Corrective Action Plans

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Finding 1224651 (2024-003)
Material Weakness 2024
We agree with the recommendations offered and will establish policies to ensure timely filing of the Single Audit reporting package in accordance with applicable requirements. As noted above, DWX is replacing its legacy accounting system with Deltek Costpoint, which should result in more timely repo...
We agree with the recommendations offered and will establish policies to ensure timely filing of the Single Audit reporting package in accordance with applicable requirements. As noted above, DWX is replacing its legacy accounting system with Deltek Costpoint, which should result in more timely reporting and audits. The anticipated completion date is October 2026.
Recommendation We recommend that UVNR strengthen its payroll review and approval procedures by requiring that: - The final timesheet used to process payroll be reviewed and approved by the appropriate supervisor before payroll is submitted; - Approved timesheets be reconciled to the payroll register...
Recommendation We recommend that UVNR strengthen its payroll review and approval procedures by requiring that: - The final timesheet used to process payroll be reviewed and approved by the appropriate supervisor before payroll is submitted; - Approved timesheets be reconciled to the payroll register and retained with the payroll documentation; - Timesheet calculations and total hours be independently reviewed for math accuracy; - Version controls be implemented to clearly identify the final approved timesheet when corrected or revised timesheets are submitted; and - Payroll errors and discrepancies be documented and corrected promptly through a subsequent payroll. Management Response Corrective Action: The identified exceptions resulted from isolated administrative errors in the payroll review process and did not reflect intentional noncompliance. Specifically, one exception occurred because an updated Excel timesheet was used for payroll processing without obtaining the required supervisory approval or retaining documentation demonstrating approval of the final version. The second exception resulted from a clerical error in totaling hours on a timesheet. Management acknowledges that these errors indicate opportunities to strengthen payroll review, documentation, and reconciliation procedures. To address the finding, UVNR has implemented enhanced payroll controls designed to improve the accuracy, completeness, and documentation of payroll transactions charged to federal awards: • All payroll timesheets must receive documented supervisory approval before payroll is processed. Only the final approved version of the timesheet may be submitted for payroll processing. • Payroll staff will reconcile approved timesheets to the payroll register prior to payroll submission and retain the approved timesheets with the supporting payroll documentation. • An independent review of timesheet calculations and total hours will be performed before payroll is finalized to verify mathematical accuracy. • Version control procedures have been established to ensure that revised or corrected timesheets are clearly identified as the final approved version, with prior versions retained as appropriate for audit purposes. • Any payroll discrepancies identified after processing will be documented and corrected through the next available payroll cycle, with supporting documentation maintained for the adjustment. • In addition, management will provide refresher training to supervisors and payroll personnel regarding timesheet approval requirements, documentation retention, and payroll review procedures to promote consistent compliance with internal controls and federal grant requirements. Management expects these corrective actions to strengthen internal controls over payroll processing and prevent similar exceptions in the future. Due Date of Completion July 21, 2026 Responsible Party(ies) Co-Executive Directors
As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms w...
As noted in the findings of the Single Audit Report, there was a delay in completing the annual audit and therefore the data collection form was unable to be completed timely. Management is currently getting all outstanding audits completed and up to date and subsequently the data collection forms will be submitted.
Internal Control Over General Disbursements Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implement a formal way to document the review and approval of transportation costs charged from Knox County to provide evidence that internal controls are eff...
Internal Control Over General Disbursements Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: Implement a formal way to document the review and approval of transportation costs charged from Knox County to provide evidence that internal controls are effectively designed and implemented and functioning. Explanation of disagreement with audit finding: There is no disagreement with the finding regarding the need to formally document the review and approval of transportation costs charged by the Knox County Service Center (Garage). Action taken in response to finding: CAC’s vehicles are serviced at the Knox County Service Center (garage), with services billed monthly. Although transportation charges from the County were reviewed monthly, documentation of that review was not formally retained. Because the FY2023 and FY2024 audits were conducted concurrently, the enhanced documentation procedures implemented during FY2026 were not yet in operation during the FY2024 audit period. CAC implemented the following corrective actions: • Monthly review and approval of transportation charges by designated Finance personnel, including signature and date of review • Retention of supporting documentation with the monthly review to provide evidence of management approval Management will perform periodic review to ensure documentation controls are consistently applied. Name(s) of the contact person(s) responsible for corrective action: Misty Goodwin, Chief Executive Officer, Anna Roeder, Chief Financial Officer. Planned completion date for corrective action plan: Documentation procedures were implemented in February 2026 and remain operational with ongoing monitoring.
Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over documentation of periodic review of tenant files. Completion Date – 12/31/26
Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over documentation of periodic review of tenant files. Completion Date – 12/31/26
Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over timely reporting submissions. Completion Date – 12/31/26
Contact Person – Terry Hanson, Executive Director Corrective Action Plan – The Project will review its policies and procedures over timely reporting submissions. Completion Date – 12/31/26
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
Finding 2024-002: Internal Control over Compliance (Material Weakness) Name of Auditee’s Contact Person Responsible for Corrective Action: Nand Todi Corrective Action Planned: Management will enhance policies, procedures and controls to ensure appropriate reviews and approvals are in place and prope...
Finding 2024-002: Internal Control over Compliance (Material Weakness) Name of Auditee’s Contact Person Responsible for Corrective Action: Nand Todi Corrective Action Planned: Management will enhance policies, procedures and controls to ensure appropriate reviews and approvals are in place and properly documented. A member of the executive team will approve all invoices over $10,000 and treasurer will process the payment to the vendor. Management will also ensure formal documentation of executive team meetings related to approvals of expenses for vendors over $50,000, and a formal review to ensure the selected vendor is not debarred will be put into place. A member of the executive team will prepare the financial reports, which will be reviewed and approved by the treasurer prior to submission of future construction projects over $100,000. Anticipated completion date: Implemented July 2026
Finding 2024-001: Late Submission of Data Collection Form Name of Auditee’s Contact Person Responsible for Corrective Action: Nand Todi Corrective Action Planned: Management will ensure that submission of the data collection form to the federal clearinghouse is completed prior to the 9 month subsequ...
Finding 2024-001: Late Submission of Data Collection Form Name of Auditee’s Contact Person Responsible for Corrective Action: Nand Todi Corrective Action Planned: Management will ensure that submission of the data collection form to the federal clearinghouse is completed prior to the 9 month subsequent to the year end mandated deadline. Anticipated completion date: Implemented July 2026
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Lack of documentation of employee wages and lack of approval on employee time records. Management concurrence: Management concurs with this finding. ...
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Lack of documentation of employee wages and lack of approval on employee time records. Management concurrence: Management concurs with this finding. Corrective action plan: VAMHAR now has clear documentation on all payroll transactions and employee timesheets. In addition, there is adequate documentation of each employee's wage rate. Name of contact person: Daniel Franklin, Executive Director. Projected completion date: July 1, 2026.
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Lack of documentation and approval for certain purchases. Management concurrence: Management concurs with this finding. Corrective action plan: Manag...
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Lack of documentation and approval for certain purchases. Management concurrence: Management concurs with this finding. Corrective action plan: Management will ensure there is adequate documentation and approval for all purchases. Name of contact person: Daniel Franklin, Executive Director. Projected completion date: July 1, 2026.
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Incomplete procurement policies and procedures. Management concurrence: Management concurs with this finding. Corrective action plan: VAMHAR now has ...
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Incomplete procurement policies and procedures. Management concurrence: Management concurs with this finding. Corrective action plan: VAMHAR now has a procurement policy that aligns with the Uniform Guidance and it will be followed for future purchases under federal awards. Name of contact person: Daniel Franklin, Executive Director. Projected completion date: July 1, 2026.
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Late submission of audit reporting package. Management concurrence: Management concurs with this finding. Corrective action plan: Management will ens...
Finding type: Significant deficiency. Federal award: 93.912, Rural Health Care Services Outreach. Passthrough organization: Not applicable. Condition: Late submission of audit reporting package. Management concurrence: Management concurs with this finding. Corrective action plan: Management will ensure that the audit package is submitted to the clearinghouse in a timely manner. Name of contact person: Daniel Franklin, Executive Director. Projected completion date: December 31, 2026.
2024-010– Quarterly Project and Expense Reports Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Program. Coronavirus State and Local Fiscal Recovery Funds (CLSFRF); U.S. Department of Treasury; Assistance Listing Number 21.027; Direct aw...
2024-010– Quarterly Project and Expense Reports Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Program. Coronavirus State and Local Fiscal Recovery Funds (CLSFRF); U.S. Department of Treasury; Assistance Listing Number 21.027; Direct award only. Auditor Description of Condition and Effect: Although the City did prepare all of the quarterly reports required for fiscal year 2024, we noted that while the City had supporting reports from the accounting system for the amounts reported, there were several inconsistencies between the supporting reports and the report submitted. In addition, there were large variances between what was reported quarterly and what was posted to the general ledger and ultimately the schedule of expenditures of federal awards. Lastly, our testing of AP expenditures noted two items of cost, out of 40 tested, that did not appear to be related to approved projects noted in the quarterly reporting. The items were allowable costs for the CSLFRF grant, but the reports were not updated to reflect the inclusion. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all reporting of financial data is supported by the City's accounting records. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Chief Financial Officer Anticipated Completion Date: July 31, 2026
2024-009– Report Filing - 2024 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All awards. Audi...
2024-009– Report Filing - 2024 CAPER Finding Type. Immaterial Noncompliance/Significant Deficiency in Internal Control over Compliance (Reporting). Program. Community Block Grants/Entitlement Grants; U.S. Department of Housing and Urban Development; Assistance Listing Number 14.218; All awards. Auditor Description of Condition and Effect: As of the completion of audit fieldwork, the 2024 CAPER has not been filed. The City is exposed to an increased risk that future noncompliance could occur and not be prevented or detected by the City's internal controls. Auditor Recommendation: We recommend that the City implement necessary internal controls to ensure that all required reports are submitted in a timely manner. Corrective Action: The City will implement the necessary internal controls to ensure the policy for compliance is followed and documented. Responsible Person: Chief Financial Officer Anticipated Completion Date: July 31, 2026
Juel Fairbanks Chemical Dependency Services has implemented a signature of approval of all timecards and invoices before the payroll and invoices are printed.
Juel Fairbanks Chemical Dependency Services has implemented a signature of approval of all timecards and invoices before the payroll and invoices are printed.
LACK OF SEGREGATION OF DUTIES AND DISBURSEMENT CONTROLS RESULTING IN MISAPPROPRIATION OF FUNDS (ALN 10.558) 2024-003 Delaware Parents Association, Inc. acknowledges this finding. The individual responsible for the misappropriation has been relieved of duties and additional internal controls, includi...
LACK OF SEGREGATION OF DUTIES AND DISBURSEMENT CONTROLS RESULTING IN MISAPPROPRIATION OF FUNDS (ALN 10.558) 2024-003 Delaware Parents Association, Inc. acknowledges this finding. The individual responsible for the misappropriation has been relieved of duties and additional internal controls, including executive director oversight of timely bank reconciliations, have been implemented. The Organization will aggressively pursue all available avenues for recovery of misappropriated funds.
2024-008 Uniform Guidance Audit Pamela Mentz, 6/30/2027 Submission City Administrator Corrective Action planned to be taken: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facilitate a timely audit submission...
2024-008 Uniform Guidance Audit Pamela Mentz, 6/30/2027 Submission City Administrator Corrective Action planned to be taken: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facilitate a timely audit submission as set forth in the Uniform Guidance.
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, ...
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, the Payroll Specialist began saving physically signed timesheets that document allocations to grants. Beginning August 1, 2025, allocations to grants are captured within the payroll system, ADP, along with the supervisor approval. The Payroll Specialist verifies each line on the timesheet is approved, which the system requires for the employee to receive payment. Anticipated completion date: Corrective action of signed allocation timesheets was implemented July 1, 2025. Corrective action of allocations to grants within ADP was implemented August 1, 2025.
Views of Responsible Officials: Management has made significant changes in staffing and processes to ensure future Single Audit reports are completed within the required timeframes. Name and Title of Responsible Official: Oliver Rivers, Chief Operating Officer Anticipated Completion Date: September ...
Views of Responsible Officials: Management has made significant changes in staffing and processes to ensure future Single Audit reports are completed within the required timeframes. Name and Title of Responsible Official: Oliver Rivers, Chief Operating Officer Anticipated Completion Date: September 30, 2026
Finding Number: 2024-009 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Tarah Yaggie Corrective Action Planned: I was hired on 4/17/2024 and didn’t know about Covid 19 recovery funds. I r...
Finding Number: 2024-009 Finding Title: Reporting Program: 21.027 COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Tarah Yaggie Corrective Action Planned: I was hired on 4/17/2024 and didn’t know about Covid 19 recovery funds. I reached out to ABDO for assistance going forward. Anticipated Completion Date: 6/12/2026
Finding Number: 2024-007 Finding Title: Eligibility – MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cindy Noetzelman Corrective Action Planned: Cases have been corrected and there was a discussion with staff on the process and the need ...
Finding Number: 2024-007 Finding Title: Eligibility – MAXIS Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cindy Noetzelman Corrective Action Planned: Cases have been corrected and there was a discussion with staff on the process and the need for correct entries. We will continue to review at monthly staffing meetings to ensure correct procedures continue to be followed. Anticipated Completion Date: Cases have been corrected as of Dec 31, 2025
U.S. Department of Housing and Urban Development Community Development Block Grant – Assistance Listing No. 14.218 Recommendation: We recommend the City implement policies and procedures to ensure that the Federal Funding Accountability and Transparency Act (FFATA) reporting occurs for all subawards...
U.S. Department of Housing and Urban Development Community Development Block Grant – Assistance Listing No. 14.218 Recommendation: We recommend the City implement policies and procedures to ensure that the Federal Funding Accountability and Transparency Act (FFATA) reporting occurs for all subawards of $30,000 or more for all federal awards and that the reporting be performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Finance Department will ensure that all departments are aware of this compliance requirement and ensure reporting requirements are performed timely in relation to subawards. Name(s) of the contact person(s) responsible for corrective action: Rebecca Campbell, Finance Director Planned completion date for corrective action plan: July 2026
Root Cause Analysis: The root cause of this finding was a misapplication of the approved indirect cost rate to the appropriate Modified Total Direct Cost (MTDC) base in connection with drawdown calculations. Although The EPI Center had an approved indirect cost rate and related policy in place, the ...
Root Cause Analysis: The root cause of this finding was a misapplication of the approved indirect cost rate to the appropriate Modified Total Direct Cost (MTDC) base in connection with drawdown calculations. Although The EPI Center had an approved indirect cost rate and related policy in place, the operational procedures and system configurations necessary to consistently apply the methodology were still being refined and operationalized. The EPI Center notes that a formal, written Indirect Cost Rate Policy consistent with Uniform Guidance (2 CFR Part 200) was in place at the time of award. However, during the initial year of administering a federal award as fiscal agent, the procedures outlined in the policy were not fully operationalized. This resulted in a misapplication of the approved indirect cost rate. The overdraw resulted from applying the indirect cost rate to budgeted, rather than actual, direct expenditures. Management has since recalculated allowable indirect costs based on actual expenditures and has implemented enhanced controls to ensure accurate application of the MTDC base and compliance with federal requirements going forward. Response, with details: ☒Corrective Action Plan ☐Clarification Management acknowledges the misapplication of the approved indirect cost rate and has taken immediate steps to correct the calculation and ensure full alignment with federal requirements. Specifically, The EPI Center has recalculated indirect costs based on allowable expenditures within the Modified Total Direct Cost (MTDC) base and is actively engaging with the U.S. Department of Education to determine the appropriate resolution of the overdrawn amount. Management confirms that all underlying expenditures charged to the program were allowable, allocable, and supported by appropriate documentation, and no unallowable costs were identified. Corrective Actions Management has implemented the following corrective actions to address the issue and strengthen internal controls: 1. Training and Capacity Building (Completed - April 2026) Finance staff and senior leadership have completed targeted training on the application of indirect cost requirements under Uniform Guidance to reinforce compliance expectations. 2. Recalculation and Resolution of Overdraw (Implementation Initiated) The EPI Center has recalculated allowable indirect costs by applying the restricted 8 percent indirect cost rate for Teacher and School Leader Incentive Program (TSL) grants to actual expenditures incurred during the reporting period. The program officer has been informed of the miscalculation and resulting overdraw. The EPI Center will follow all applicable agency protocols upon receiving formal guidance from the U.S. Department of Education. Management is actively coordinating with the U.S. Department of Education to resolve the calculated overdraw and will comply with all agency guidance, including repayment of any amounts determined to be unallowable. Controls are now in place to ensure that all future drawdowns are calculated based on the approved indirect cost rate applied to the MTDC base and are subject to documented review prior to submission. 3. Standardized Indirect Cost Calculation Worksheets (Completed - April 2026) A standardized indirect cost calculation worksheet will be required and reviewed prior to approval of all drawdown requests. 4. Independent Oversight (Completed – June 2025) The EPI Center has engaged a third-party controller who will review and independently validate indirect cost calculations prior to submission, providing an added layer of oversight and control. Responsible Party: Finance and Compliance Manager, Third-party Controller, CEO Timeline for Completion: May 2026
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