Corrective Action Plans

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Plan: The management agent has already started exploring consulting options to support the performance of duties, ensuring file accuracy, timely and accurate recertifications, and prompt filling of vacancies. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of...
Plan: The management agent has already started exploring consulting options to support the performance of duties, ensuring file accuracy, timely and accurate recertifications, and prompt filling of vacancies. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
Plan: The management agent has already started exploring consulting options to support the performance of duties, ensuring file accuracy, timely and accurate recertifications, and prompt filling of vacancies. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of...
Plan: The management agent has already started exploring consulting options to support the performance of duties, ensuring file accuracy, timely and accurate recertifications, and prompt filling of vacancies. Anticipated Completion Date: 09/30/2024 Responsible person: Jackie Oliveira, Director of Affordable Housing
2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income ...
2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income received during 2023, it was noted that the Authority did not report all program income received into IDIS. As a result of not entering all program income into IDIS, our testing indicated that new entitlement funds were drawn down prior to utilizing all available program income on hand. The Authority utilizes a separate general ledger account in the financial reporting software to record all program income received for each federal grant program. The Fiscal Officer enters the program income into IDIS. No internal control existed to ensure the completeness or accuracy of the program income information entered into IDIS. Recommendation We recommend the Authority develop and implement an internal control procedure to ensure that all program income is entered timely within the IDIS system. Prior to drawing down new entitlement funding, the program income general ledger account associated with the grant program should be reviewed and compared to the program income reported within IDIS to ensure all program income is recorded and fully utilized before drawing down additional entitlement funding. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. Current Status of Corrective Action Plan This finding has been resolved by management. The new policy was implemented on April 1, 2025.
Finding 1166078 (2023-003)
Material Weakness 2023
Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Depa...
Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Department to address this finding. The context below is from CD: Corrective action implemented with City FY24 (07/01/23-06/30/24). Annually, a budget for staff salary and fringe is developed and approved by CD Director Marsh. The annual budget details staff hours and cost centers each will be charged during the year ( e.g. CDBG activity delivery, CDBG admin, Seaport Marina, Auditorium, ESG, etc.). Additionally, employees track time on individual time sheets weekly. This finding was also noted at the last HUD monitoring review, and marked as resolved and closed in June 2024 following HUD's post review. Name of Contact Person and Completion Date James Marsh, Executive Director of The Office of Community Development & Kevin McHugh, School Business Administrator December 31, 2025
Finding 1166049 (2023-001)
Material Weakness 2023
Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressin...
Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressing that this is a finding and more diligence needs to occur in order to remove this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: J...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Foster Care Title IV-E & Stephanie Tubbs Jones Child Welfare Services Program Assistance Listing Numbers: 93.658 & 93.645 Federal Award Identification Number and Year: 21-20016 (2023) & 21-20017 (2023) Award Period: July 1, 2022 through June 30, 2023 Type of Finding: Material Weakness in Internal Control over Compliance and Cash Management Recommendation: We recommend that management ensure that all invoices are based on actual expenses incurred and that there is a review an approval process of invoices before submission. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Aciton take in response to finding: Management has implemented a policy which requires each invoice to be based only on actual expenses incurred for the period and prohibits the use of a straight-line calculation to draw down funds. Invoices are also approved by the CFO prior to submission for reimbursement. Name of contact person responsible for corrective action: Regan Kelly, CEO of NorthEast Treatment Cetners, Inc. (215) 451-7000 Planned completion date for corrective action plan: January 31, 2024
View Audit 374235 Questioned Costs: $1
Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025
Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025
Audit Finding: Finding 2023-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage audit...
Audit Finding: Finding 2023-002: Submission of Single Audit Management’s Comments on Findings and Recommendation: We concur with the auditor's findings. Management’s Corrective Action Plan: We now are aware of the audit requirements and are committed to compliance. The Organization will engage auditors to perform subsequent period audits, as applicable. Employee / Division Responsible for Execution: Executive Director Timeline and Estimated Completion Date: Effective Immediately
Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unre...
Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unrestricted. As a result, the ledger detail did not clearly demonstrate the grant claim support without additional reconciliation. Cause: A comprehensive system for allocating and documenting grant-related costs had not yet been implemented. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands and acknowledges the significance of this finding and the potential that it creates for documentation gaps. The Controller and Director of Finance have implemented an ERP system which allows for better cost reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. While the general ledger details do not align, SacAsian did provide full documentation to substantiate the expenses claimed in each billing. Moving forward, all expenditures that have been billed will be reconciled to the general ledger monthly by the Director of Finance, Controller, and external CFO firm to ensure that billings match to expenditure detail and have been correctly allocated. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: October 2025
View Audit 372580 Questioned Costs: $1
Finding: 2023-001: Material Weakness - Untimely Audit Submission in Accordance with 0MB Uniform Guidance Description of Finding: The Sacramento Asian-Pacific Chamber of Commerce (SacAsian) did not submit its December 31, 2023 Single Audit reporting package—including the audited financial statements,...
Finding: 2023-001: Material Weakness - Untimely Audit Submission in Accordance with 0MB Uniform Guidance Description of Finding: The Sacramento Asian-Pacific Chamber of Commerce (SacAsian) did not submit its December 31, 2023 Single Audit reporting package—including the audited financial statements, Data Collection Form, prior-year status, and Corrective Action Plan—to the Federal Audit Clearinghouse by the required deadline. Cause: The submission was delayed because the Single Audit could not be completed on time due to change in audit firm and staffing shortages. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands the seriousness of this deficiency and the need for strict adherence to timely audit submissions per the OMB Uniform Guidance. Additional staff have been hired to assist in accounting processes, including a Controller to review all accounting processes and procedures with the Director of Finance and implement best practice recommendations and stronger month-end closing procedures and schedule. The delay in performing the 2023 audit was caused by a change in auditors. Our previous auditor did not have the capacity to continue our audit engagement due to staff shortages related to COVID. A new audit firm identified and engaged. However, there were delays in beginning the audit, and staffing challenges internally with completing the audit such that deadlines were not met. Additionally, an external finance and accounting firm was hired in September 2025 to provide additional capacity and high-level support to bring our audits current by March 2026. The additional staffing, external expertise, and improved procedures will prevent untimely submissions in future years. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: March 2026
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal ...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal year (FY) 2023. Management has made clearing this backlog its highest priority. The schedule is to complete and file the FY 2023 package by fall 2025 and the FY 2024 package shortly thereafter, at which point CUAHSI expects to return to on-time Federal Audit Clearinghouse filings. Recent upgrades to the accounting system, the hiring of in-house finance staff, and revised closing procedures are designed to streamline and accelerate future audit preparation so that all subsequent audits are filed by the required deadlines. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339) 221-5400 • Email: msabino@cuahsi.org Projected Completion Date: 2026-09-30
Corrective Action Taken: A qualified CFO has been hired and controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: A qualified CFO has been hired and controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of d...
Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of debt service by ten years, we began funding it in order to meet that requirement by the end of fiscal year 2023, which we did, and we have maintained the required funding since then. Contact person responsible for corrective action: Eric Draime, CFO Anticipated Completion Date: 6/30/2023
FINDING 2023-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audi...
FINDING 2023-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Material Weakness, Noncompliance Condition: The District did not have proper controls in place to ensure that the RD442-2 and RD 442-3 forms were filled out and submitted. Context: Form RD442-2 and Form RD442-3 were not submitted to the granting agency. The District may submit the financial data in other forms, however, the required reporting information was not submitted at all for the year under audit. The forms are required to be submitted on GAAP accrual basis. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will prepare the required forms which will be reviewed by the Board of Directors prior to submission. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect with the next required submission for 2025.
Management concurs with the finding. The delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse was due delayed completion of audited financial statements. The school is in the process of getting current with audited financials statements.
Management concurs with the finding. The delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse was due delayed completion of audited financial statements. The school is in the process of getting current with audited financials statements.
Based on the recommendation, Management agrees with the finding and will ensure all requested information is available for the auditor in order to facilitate timely completion of the audit by March 31.
Based on the recommendation, Management agrees with the finding and will ensure all requested information is available for the auditor in order to facilitate timely completion of the audit by March 31.
Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance. In addition, management will prepare information on federal awards to determine whether...
Based on the recommendation, management anticipates taking actions such as updating its process for recording transactions, addressing cutoff, and implementing a more rigorous review process to ensure compliance. In addition, management will prepare information on federal awards to determine whether a Single Audit is necessary and prepare a Schedule of Expenditures of Federal Awards as part of preparation for future audits.
Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.
Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.
Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.
Action Taken: The Borough will review guidance and create missing policies. Anticipated Completion: During 2024.
Finding 1161188 (2023-002)
Material Weakness 2023
Responsible Official's Response: In addition to our response to Finding 2023-001, we have hired a new Director of Human Resources as of December 2023. Most of the issues regarding record retention revolve around HR documentation. As such our new Director will have a significant impact on this proces...
Responsible Official's Response: In addition to our response to Finding 2023-001, we have hired a new Director of Human Resources as of December 2023. Most of the issues regarding record retention revolve around HR documentation. As such our new Director will have a significant impact on this process going forward more so in FY 24-25 rather than FY 23-24. We have taken steps to insure the Human Resources records are audit ready and we have implemented our own internal review process to insure record readiness.
View Audit 371186 Questioned Costs: $1
Management will verify and reconcile funds by fiscal year. Funds drawn after end of FY will be accrued back to correct FY and will include auto-reversal 1st day of new FY. Timing for implementation: Fiscal Year 23-24 Person responsible: Finance Director, Collice Martens
Management will verify and reconcile funds by fiscal year. Funds drawn after end of FY will be accrued back to correct FY and will include auto-reversal 1st day of new FY. Timing for implementation: Fiscal Year 23-24 Person responsible: Finance Director, Collice Martens
Toledo Northwestern Ohio Food Bank, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2023 Organization Contact Person: James Caldw...
Toledo Northwestern Ohio Food Bank, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2023 Organization Contact Person: James Caldwell, President/CEO The findings from the December 31, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings 2023-001 - Material Journal Entries Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Anticipated Completion Date: June 30, 2024 2023-002 - Timeliness of Bank Reconciliations Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Anticipated Completion Date: June 30, 2024 Federal Award Findings 2023-003 - Written Policies and Procedures Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Completion Date: May 14, 2025 2023-004 - Timeliness of Reporting Audited Financial Statements and Federal Awards Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Anticipated Completion Date: June 30, 2026
2023-005 Eligibility – Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Material Weakness in Internal Control, Material Noncompliance This is a repeat finding of 2022-004, reported as a Material Weakness and Material Noncompliance from June 30, 2022 (initially occurred as Finding ...
2023-005 Eligibility – Tenant Files Public and Indian Housing Program – CFDA Number 14.850 Material Weakness in Internal Control, Material Noncompliance This is a repeat finding of 2022-004, reported as a Material Weakness and Material Noncompliance from June 30, 2022 (initially occurred as Finding 2021-002, Material Weakness and Material Noncompliance) Condition: Out of a total tenant population of approximately 269 tenant files, 25 files were selected for testing. Exceptions were noted as follows: • 4 tenant files where the 214 Affidavit was not in the file or was incorrectly completed (2 files for missing 214 affidavits and 2 files where boxes were not checked to indicate adults were signing for dependents). • 5 tenant files where the tenant’s personal declaration form was missing for the time period tested. • 2 tenant files where the Form 9886 were missing for the time period tested. • 10 tenant files where there were income issues (including income calculation errors or missing support or missing Forms 50058). • 7 tenant files had deduction issues (several for deductions that were taken twice for food stamp income that was “excluded” and then deducted again, incorrect utility allowances, incorrect child care costs). • 1 tenant file where the Form 50058 was missing so unable to determine if recertification date was correct. • 4 tenant files with missing birth certificates • 1 tenant file where the tenant’s date of birth on the 50058 form did not match the tenant’s birth certificate. • 5 tenant files with missing social security cards. • 1 tenant file where the adult tenants did not sign the lease agreement. • 5 tenant files with missing EIVs. Auditor’s Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: As was also instituted for HCV participant files, the Authority has instituted a checklist sheet that will occupy the front interior of all tenant files. This checklist will contain every document that is required to be placed in the tenant file. The Authority has and will affirm the use of its procedures, and continue to implement procedures to ensure all tenant files are maintained in accordance with policies and procedures. Additionally: • All noted deficiencies will be corrected and cured. • The Authority has also taken steps to stabilize staff by hiring a Property Manager and an Occupancy Specialist that will support the Public Housing Department. • The Authority has implemented a 100% quality control review of all participant files. Task will be completed by an outside specialized compliance consulting company. The consulting company will report initial findings to the Authority and deficiencies will be cured. Thereby reducing any additional findings with tenant files. • Repeated noted errors will be reported to the Senior Property Manager and additional hand's-on training regarding deficient items will be completed as necessary.
Finding Reference Number: 2023-003 Description of Finding: SEFA reporting Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the significance of this finding and the potential for n...
Finding Reference Number: 2023-003 Description of Finding: SEFA reporting Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian acknowledges the significance of this finding and the potential for noncompliance with Uniform Guidance with the grantors and Federal entities, as well as potential increased risk of omitted federal programs and incorrect major program determination. Moving forward, SEFA reporting will be reviewed and approved by multiple reviewers, including the President & CEO, Controller, and Director of Finance. Individual directors under relevant federal programs being reported on the SEFA will also be required to review that the information listed on the SEFA report is complete and accurate. This review process will be in place for the 2024 audit and subsequent audits. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: September 2025
Finding Reference Number: 2023-001 Description of Finding: Untimely audit submission in accordance with OMB Uniform Guidance Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the se...
Finding Reference Number: 2023-001 Description of Finding: Untimely audit submission in accordance with OMB Uniform Guidance Statement of Concurrence or Nonconcurrence: The California Asian Pacific Chamber of Commerce (CalAsian) agrees with the finding. Corrective Action: CalAsian understands the seriousness of this deficiency and the need for strict adherence to timely audit submissions per the OMB Uniform Guidance. Additional staff have been hired to assist in accounting processes, including a Controller to review all accounting processes and procedures with the Director of Finance, implement best practice recommendations and month-end closing schedule. We also understand these findings are repetitive from the 2021 and 2022 audits; however, due to catch-up of the prior year audits, we were unable to address these issues prior to completion of the 2023 audit. This delay was caused by a change in auditors as our previous auditor did not have the capacity to retain us as clients due to staff shortages related to COVID. An outside finance and accounting firm has been hired to provide additional support to bring the audits current by March 2026. This issue will be further mitigated in subsequent periods with the implementation of the new accounting system, which was implemented effective January 2025. Monthly reviews of the 2024 financial data, including reconciliations of all accounts were performed and reviewed by the Controller and Director of Finance. This will allow us to provide the 2024 financial data to the auditors in a more timely manner to ensure completion and submission of the audit per the OMB guidance. Continued compliance with these new procedures will help to mitigate the risk of untimely submissions in future years. Name of Contact Person: Ryan Fong, Director of Finance, 916-446-7883, rfong@calasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfongkushida@calasiancc.org Projected Completion Date: March 2026
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