action: In response to the first finding, we have implemented a comprehensive payroll review process that addresses both the initial concern and the subsequent finding. The new payroll process that has been established will ensure that costs charged to the grant do not exceed the hours reported on employee timesheets, effectively eliminating both issues: Responsible Parties: Sandra Robicheaux – Executive Director Claudia Dixon – CFO Tyler Starkel - YPTC Date to be Corrected: Implementation for above changes went into effect 6/01/2024
The City will continue to work with the grant administrator who is managing the grant for the funding agency. The Administration will only submit invoices once for reimbursement and identify which invoices are local funding versus grant funding to avoid this in the future.
The City will continue to work with the grant administrator who is managing the grant for the funding agency. The Administration will only submit invoices once for reimbursement and identify which invoices are local funding versus grant funding to avoid this in the future.
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
The City will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.327 Contract provisions.
The City will develop written policies and procedures which include the relevant provisions required by 2 CFR § 200.318 through 2 CFR § 200.327 Contract provisions.
The City will develop written standards of conduct that satisfy the requirements of 2 CFR § 200.318(c)(1).
The City will develop written standards of conduct that satisfy the requirements of 2 CFR § 200.318(c)(1).
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City has will develop written procedures for determining the allowability of costs in accordance with 2 CFR 200, Subpart E—Cost Principles and the terms and conditions of the Federal award.
The City will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.
The City will develop written procedures to implement the requirements of 2 CFR § 200.305 Payment.
Response to finding 2023-005 – Reporting Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-005. During the audit period, recordkeeping was not centrally maintained, and key docu...
Response to finding 2023-005 – Reporting Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-005. During the audit period, recordkeeping was not centrally maintained, and key documents were often stored under individual employee drives rather than within a shared, organization-controlled system. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization had limited capacity to implement formal reporting controls; however, foundational corrective steps were initiated in 2025 to support full compliance during the 2026 operating year. Corrective Action taken in 2025: The Operations Manager conducted a full triage of existing accounts and transferred organizational documents into centralized CSforALL Drives. Files were reorganized by year and subject matter to ensure accessibility, consistency, and proper retention. This restructured system now provides a unified location for all grant-related documents, reporting records, and compliance materials, establishing a baseline for future Uniform Guidance reporting requirements. Corrective Action Planned for 2026: Beginning in 2026, CSforALL will implement formalized policies and procedures to ensure records are maintained in accordance with applicable compliance requirements and that all Uniform Guidance reports are submitted timely. The Operations Manager and Accounting team will oversee ongoing documentation, retention, and periodic internal review to ensure the reporting structure remains organized, accessible, and compliant throughout the 2026 operating year and beyond. Page
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
Finding 1167722 (2023-007)
Material Weakness 2023
We agree with the recommendations offered for the relevant programs and will establish updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel.
We agree with the recommendations offered for the relevant programs and will establish updated policies and procedures to address the finding regarding the retention of evidence of the funders’ approval of any changes in identified key personnel.
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