Corrective Action Plans

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2023-010 Reporting - Title I, Impact Aid and ESSER Grants - Repeat Finding Individual responsible: Business Manager and Federal Grants Director Anticipated completion date: FY 2026 Corrective action plan: At this point in time the ESSER funds are no longer available, so there will not be any other d...
2023-010 Reporting - Title I, Impact Aid and ESSER Grants - Repeat Finding Individual responsible: Business Manager and Federal Grants Director Anticipated completion date: FY 2026 Corrective action plan: At this point in time the ESSER funds are no longer available, so there will not be any other documentation going forward. However, with other grants the processes have changed. Since FY 2022 an accounting firm was hired to catch the school district up on grant requests. This accountant requested funds on a quarterly basis. On July 1, 2025, the District hired a Federal Grants director to work with the Business Manager to complete the grant catch up process and to create a system that documents each expenditure and timing of the requests. Once the system is in place cash requests will be completed monthly.
2023-009 Unsupported Expenditures - Title I, Impact Aid, and ESSER Grants - Repeat Finding Individual responsible: Business Manger and Federal Grants Director Anticipated completion date: FY 2026 Corrective action plan: The District acknowledges the deficiencies in documentation and reporting for fe...
2023-009 Unsupported Expenditures - Title I, Impact Aid, and ESSER Grants - Repeat Finding Individual responsible: Business Manger and Federal Grants Director Anticipated completion date: FY 2026 Corrective action plan: The District acknowledges the deficiencies in documentation and reporting for federal grant expenditures. At this time, ESSER funds are no longer available; therefore, additional supporting documentation for those programs will not be developed. However, the District has implemented corrective actions to imporve processes over other federal programs going forward. Since fiscal year 2022, the District engaged an external accounting firm to assist with grant reporting and cash request processes. This firm implemented a process to request funds on a quarterly basis and assisted in organizing available grant information. Effective July 1, 2025, the District hired a Federal Grants Director to work in cordination with the Business Manager to complete the grant reconciliation process and implement formal procedures for tracking grant expenditures and cash requests. These procedures include maintaining documentation for each expenditure, tracking the timing and support for drawdowns, and ensuring that all activity is properly recorded and supported. Upon full implementation of these procedures, the Distirct will transition to submitting cash requests on a monthly basis and maintaining complete and accessible documentation to support all reported amounts. The District expects these improvements to resolve the finding for current and future federal programs.
Incomplete Documentation – Material Weakness Condition: During testing of the Center's activities, one (1) of the nine (9) disbursements selected for testing did not have an application checklist that was reviewed and approved prior to awarding and disbursement of funds. Corrective Action Planned: T...
Incomplete Documentation – Material Weakness Condition: During testing of the Center's activities, one (1) of the nine (9) disbursements selected for testing did not have an application checklist that was reviewed and approved prior to awarding and disbursement of funds. Corrective Action Planned: The Center will implement a standardized pre-disbursement checklist for all award applications, requiring that the checklist be fully completed, reviewed, and signed by an authorized reviewer before any funds are awarded or disbursed. No disbursement will be processed without a completed checklist on file. This step will be incorporated into the Center's written internal control procedures. Name(s) of Contact Person(s) Responsible for Corrective Action: Kendy Alvarez, Grant Program Manager; Stephanie Desaulniers, Executive Director Anticipated Completion Date: December 31, 2026
Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun strengthening year-end financial reporting and audit planning through formal close schedules, defined responsibilities, milestone...
Reporting - Deadline for Federal Single Audit - Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun strengthening year-end financial reporting and audit planning through formal close schedules, defined responsibilities, milestone tracking, enhanced interdepartmental coordination, and increased management oversight to support the timely completion of future Federal Single Audits. Management will evaluate the effectiveness of these improvements through completion of a full audit cycle. Anticipated Completion Date June 30, 2027
Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing an enterprise-wide corrective action strategy to strengthen grant administration and reporting processes. Corrective actions include developing...
Reporting – Material Noncompliance and Material Weakness in Internal Control Over Compliance Corrective Action Plan: The Municipality has begun implementing an enterprise-wide corrective action strategy to strengthen grant administration and reporting processes. Corrective actions include developing standardized policies and procedures, formalizing documentation and supervisory review requirements, improving subrecipient monitoring, strengthening cross-departmental coordination, and incorporating these processes into formal year-end close and audit planning activities. Management will evaluate the effectiveness of these controls through completion of a full audit cycle. Anticipated Completion Date March 31, 2027
Management’s Response All participant eligibility documents are now in house and stored in a secure location on the NIBC server Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Management’s Response All participant eligibility documents are now in house and stored in a secure location on the NIBC server Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Finding 2023-002: Internal Control Over Financial Reporting – Internal Control Evidence Management’s Response Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal...
Finding 2023-002: Internal Control Over Financial Reporting – Internal Control Evidence Management’s Response Now that disbursements are 100% in-house, the President & CEO provides final written approval on all timecards and payables. Chairman of the Loan & Finance Committee remotely reviews journal entries in accounting software monthly. Contact Person Responsible for Corrective Action: Whitney Wardell Anticipated Completion Date: 7/1/2024
Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on ac...
Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on actual costs incurred, supported by documentation such as timesheets and receipts. As of October 2025, CDHS no longer required supporting documentation at the time of submission; however, supporting documentation continues to be maintained and is provided upon request for monitoring or audit purposes. Standardized Excel-based tools provided by CDHS are utilized for reimbursement submission (Invoice and Ledger). Transaction-level cost tracking was implemented to ensure allowable and eligible costs are recorded and supported. Financial and grant-related policies were standardized and incorporated into Financial Policies and Procedures in May 2024, with a comprehensive grant management framework implemented in May 2026. Control Enhancement: Beginning in 2025, all grant-related expenditures are recorded and tracked at the transaction level within the accounting system. Each transaction must include appropriate supporting documentation and be coded to the correct funding source. A standardized payroll-to-invoice reconciliation process has been implemented to ensure that all costs charged to federal awards are allowable, allocable, and properly supported. Monitoring & Review: • Costs are reviewed by the Senior Accountant prior to inclusion in reimbursement requests • A secondary monthly review is performed by the Director of Finance & Operations to validate allowability, completeness, and alignment with funding requirements • Exceptions are documented and resolved prior to submission Testing & Validation: • Beginning in June 2026, quarterly internal reviews will be conducted to test a sample of transactions for compliance with documentation and allowability requirements • Results will be documented and tracked, and any identified deficiencies will require corrective action Documentation & Evidence: • Supporting documentation is maintained in Microsoft Teams / SharePoint • Review and approval are evidenced via email approval and retained as part of the audit record Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Finance Staff Anticipated Completion Date: All corrective actions will be implemented as of June 30, 2026. Ongoing monitoring, quarterly testing, and policy updates will continue.
Finding 2023-003 Material Audit Adjustments Contact person responsible for corrective action: Bryana Marsicano, Chief Executive Officer Anticipated completion date: June 30, 2027 Corrective Action: Management agrees with the finding and will strengthen its month-end and year-end closing processes as...
Finding 2023-003 Material Audit Adjustments Contact person responsible for corrective action: Bryana Marsicano, Chief Executive Officer Anticipated completion date: June 30, 2027 Corrective Action: Management agrees with the finding and will strengthen its month-end and year-end closing processes as follows: • Adopt a written month-end and year-end close calendar identifying each required procedure, the assigned preparer, the reviewer, and the due date. • Reconcile all significant balance sheet accounts on a monthly or quarterly basis, including cash, fees and grants receivable, property and equipment, accrued payroll and related liabilities, and refundable advances. • Reconcile the fixed asset subledger to the general ledger at least annually, including the fixed asset clearing account, and document the reconciliation. Prepare a schedule of refundable advances by funding source at each reporting date, reconciled to the executed award, cumulative expenditures, and cumulative amounts drawn. • Review all clearing and suspense accounts monthly, clear them to zero, and document any balance that remains. • Require documented supervisory review of journal entries above an established dollar threshold before posting. • Complete and review a year-end close checklist before the trial balance is released to the auditors. Corrective action already taken: The fixed asset subledger has been rebuilt and reconciled to the general ledger, and the land account has been reconciled in full from inception. Reconciliations of deferred and refundable grant balances by funding source have been prepared and provided to the auditors.
Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...
Finding No. 2023-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% FPL with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the Federal poverty level (FPL). Patients whose incomes are above 100% and at or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of non-discrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.
Finding 2023-006: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically des...
Finding 2023-006: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically designated to cover payroll costs, this process now includes the following: • A drawdown allocation schedule for the employee’s making up the amount requested • A budget breakdown by department for the amounts making up the drawdown request • A supporting schedule and related invoices for amounts to be reimbursed (e.g., malpractice insurance, etc.) • A completed Standard Form (SF) 270 that tracks the applicable grant amounts previously drawdown that also specifies the amount to be currently drawn.
Management acknowledges the auditors’ findings and will develop and implement a formal internal control over the preparation and review of the Schedule of Expenditures of Federal Awards to ensure accuracy and compliance with Uniform Guidance. SEFA preparation will be assigned to designated staff, wi...
Management acknowledges the auditors’ findings and will develop and implement a formal internal control over the preparation and review of the Schedule of Expenditures of Federal Awards to ensure accuracy and compliance with Uniform Guidance. SEFA preparation will be assigned to designated staff, with a separate supervisory review to verify completeness, proper classification, and reconciliation to the general ledger. Written procedures, checklists, and documented reviews will be established, along with staff training on federal award requirements. These actions will reduce the risk of errors and strengthen the reliability of the Town’s federal award reporting
Finding 2023-006: Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Josh Verhagen, Patricia Jirsa Corrective Action Plan: This issue will be resolved as the City now has greater capacity to spread out the workload and keep up with things as a much more streamlined trackin...
Finding 2023-006: Late Reporting and Noncompliance with Reporting Requirements Name of Contact: Josh Verhagen, Patricia Jirsa Corrective Action Plan: This issue will be resolved as the City now has greater capacity to spread out the workload and keep up with things as a much more streamlined tracking, reporting and approval process has been implemented. Proposed Completion Date: December 2026.
Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this rec...
Item 2023.007 – Period of Performance Recommendation The Center should develop written procedures to review all expenditures to ensure they are within the proper period of performance of the grant. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Conduct a pre-approval of expenditures, verifying that the expense is allowable under the grant terms and falls within the period of performance • Utilize a pre-approval form that includes details of the proposed expenditure, its necessity, and confirmation in the form of authorized signatures that it is within the grant period. • Require all relevant supporting documentation with the date the expense was incurred, ensuring it falls within the grant's period of performance. This is further reviewed by the CFO who will verify that the expenditure meets all requirements and is then able to record it in the accounting system. • Conduct regular reviews of expenditures to ensure compliance with the grant period and maintain audit trail • Review these procedures annually to ensure they ongoing compliance with the grant's period of performance
Item 2023.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures ...
Item 2023.006 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Prepare written procedures to document the process for Drawdown requests, including the initial review, documented approval process, submission to the funding agency, and the recording of the drawdown in the accounting system immediately after submission • Maintain detailed records of all drawdown requests, supporting documentation, approvals, and correspondence • Conduct regular internal reviews of drawdown activities to ensure compliance with procedures and maintain audit trail • Review drawdown procedures annually to ensure they remain current with funding agency guidelines and best practices
Item 2023.004 – Reporting Recommendation The Center should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the Federal government. Repeat Finding Yes Action Taken ...
Item 2023.004 – Reporting Recommendation The Center should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the financial statement audit is submitted on a timely basis to the Federal government. Repeat Finding Yes Action Taken Island Health Care will take the following actions to address this recommendation: • Ensure proper analysis and support of accounting records through a monthly financial close process that enforces standards for supporting documentation, and internal review and approval • Ensure timely submission of financial statement audit by establishing a Master Calendar for the organization's required submissions. Depending on the required submission deadline, we would ensure that we properly allocate time and tasks into a schedule that would assist us in making our submission on a timely basis.
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the documentation submissions to HUD to ensure timely submissions of items ...
Condition: The Organization did not submit the budget to HUD within 30 days of the start of its fiscal year. Planned Corrective Action: Management has implemented a new review and oversight process related to the process for the documentation submissions to HUD to ensure timely submissions of items and to ensure documentation of review of submitted information is retained on a goforward basis. Contact person responsible for corrective action: Louise Arzu, Vice President, Finance Anticipated Completion Date: 9/30/2026
Finding No.: 2023-045 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Reporting Questioned Costs: $-0- Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. Wh...
Finding No.: 2023-045 AL Program: 93.778 – Medical Assistance Program (Medicaid; Title XIX) Area: Reporting Questioned Costs: $-0- Contact Person(s): George J. Cruz, Medicaid Director Corrective Action Plan: The Commonwealth Medicaid Agency (CMA) respectfully disagrees with the auditor’s finding. While the Agency acknowledges that certain supporting documentation was not provided within the timeframe requested during the audit, CMA does not agree that the reported expenditures were unsupported. The Agency experienced resource and staffing constraints that affected its ability to compile and produce all requested documentation within the audit timeline. However, the office maintains all relevant supporting documentation and is prepared to provide it upon request from the Grantor. To strengthen reporting processes and ensure timely availability of supporting records, CMA has developed reporting procedures and is currently recruiting a Fiscal Analyst position that will be responsible for CMS-64 reporting, reconciliations, documentation retention, and related federal reporting requirements. The Agency continues to improve its reporting processes and internal controls to ensure supporting documentation is maintained and readily available for future audits and reviews. Proposed Completion Date: Ongoing
Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit pr...
Management should establish and implement a robust tracking system to monitor reporting deadlines, ensure timely financial statement preparation, and improve coordination with external auditors. Additionally, assigning a compliance officer or designated staff member responsible for tracking audit progress and submission deadlines can help prevent future delays.
Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Ch...
Prevent Child Abuse Utah should strengthen its year-end financial close process to ensure the proper closing and review of account balances. Prevent Child Abuse Utah’s internal control system does not provide for the preparation of a complete set of financial statements. We recommend that Prevent Child Abuse Utah evaluate the ongoing benefits and expenses of including this element into its system of internal control.
2023-010-Cash Management Suggested Action: Ensure timely payment of subcontracts with minimal delay between time of grant disbursement and expense payment. Responsible Official: Global Finance Director Completion Date: 4/30/2026
2023-010-Cash Management Suggested Action: Ensure timely payment of subcontracts with minimal delay between time of grant disbursement and expense payment. Responsible Official: Global Finance Director Completion Date: 4/30/2026
2023-009-Reconciliation of accounts Suggested Action: Ensure proper month end close, including reconciliation of major accounts. Responsible Official: Assistant Controller Completion Date: 4/30/2026
2023-009-Reconciliation of accounts Suggested Action: Ensure proper month end close, including reconciliation of major accounts. Responsible Official: Assistant Controller Completion Date: 4/30/2026
We acknowledge the finding. The Municipality has developed an internal plan with the auditors and consultants to perform all pending Single Audits to the Federal Audit Clearinghouse as soon as possible. The Single Audit for the fiscal years ended June 30, 2024 and June 30, 2025 are already contracte...
We acknowledge the finding. The Municipality has developed an internal plan with the auditors and consultants to perform all pending Single Audits to the Federal Audit Clearinghouse as soon as possible. The Single Audit for the fiscal years ended June 30, 2024 and June 30, 2025 are already contracted and are expected to begin in August 2026. Personnel in charge: Daiana González Hernández, Finance Director Projected Completion Date: June 30, 2027
We acknowledge the finding. The Municipality will be working on scheduling the reports required by each program. It is important to note that all reports are prepared by the accountants assigned to each federal program and reviewed and approved by the Finance Department and the Mayor. This process s...
We acknowledge the finding. The Municipality will be working on scheduling the reports required by each program. It is important to note that all reports are prepared by the accountants assigned to each federal program and reviewed and approved by the Finance Department and the Mayor. This process sometimes results in late report submissions. Staff have been instructed to work on the reports before the 10th of each month to allow sufficient time for proper review and submission, ensuring they are duly reviewed and approved. The reports due on September 15, 2022, and October 15, 2022, were delayed due to Hurricane Fiona's passage through Puerto Rico on September 14, 2022. We experienced power and internet outages at the Municipality. Personnel in charge: Daiana González Hernández, Finance Office Director Projected Completion Date: August 31, 2026
Audit Finding Reference: 2023-002 Internal Controls Over Reporting Planned Corrective Action: Finance Director will review quarterly report prior to submission Planned Implementation Date of Corrective Action: Immediately upon notification, June 09, 2025. Person Responsible for Corrective Action: Co...
Audit Finding Reference: 2023-002 Internal Controls Over Reporting Planned Corrective Action: Finance Director will review quarterly report prior to submission Planned Implementation Date of Corrective Action: Immediately upon notification, June 09, 2025. Person Responsible for Corrective Action: County Administrator and Finance Director
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