Corrective Action Plans

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2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City ...
2024-002 – Written Policies and Procedures Required by the Uniform Guidance Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): o City Council o City Manager o City Finance Director Anticipated Completion Date: June 18, 2025
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be c...
Need Analysis Planned Corrective Action: A report was created in Populi (Subsidized Eligibility Report) that will capture the students’ Cost of Attendance, SAI and if the student has zero need. A separate report will be generated to capture subsidized loan disbursements. The two reports will be combined to identify students who were awarded the subsidized loan in error. These reports will be reviewed after each add/drop period. Management has made a request to our vendor to create a special report that will capture this data in a more time efficient manner. Person Responsible for Corrective Action Plan: Darla Hopper, VP of Enrollment Management Anticipated Date of Completion: 09/30/2025
Finding 574638 (2024-005)
Material Weakness 2024
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will ha...
FINDING 2024-005 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will have the Deputy Auditor start signing off on all reports to verify the dates are correct for the reporting period. Anticipated Completion Date: August 30, 2025
Finding 574636 (2024-003)
Material Weakness 2024
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Depa...
FINDING 2024-003 Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number: 317-392-6310 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor or Department head will review and document their review for all Federal Grant disbursements for applicable grant requirements and Federal regulations. Anticipated Completion Date: August 30, 2025
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur wi...
FINDING 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Heather Huff Contact Phone Number and Email Address: 812-265-8907 heather.huff@jeffersoncounty.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Auditor’s Office will collect dual signatures on all submissions for reporting requirements. The Auditor’s Office will also have additional employees verify submissions to ledgers for accuracy. Anticipated Completion Date: Completion is anticipated for all reports due after 12-31-2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
We are working in implementing adequate external and internal control procedures in order to comply with the submission of all required information for the Single Audit for Fiscal Year 2025.
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan:...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants FFAL #10.766 Finding Summary: There was no documented independent review of the monthly reserve fund account balance as compared to the required minimum balance. Corrective Action Plan: The required monthly balance and the actual monthly reserve fund account balance will be presented to the board on a monthly basis for review and approval. Previously only the actual balance and a YES/NO were provided. Starting in August 2025, monthly board packets for approval will now include the required vs actual comparison with a YES/NO of meeting the requirement. Responsible Individuals: Amanda Soesbe, Chief Finance Officer Anticipated Completion Date: August 2025
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Su...
June 26, 2025 JGD & Associates LLP 9191 Towne Centre Drive Suite 340 San Diego, California 92122 Re: Corrective Action Plan Dear JGD & Associates LLP, The following are responses to the program audit findings from the most recent audit of Adjoin. 1. Current Year Findings 2024-001 a. Program Name: Supportive Services for Veterans Families: CFDA 64.033 b. Criteria: Failure to comply with the grant agreement’s terms and applicable regulations: The Organization did not comply with grant compliance requirements such as tracking administrative expenses charged to the program outside of the general ledger and in other matters noted in licensing reviews. c. Condition: The Organization has failed to comply with grant requirements due to lack of proper tracking of administrative expenses, limited compliance policies including approval over supplemental pay wages, and lack of proper training over verification and documentation processes. d. Response: The organization has been successfully running the SSVF program for 11+ years and tracking/calculating administrative costs utilizing offline Excel spreadsheets since inception which provided a low cost and flexible solution for our accounting team. However, as an outcome of our last SSVF audit and due to the size and scope of our SSVF operations, the VA is requiring Adjoin to cease maintaining offline spreadsheets and ensure that all SSVF grant costs are logged in the general ledger. We're partnering with JMT Consulting (our Sage Intacct solution provider) for their assistance in implementing a new Dynamic Allocation Module to our Sage platform allowing click thru capabilities to all of the administrative costs that hit the grant (not to exceed 10%). We're committed to rolling out this functionality and are excited about the efficiencies it will bring to the team along with ensuring compliance with VA requirements. 2. Prior Year Finding 2023-001 None noted. Contact person responsible for corrective action: Pat Phelan, CFO Completion date: August 31, 2025 If you have any questions regarding this plan, please contact Pat Phelan, CFO, 858- 292-2030, pat.phelan@adjoin.org. Sincerely, Pat Phelan CFO Adjoin
View Audit 364796 Questioned Costs: $1
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees...
Finding 2024-02 Reporting (ALN 10.557) Indiana University Health analyzed the miscalculation to determine if the failed control resulted in a material misstatement as well as similar transactions to determine if the miscalculation was isolated. The risk was determined to be isolated to new employees to the program who were transferred internally. A correction was made to the April 2025 claim to adjust for the amount overclaimed. Indiana University Health strengthened claim review controls to ensure such changes go through additional review before claim submission. Contact Person(s) Responsible for Corrective Action: Christine Smith Completion Date: July 31, 2025
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Chri...
Finding 2024-01 Scope Limitation – Eligibility (ALN 10.557) Indiana University Health utilizes a paperless system in accordance with U.S. Department of Agriculture and State of Indiana guidelines. As such, no corrective action will be taken. Contact Person(s) Responsible for Corrective Action: Christine Smith Anticipated Completion Date: N/A
Management agrees with the finding and recommendation.
Management agrees with the finding and recommendation.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Reports were not sent in a way that does not show proof that they were received and reviewed. In the future all reports will be sent and approved through a channel that can be proven and pulled upon request at any time.
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Action taken in response to finding: A new process has been put in place documenting the review and approval of payroll. Name(s) of the contact person(s) responsible for corrective action: Melissa D’Onorio, CEO, and Donna Landy, CFO. Planned completion date for corrective action plan: 07/14/2025
Finding 574022 (2024-004)
Significant Deficiency 2024
During our testing, we found that the Organization provided documentation showing that the vendors used in the federal program were not listed as suspended or debarred according to the Sam.gov website, in line with their internal control procedures. However, there was no documentation indicating tha...
During our testing, we found that the Organization provided documentation showing that the vendors used in the federal program were not listed as suspended or debarred according to the Sam.gov website, in line with their internal control procedures. However, there was no documentation indicating that the verification was performed prior to entering the transactions. Recommendation: The Organization should establish and enforce controls to verify that vendors are not suspended or debarred prior to entering any transactions and maintain this documentation. This measure ensures the integrity of the procurement process and mitigates risks associated with engaging disqualified vendors. In 2024, the threshold amount for suspension and debarment checks was $25,000. Transactions equal to or exceeding this amount required verification to confirm that the entity involved was not debarred or suspended. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement a process to screen vendors to ensure compliance with applicable regulations. Planned completion date for corrective action plan: the planned corrective action will be completed by August 2025. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance If the oversight agency has questions regarding this plan, please call Regine Metellus, Vice President of Finance at 215-575-0444 ext. 163.
Finding 574021 (2024-002)
Significant Deficiency 2024
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort ...
During our testing, we noted the organization does not have adequate controls designed to ensure personnel costs are documented with time and effort certifications. Recommendation: We recommend The Food Trust establish and implement controls that require employees to document their time and effort spent on various activities. Time and effort certifications should be regularly reviewed and approved by appropriate personnel to ensure accuracy and completeness of personnel cost documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement processes and tools to ensure that all employee time and effort charged to federal grants is appropriately documented. Name(s) of the contact person(s) responsible for corrective action: Regine Metellus, Vice President of Finance Planned completion date for corrective action plan: The planned corrective action will be completed by October 2025.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD guidelines require Project cash to be maintained in financial institutions, which meet minimum GNMA ratings, when balances exceed federal insurance limits. Condition: The Organization maintains cash balances in excess of federally insured limits in a financial institution that does not meet HUD guidelines. Questioned costs: None Context: The cash balance as of December 31, 2024 was approximately $740,000, held in two financial institutions, which exceeded federal insurance limits by approximately $470,000. Cause: As the Organization is a community based non-profit organization, management considers supporting a local bank to be a worthwhile endeavor. Effect: No negative effect was discovered during the audit. Repeat Finding: No. Recommendation: The Organization should transfer all funds to a financial institution that meets HUD guidelines. Action Taken: Nevins moved to this financial institution with the first HUD loan in 2015. This is a local bank that actively supports Nevins mission in the community. Given Nevins current financial struggles, the balance in the bank seldom exceeds the $250,000.00 threshold.
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through Dec...
Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Section 232 Mortgage Insurance for Nursing Homes and Section 241(a) Supplemental Loan Insurance Multifamily Rental Housing Assistance Listing Number: 14.129 and 14.151 Award Period: January 1, 2024 through December 31, 2024 Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Criteria or specific requirement: HUD requires the Organization to make mortgage payments on a timely basis. Condition: Mortgage payments for February, March, April and May 2024 were not received by the mortgage company promptly. Questioned costs: None Context: February, March, April and May 2024 mortgage payments were received by the mortgage company subsequent to the 15th of the following month, which is considered late per HUD guidelines. Cause: Mortgage payments were being funded with approved withdrawals from reserve accounts which delayed timing of payment. Effect: Late charges were assessed to the Project. Repeat Finding: No. Recommendation: Mortgage payments should be made by the due date. Action Taken: Nevins was in touch with HUD monthly and developed a repayment plan but could not follow through. Nevins engaged with Alliance Healthcare for Accounts Receivable assistance in the fall of 2024 and then entered into a Management agreement with Alliance Healthcare in June of 2025.
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management shoul...
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Supportive Housing for Persons with Disabilities (Section 811) Program Federal Assistance Listing: Number 14.157 Recommendation: Management should immediately reimburse the amount due to the property and establish procedures to ensure payments of this nature are not made in the future. Action Taken: REACH has policies in place to ensure that costs are allocated to the appropriate property. In 2024, costs from an adjacent property, Community Housing I, were accidentally paid by Community Housing II. These funds were repaid to the Community Housing II in 2025. Completion Date: June 30, 2025
View Audit 364592 Questioned Costs: $1
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor c...
Federal Award Findings and Questioned Costs Item 2024-003 Name of Federal Agency: U.S. Department of Housing and Urban Development Federal Program Name: Home Investment Partnership Program Federal Assistance Listing: Number 14.239 Recommendation: Management should establish procedures and monitor compliance with those procedures to ensure that recertifications are performed timely and signed, tenant eligibility is correctly determined and that tenant lease files are properly maintained in accordance with the requirements of HUD Handbook 4350.3, Occupancy Requirements of Subsidized Multifamily Housing Programs. Action Taken: REACH has policies in place to ensure that HQS inspections are done in a timely manner. Staffing shortages at the property had an impact on the completion of HQS inspections in 2024. As new staff are brought onboard training is provided and management will continue to coordinate and provide assistance to on-site staff to ensure that the inspections are being completed and properties are in compliance.
Finding 573824 (2024-012)
Material Weakness 2024
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #...
Finding #2024-001 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Student Financial Assistance Programs Cluster, Assistance Listing #84.063, Federal Pell Grant Program, Assistance Listing #84.268, Federal Direct Student Loans, Contracts #003556 and G03556, Contract years: 05/05/21 – 12/31/26. Recommendation: Emphasize the importance of accurately reporting enrollment status. Planned corrective action: Management agrees with audit finding #2024-001. The Financial Aid Coordinator is responsible for reporting enrollment status changes, certifying enrollment every 60 days, and responding to NSLDS Roster files within 15 days, all through the NSLDSFAP website. To enhance the accuracy of these enrollment reports, the Institute is implementing a new double-check process. Henceforth, the Financial Aid Coordinator will print all enrollment status changes or enrollment report rosters prior to making any online updates or certifications. These printed reports will then be given to the Director of Operations for verification. Only after this verification will the Financial Aid Coordinator proceed with the necessary changes or certifications on the NSLDSFAP website. All printed reports will be retained by the Financial Aid Coordinator for documentation. Responsible officer: Cody Lopasky, President. Estimated completion date: June 1, 2025.
Finding 573777 (2024-001)
Significant Deficiency 2024
We will continue to follow up with our HUD fuekd representative to determine the next steps for determining the repayment of the Flexible Subsidy Loan.
We will continue to follow up with our HUD fuekd representative to determine the next steps for determining the repayment of the Flexible Subsidy Loan.
Federal Awards Finding 2024-002: Suspension and Debarment Finding: The City receives State and Local Fiscal Recovery Funds (SLFRF) from the U.S. Treasury as outlined in the American Rescue Plan Act (ARPA). In 2024, the City originally planned to utilize the ‘revenue replacement’ provision in ARP...
Federal Awards Finding 2024-002: Suspension and Debarment Finding: The City receives State and Local Fiscal Recovery Funds (SLFRF) from the U.S. Treasury as outlined in the American Rescue Plan Act (ARPA). In 2024, the City originally planned to utilize the ‘revenue replacement’ provision in ARPA and did not interpret the guidance at that time to require the check for suspension and debarment but rather thought that revenue replacement provision would require the City only to conduct “business as usual” regarding purchasing, acquisitions and contracts. However, after the first single audit was completed and new guidance was released by the treasury, it was determined that this requirement was needed and as all the contracts and purchases had been entered into or were at a stage where they could not be checked prior to award it was determined that prior to submitting any expenses to the treasury, each quarter that suspension and debarment checks would be done on any vendors/contracts with a purchase or contract greater than $25,000. Corrective Actions Taken or Planned: As there is no opportunity to correct this since all contracts are already in place for the ARPA SLFRF, we will continue to check for suspension and debarment each quarter before submitting the expenses to the Treasury and will not submit any expenses related to vendors or contractors that are suspended or debarred. We will implement a review by the controller to make sure that the suspension and debarment check is being done quarterly and will document such review. All other contracts and awards related to federal funds will continue to have the suspension and debarment check performed by the contracts and purchasing department before issuance of the contract or award. Anticipated Date of Implementation/Completion: July 31, 2025 Name of contact person responsible for correction action: Doug Farmen, Controller
Federal Awards Finding 2024-003: Reporting Finding: The City receives Community Development Block Grant (CDBG) funding through the U.S. Department of Housing and Urban Development (HUD). During the year, the Cash on Hand & FFATA reporting did not have proper approval and review documentation. C...
Federal Awards Finding 2024-003: Reporting Finding: The City receives Community Development Block Grant (CDBG) funding through the U.S. Department of Housing and Urban Development (HUD). During the year, the Cash on Hand & FFATA reporting did not have proper approval and review documentation. Corrective Actions Taken or Planned: The Senior Accountant works with the Grant and Housing Supervisor to manage these funds. They will work together so that one employee completes the Cash on Hand or FFATA report and the other reviews, approves, and documents the approval. Anticipated Date of Implementation/Completion: July 31, 2025 Name of contact person responsible for correction action: Pam Goodwin, Senior Accountant
New Community Urban Renewal Corporation (“NCURC”, “the Corporation” or “the Project”) agreed to a HUD proposal for repayment of the funds and adopted a resolution by the Board indicating such acceptance which was submitted to HUD and includes the following: 1. An acknowledgement of the obligations s...
New Community Urban Renewal Corporation (“NCURC”, “the Corporation” or “the Project”) agreed to a HUD proposal for repayment of the funds and adopted a resolution by the Board indicating such acceptance which was submitted to HUD and includes the following: 1. An acknowledgement of the obligations set forth in the Regulatory Agreement with HUD dated April 11, 1984 and the intention to fully comply with the provisions therein going forward. 2. NCURC’s affiliates, New Community Corporation (“NCC”) and New Community Healthcare, Inc.’s (“NCHC”) intention to make full restitution of the outstanding balances due to the Corporation. Annual payments will not be less than $150,000 for the next ten years beginning in 2015 through 2024. NCURC is currently in communication with HUD regarding the new repayment proposal. Until such time as the parties agree to new terms, NCURC’s intention is to continue making payments of not less than $150,000. 3. One year prior to the expiration of the 10-year repayment period (2023), a new repayment proposal will be provided to HUD requiring payments not less than $250,000 per year. NCURC is currently in communication with HUD regarding the new repayment proposal. 4. No Project funds or other HUD funds will be used as a source for repayment. 5. An accounting system must be maintained to track restitution payments acceptable to HUD. 6. Management is required to provide to HUD responses to any management letters received in connection with the annual audits. 7. Certain monthly financial reports and other program specific reports are required to be submitted to HUD. 8. The Boards of NCC / the Corporation are required to conduct quarterly compliance briefings with the minutes of such meetings sent to HUD.
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