Corrective Action Plans

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Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Cont...
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Control over Compliance Criteria and Condition: According to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), section 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of the activity actually performed; significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges based on budget estimates. Proof of these employees' approved compensation and job title is required to ensure their roles are allowable under the grant. Timesheets provided to support payroll charges did not accurately support the payroll expenses charged to the grants. Also, approval of the timesheets was not evident by the documentation provided. Finally, documentation supporting approval of each employee’s compensation was not maintained and provided to support the accuracy of employee compensation. Cause: During 2024, CVC’s management team underwent significant turnover, including the top finance officer, who represents the entire accounting department, as well as the HR director. Documentation was not maintained or could not be located to support payroll expenses allocated to the federal program. Effect and Context: When adequate support is not obtained and used to support the amount charged to the federal program, there is a risk that unsupported or inaccurate costs are being charged to the federal program. Questioned Costs: Payroll costs charged to the awards total $2,570,558. Recommendation: We recommend proper control activities should be implemented to allow for a consistent, accurate, and allowable method to support distribution of personnel charges to federal programs. Documentation should be properly maintained in the organization’s records. Views of responsible officials and planned corrective actions: CVC management will implement a process to perform timely review of salary expenses charged to federal awards, and retain records by pay period, and any pay rate and title changes, as support for expenditures charged to federal awards. Name of Contact Person: Gil Catbagan, Director of Finance Proposed Completion Date: December 31, 2025
View Audit 368632 Questioned Costs: $1
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Proposed Completion Date: January 1, 2026
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regardin...
CORRECTIVE ACTION PLAN Name and Number of the Project: Sunray Communities, Inc. No. 112-EE003 Audit Firm: M Group, LLP Audit Period: The year ended December 31, 2024 Compliance Review A. Comments on Findings and Recommendations We concur with the findings and recommendations of our auditors regarding our noncompliance as cited in the accompanying Schedule of Findings and Questioned Costs. Actions Taken FINDING 2024-002: Supportive Housing for the Elderly, Assistance Listing 14.157 CORRECTIVE ACTION COMPLETED: The property management company obtained property insurance effective March 2025. We have prepared the corrective action plan as required by the standards applicable to financial statements contained in Government Auditing Standards and by the audit requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principals, and Audit Requirements for Federal Awards. Any questions regarding the above corrective action plan should be directed to Ms. Natalie Bastien, Vice President, RPM Living.
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review all participant files to ensure proper documentation is retained supporting eligibility of applicants. We noted that there is currently a p...
Refugee and Entrant Assistance State/Replacement Designee Administered Programs Assistance Listing No. 93.566 Recommendation: Auditor recommends that KOM review all participant files to ensure proper documentation is retained supporting eligibility of applicants. We noted that there is currently a process in place to perform an annual review of random files to ensure that only eligible participants are being served, but we recommend that a process is implemented to ensure that there is proper review and approval of all applicants prior to the individual receiving services and that this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has implemented enhanced processes for regular client file checks to ensure all clients have adequate documentation. Name(s) of the contact person(s) responsible for corrective action Eh Tah Khu, Co- Executive Director Planned completion date for corrective action plan: August 2025
Finding 1156122 (2024-003)
Material Weakness 2024
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: As part of the recent audit of...
Finding Number: 2024-003 Finding Title: Eligibility - MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Quinn Jaeger, Social Services Director Mikala Wodarek, Social Services Supervisor Corrective Action Planned: As part of the recent audit of MAXIS Medical Assistance eligibility determinations, Clay County Social Services recognizes that errors were found in several case files. In response, eligibility workers will receive targeted training on timely and accurate case entry in MAXIS, with particular emphasis on the verification and documentation of citizenship, income, and assets in accordance with OHS policy. The lead worker for this program will conduct random case reviews monthly, in addition to 3 case reviews for each worker around their annual performance evaluation. These case reviews will be reviewed with the worker thoroughly, coaching provided if necessary, and any errors found will be corrected. The supervisor will retain these case reviews and analyze them for patterns and provide team training and guidance as appropriate. For staff with repeated errors, performance management will be enacted in the form of verbal coaching, performance improvement plans, etc. The Health Care Team supervisor will strengthen internal procedures to reinforce documentation and timeliness standards, review results from case reviews on a regular basis, and initiate corrective performance measures when patterns of errors are observed. In addition, annual training on eligibility documentation will also be incorporated into the department's training plan. Anticipated Completion Date: Refresher training for eligibility workers and thorough review of 2024 audit findings both individually and as a group: completed on August 7, 2025 Case reviews by lead worker: Already implemented at the time of this 'writing and ongoing January 2026 and ongoing: Health Care supervisor begins quarterly reviews of audit findings and reports results to department leadership. January 2026 and ongoing: Annual eligibility documentation training incorporated into the department training calendar.
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the find...
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Below is the process for submitting required grant reporting. 3. The Director will input the required information 4. Prior to submission of the report, the Director will have the Deputy Director verify the information that has been entered against the supporting documentation. 5. The Deputy Director will let the Director know if it is ok to submit the report. 6. The Director will submit and print a completed submission document that the Deputy Director will verify again. 7. The Deputy Director and Director will both sign and date the completed report. 8. This will be filed for audit purposes. Anticipated Completion Date: This is already taking place. The 2025 filing in April followed this process.
Corrective Action Plan: Management will formalize a procurement policy in line with federal guidelines. Anticipated Completion date: 10/31/2025 Responsible Person: Rebecca Solow, Co-Founder and Executive Director
Corrective Action Plan: Management will formalize a procurement policy in line with federal guidelines. Anticipated Completion date: 10/31/2025 Responsible Person: Rebecca Solow, Co-Founder and Executive Director
Finding 2024-004: Cutoff Procedures Issue: Previously, there were no formal cutoff procedures to ensure expenses were recorded in the correct period, which caused inconsistencies and required post-year-end journal entries to correct expense timing. • What's been done: Contracts are now recorded as p...
Finding 2024-004: Cutoff Procedures Issue: Previously, there were no formal cutoff procedures to ensure expenses were recorded in the correct period, which caused inconsistencies and required post-year-end journal entries to correct expense timing. • What's been done: Contracts are now recorded as prepaid or accrued expenses and are being expensed monthly. • Next steps: Salaries and benefits incurred before month-end will be accrued to grants at grant cutoff dates (e.g., September 30) and at year-end. Estimated monthly accruals for salaries will be implemented. • Timeline: Full implementation by the end of September 2025. • Responsible party: Finance manager with oversight by President
Finding ref number: 2024-001 Finding caption: The City did not have adequate internal controls and did not comply with federal wage-rate requirements. Name, address, and telephone of City’s contact person: Josh DeLay 271 9th St NE East Wenatchee, WA 98802 (509) 886-4507 Corrective action the auditee...
Finding ref number: 2024-001 Finding caption: The City did not have adequate internal controls and did not comply with federal wage-rate requirements. Name, address, and telephone of City’s contact person: Josh DeLay 271 9th St NE East Wenatchee, WA 98802 (509) 886-4507 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). All the projects audited this period are still in progress and have not been closed out or accepted by the City. As a result, the final project files were not available, leading to the audit evaluating “working” files. Auditing these files with the expectation that they would be in a finalized state is both misrepresenting the City’s standard of care for accepted projects and created an added financial burden to provide support from working files. The City would like it noted the audit did not find any payments to have been processed that did not include payment of prevailing wage. Additionally, as stated above, these projects are all still in progress and will not be fully closed out until all certified payrolls are received. In a theoretical case where there was an instance of a contractor not paying prevailing wage on one of these projects, the City would address it prior to closeout, which would ensure it is not liable for paying additional wages. The City hires consultants to administer these projects in accordance with all relevant statutes and best practices. The City also provided the SAO with emails showing the City’s consultants requesting overdue certified payrolls as a part of the pay estimate preparation process. To mitigate any risk that may exist in the City’s current process the City will develop a cover sheet to accompany pay estimates on federally funded projects that will require the consultant to certify that certified payrolls from all contractors are up to date, tracks how far overdue any non-submitted certified payrolls are, and ensure the City verifies certified payrolls in a timely manner. The City will also look further into the applicable statutes to determine whether it needs to establish a policy outlining when to withhold payment from a contractor due to outstanding certified payrolls. The City does not believe that an audit finding is necessary on this issue. These certified payrolls will be collected prior to the projects being accepted, ensuring that any noncompliance from contractors are not the financial responsibility of the City. As outlined above, the City acknowledges that there are areas that it could improve its process and will implement policies and systems to continue delivering the best possible projects for taxpayers. Anticipated date to complete the corrective action: Immediately, where necessary
MATERIAL WEAKNESS Financial Statement Preparation and Audit Adjustments Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to...
MATERIAL WEAKNESS Financial Statement Preparation and Audit Adjustments Recommendation: We recommend that management review controls related to financial statement preparation review at the end of each period. Financial statement preparation should include a review of reconciliations and balances to ensure that financial statement line items are properly stated and classified. Internally prepared financial statements should also be thoroughly reviewed by members of the board and management outside the finance department on a periodic (monthly or quarterly) basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action Planned/Taken : Management agrees with the finding and has contracted with an outside firm that specializes in SBOA compliance, to assist with developing the required Internal Controls and Processes, with an estimated completion date of December 31, 2025.
Management concurs with the findings. The closing process will be improved; physical inventory will be taking and improvements for documentation will be made.
Management concurs with the findings. The closing process will be improved; physical inventory will be taking and improvements for documentation will be made.
Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any rev...
Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any reviews will be documented with an approval via a formal email confirmation. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail
Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion ...
Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail
The Foundation immediately paid the vendor the full amount upon learning of this finding from the auditor and verified that the vendor received the payment. The recording of Grant Revenue/Accounts Receivable and Grant Expenses/Accounts Payable is now done for each grant expense immediately upon appr...
The Foundation immediately paid the vendor the full amount upon learning of this finding from the auditor and verified that the vendor received the payment. The recording of Grant Revenue/Accounts Receivable and Grant Expenses/Accounts Payable is now done for each grant expense immediately upon approval from the Foundation and submission to New York State for reimbursement. This was previously not done. The changes to the recognition of revenue and expenses are already in effect and should eliminate any future finding related to the non-payment of expenses that have been reimbursed through grants.
View Audit 368162 Questioned Costs: $1
Condition: The entity did not retain required support; rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. Planned Corrective Action: Although YMCA performed the proper procedures, the passage of time resulted in a m...
Condition: The entity did not retain required support; rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. Planned Corrective Action: Although YMCA performed the proper procedures, the passage of time resulted in a mis-placing of the supporting documentation. YMCA relied upon legal counsel to retain the documentation. This was a unique and one-time award. In the future, YMCA will take responsibility for the retention of the supporting documentation. Contact person responsible for corrective action: Phillip E. Platz, CFO Anticipated Completion Date: Immediate
View Audit 368158 Questioned Costs: $1
Reporting Recommendation: We recommend that management and governance review the financial status reports to supporting documentation and ensure it agrees each month. We recommend management reaches out to their grant contact to ensure cumulative amounts are adjusted through 12/31/2024 to ensure fut...
Reporting Recommendation: We recommend that management and governance review the financial status reports to supporting documentation and ensure it agrees each month. We recommend management reaches out to their grant contact to ensure cumulative amounts are adjusted through 12/31/2024 to ensure future reports are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCEDC management will continue to work with the Department of Workforce Development and the Wisconsion Economic Development Corporation to clarify expenses through 12/31/2024. Name(s) of the contact person(s) responsible for corrective action: Executive Director Jeff Mikorski Planned completion date for corrective action plan: September – November 2025
While we acknowledge the auditor’s observation, management does not concur that the absence of formal timesheets equates to unsupported labor charges. Employees completed assigned responsibilities under the Sexual Risk Avoidance Education grant. Salaries were charged consistent with approved budgets...
While we acknowledge the auditor’s observation, management does not concur that the absence of formal timesheets equates to unsupported labor charges. Employees completed assigned responsibilities under the Sexual Risk Avoidance Education grant. Salaries were charged consistent with approved budgets and federal cost principles. During the audited (12-month) period, total payroll expenses allocated to the grant reflected actual performance of program activities as contracted. Accordingly, we believe the costs are fully allowable and the questioned amount of $40,495 is valid program expense. To address auditor concerns, we will utilize the documentation of program detail and timekeeping information within the Educator Tracker to accurately charge time and effort each pay period. The Educator Tracker will include all pertinent details including staff assignments, grant source per assignment, and supervisor approval. Anticipated completion: October 15, 2025. Responsible party: Kimberly Danon, Director of Youth Education.
View Audit 368035 Questioned Costs: $1
Finding 2024-008 See response to finding 2024-004.
Finding 2024-008 See response to finding 2024-004.
Finding 2024-007 See response to finding 2024-003.
Finding 2024-007 See response to finding 2024-003.
Finding 2024-006 See response to finding 2024-002.
Finding 2024-006 See response to finding 2024-002.
View Audit 368025 Questioned Costs: $1
Finding Number: 2024-003 USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will review the loan terms and conditions to evaluate the amounts required to be in the applicable loan reserve accounts, and will bring the reserve accounts to the required balances. Person Respon...
Finding Number: 2024-003 USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will review the loan terms and conditions to evaluate the amounts required to be in the applicable loan reserve accounts, and will bring the reserve accounts to the required balances. Person Responsible for Corrective Action: Gabriel Moreno, Executive Director. Anticipated Date of Completion: December 31, 2025
2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of tim...
2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of time spent on a grant monthly. These personnel have been informed of the proposed process and trained to promote consistent and accurate reporting relative to federal standards Anticipated completion date: October 2025 Contact person responsible for corrective action: Russ Chambliss
Planned Corrective Action: The Organization will reach out to HUD again to seek assistance to resolve the REAC system technical issues in order to move forward. Person Responsible: John Murray, Chief Financial Officer
Planned Corrective Action: The Organization will reach out to HUD again to seek assistance to resolve the REAC system technical issues in order to move forward. Person Responsible: John Murray, Chief Financial Officer
CASEFILE REVIEW (PRIOR YEAR 2023-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Commu...
CASEFILE REVIEW (PRIOR YEAR 2023-005) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025
ELIGIBILITY (PRIOR YEAR 2023-008) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Communit...
ELIGIBILITY (PRIOR YEAR 2023-008) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2401MNTANF Compliance Requirement Affected: Eligibility Award Period: Year Ended December 31, 2024 Type of Finding: Material Weakness in Internal Control over Compliance Recommendation: We recommend the County review case files on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will begin reviewing case files and documenting their review. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025
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