Corrective Action Plans

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Condition The Data Collection Form was not submitted to the Federal Audit Clearinghouse within the nine-month period for the year ended December 31, 2024. Views of Responsible Officials and Corrective Action Taken The Organization agrees with the finding and will file the report.
Condition The Data Collection Form was not submitted to the Federal Audit Clearinghouse within the nine-month period for the year ended December 31, 2024. Views of Responsible Officials and Corrective Action Taken The Organization agrees with the finding and will file the report.
Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testi...
Finding 2024-006 Compliance Requirement: Special Tests and Provisions-Sliding Fee Discounts Significant Deficiency Assistance Living Number 93.224 Health Center Programs Grant Award Number H80CS00112 US Department of Health and Human Services Condition: Of the twenty-five-patients selected for testing the Federal Poverty Guideline (FPG) was inaccurately applied for two patients. Action Planned in Response to the Finding: In the past year, the collection and retention of sliding fee discount qualifying documents have been integrated and the calculation performed by the clinic’s electronic medical record system. An employee was added, in part, to provide oversite of the sliding discount process. Official Responsible for Ensuring the CAP: Darian Davis Planned Completion Date: December 2025
Finding 2024-005 Compliance Requirement: Auditee Responsibility Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The Schedule of Federal Awards (SEFA) prepared for the audit did not include ...
Finding 2024-005 Compliance Requirement: Auditee Responsibility Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The Schedule of Federal Awards (SEFA) prepared for the audit did not include pass through funds received from the State of Minnesota. Also, the SEFA for the current year contains expenditures of the prior period (COVID-19) which should have been included on the prior year SEFA. Action Planned in Response to the Finding: Additional training on single audit guidelines and federal grant management will be provided to the staff who prepare documents for submission. Official Responsible for Ensuring the CAP: Bruce Craven Planned Completion Date: December 2025
Finding 2024-004 Compliance Requirement: Reporting Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The report for the year ending December 31, 2024, was not filed within the required report...
Finding 2024-004 Compliance Requirement: Reporting Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: The report for the year ending December 31, 2024, was not filed within the required report submission period. Action Planned in Response to the Finding: The new management team has established transparency with the Finance Committee and the Governing Board to increase accountability and have established a regiment which includes timely audit engagement and monthly and annual checklists that ensure deadlines are met. Official Responsible for Ensuring the CAP: Bruce Craven Planned Completion Date: December 2025
View Audit 371776 Questioned Costs: $1
Finding 2024-003: Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: A walkthrough of fourteen individuals was performed to review person...
Finding 2024-003: Compliance Requirement: Allowable Cost/Cost Principles Material Weakness Assistance Living Number 93.224 Community Health Centers Grant Award Number H80CS00112 US Department of Health and Human Services Condition: A walkthrough of fourteen individuals was performed to review personnel files and payroll related to salary for the Organization. Of the fourteen files reviewed, eight had no approved current pay rate documented, one was paid at a rate different from the current rate in the file, two files did not contain an I-9 Form, and one was missing Form W-4. Also, there was no time sheet provided to support the time charged to the federal grant for three of the fourteen individuals tested. Action Planned in Response to the Finding: All payroll activities are managed through ADP. The Human Resources team has assigned grant codes to each staff member which identifies the source of funding that supports their salary. During the timecard approval process for each payroll, the hours worked for a particular grant source will be included. Additionally, the Finance team has taken the following steps to strengthen compliance and accuracy in grant reporting: 1. Assigned personnel whose responsibilities are 100% fully dedicated to specific grant activities. 2. Maintained a detailed allocation table tracking employee time and effort by individual grant. Official Responsible for Ensuring the CAP: Marilyn Powers-Campbell Planned Completion Date: December 2025
View Audit 371776 Questioned Costs: $1
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center will form a process to ensure filing of personnel action forms is consistent and that hardcopies of personnel action forms are available. Completion Date Fiscal Year 2025
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center will form a process to ensure filing of personnel action forms is consistent and that hardcopies of personnel action forms are available. Completion Date Fiscal Year 2025
View Audit 371750 Questioned Costs: $1
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2025
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2025
View Audit 371750 Questioned Costs: $1
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented and reviewed by outsourced CPA firm. Completion Date Fiscal Year 2025
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented and reviewed by outsourced CPA firm. Completion Date Fiscal Year 2025
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and approved and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2025
Contact Person Michelle Erickson Corrective Action Plan The Abused Adult Resource Center’s payroll allocations for grants will be documented on timesheets and approved and the hard copies will be filed or scanned onto a local drive kept by the Center. Completion Date Fiscal Year 2025
View Audit 371750 Questioned Costs: $1
Management will implement an internal procedure to ensure proper filing within 30 days of quarter end to be in reporting compliance.
Management will implement an internal procedure to ensure proper filing within 30 days of quarter end to be in reporting compliance.
To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed ...
To address the noted deficiencies in tenant file documentation, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
Finding: Reporting—financial and performance reports Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in ...
Finding: Reporting—financial and performance reports Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial processes including grant reconciliation. This updated contractual agreement & relationship occurred on March 1, 2024. ▪ Taken: An ongoing process has been put in place to ensure multiple checks and balances are conducted prior to grant submission to identify reporting requirements and responsible parties. This will be facilitated by our Development team with assistance of our outsourced accounting firm, this process was implemented July 1, 2025. ▪ Taken: Stronger supervision of required reporting and deadlines. This will be facilitated by our Chief Development Officer, Nick Roman with our Sikich partners. This control process was implemented July 1, 2025 ▪ Planned: Alignment with our Board approved Financial Policy documentation that includes information on appropriate finance and accounting processes. The review and assessment of our current processes to the Finance Policy will be conducted by our external accounting firm, with a completion of that process occurring by September 30th, 2025.
The organization acknowledges that time and effort procedures were not consistently followed throughout FY24. The organization has implemented a new system of reporting designed to capture time and effort of all employees charged to government grant and contracts, as well as other grants and contrac...
The organization acknowledges that time and effort procedures were not consistently followed throughout FY24. The organization has implemented a new system of reporting designed to capture time and effort of all employees charged to government grant and contracts, as well as other grants and contracts awarded to the agency from the philanthropic community. Additionally, along with the timesheet, the agency now requires that an attestation statement is prepared quarterly by Program Managers and Directors for all employees charged to grants to attest to the actual amount of time spent and allocated to the grants. The organization has expanded administrative oversite of the finance department and financial data and has hired a Finance Director who has spent a considerable amount of time training staff and managers regarding their allocations and their obligations to track their time. The Finance Director has trained our expanded finance team on ensuring that accounting policies and procedures are strictly adhered to and that GAAP is uniformly applied to all financial data of the agency.
View Audit 371690 Questioned Costs: $1
The organization acknowledges that unallowable rent costs were claimed and payment received under government grants and contracts resulting in overstating revenues for FY24, and that adjustments were necessary to the financial statements to correct the resulting deficiencies. As indicated, however, ...
The organization acknowledges that unallowable rent costs were claimed and payment received under government grants and contracts resulting in overstating revenues for FY24, and that adjustments were necessary to the financial statements to correct the resulting deficiencies. As indicated, however, this overstating was due to the unique situation that existed as a result of the landlord’s breaking the organization’s lease, suddenly and without notice. Rent costs were claimed for as long as the organization was liable for the rent. After the liability was forgiven by the landlord, rent costs were returned to the funders.
View Audit 371690 Questioned Costs: $1
Supporting Documentation of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure proper supporting documentation is maintained and available for each expenditure. There is no disagreement with the audit finding. Act...
Supporting Documentation of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure proper supporting documentation is maintained and available for each expenditure. There is no disagreement with the audit finding. Action planned/taken in response to finding: Outside accounting firm will be ensure proper supporting documentation is maintained and available for each expenditure. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately
Views of Responsible Officials: Management understands and agrees. Unfortunately, this issue was identified late into FY24 when the FY23 audit was being completed so the issue persisted into FY24. From the corrective action plans taken from the FY23 audit and desk review, this issue has been address...
Views of Responsible Officials: Management understands and agrees. Unfortunately, this issue was identified late into FY24 when the FY23 audit was being completed so the issue persisted into FY24. From the corrective action plans taken from the FY23 audit and desk review, this issue has been addressed and resolved in early FY25. MBN currently has an SOP regarding fixed assets that is already implemented. To address these concerns, MBN updated the SOP to include a clear process for equipment disposals, specifically for assets with a fair market value over $10,000, in accordance with Uniform Guidance. This update will ensure that all disposals are properly documented, and appropriate notifications are made to USAGM. We would like to confirm that the equipment disposal forms have already been updated to ensure that all necessary responses are reviewed and accurately completed as part of the notification process for disposals. Furthermore, we have strengthened our tracking, reporting and disposal processes to ensure the final disposition of equipment, including salvage value, is appropriately recorded.
Views of Responsible Officials: Management agrees and if funding had not stopped, audit fieldwork was originally slated to begin April 1st which would have allowed for timely completion. We fully intend to complete our FY25 audit well before the nine-month deadline.
Views of Responsible Officials: Management agrees and if funding had not stopped, audit fieldwork was originally slated to begin April 1st which would have allowed for timely completion. We fully intend to complete our FY25 audit well before the nine-month deadline.
Views of Responsible Officials: Management agrees and was fully aware of the situation it found itself in when funding was cut. The Organization was not able to keep enough staff employed during this time to review and correct these errors before the audit fieldwork began. Now that these historical ...
Views of Responsible Officials: Management agrees and was fully aware of the situation it found itself in when funding was cut. The Organization was not able to keep enough staff employed during this time to review and correct these errors before the audit fieldwork began. Now that these historical balances have been corrected, the team undergoes a rigorous month-end close process where these issues will be caught and addressed immediately going forward.
Condition: The Town’s procurement files did not contain documentation regarding competitive procurement procedures for one contract. The Town, through the Raynham Center Water District, awarded a contract for final design services for two water treatment plants to a vendor that had previously provid...
Condition: The Town’s procurement files did not contain documentation regarding competitive procurement procedures for one contract. The Town, through the Raynham Center Water District, awarded a contract for final design services for two water treatment plants to a vendor that had previously provided preliminary evaluations for the plants, without performing competitive procurement procedures. Corrective Action Planned: The Town will implement policies and procedures to ensure a competitive procurement is performed in accordance with federal procurement guidelines for all applicable contracts paid with federal funds. Anticipated Completion Date: August 2025 Contact: Christopher P. Laviolette, CPA, Finance Director/Town Accountant
Section 232 HUD Insured Mortgage Note Payable - Assistance Listing No. 14.129 Recommendation: The Community should adhere to the Regulatory Agreement and obtain HUD’s approval prior to taking any action specifically precluded in the Regulatory Agreement. Explanation of disagreement with audit findin...
Section 232 HUD Insured Mortgage Note Payable - Assistance Listing No. 14.129 Recommendation: The Community should adhere to the Regulatory Agreement and obtain HUD’s approval prior to taking any action specifically precluded in the Regulatory Agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Community is working with HUD to obtain the necessary approvals. Name(s) of the contact person(s) responsible for corrective action: Amber Swords Planned completion date for corrective action plan: December 31, 2025
Name of auditee: Neurovascular Diagnostics, Inc. TIN: 81-2945332 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: Vince Tutino vincentt@buffalo.edu Finding 2024-001 Neurovascular Diagnostics (the Company) attempted to receive ap...
Name of auditee: Neurovascular Diagnostics, Inc. TIN: 81-2945332 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: Vince Tutino vincentt@buffalo.edu Finding 2024-001 Neurovascular Diagnostics (the Company) attempted to receive approval from the federal awarding agency to elect the program-specific audit option to satisfy reporting requirements. After several attempts without response, the Company opted to have a full financial statement audit conducted. The Company engaged a certified public accounting firm to conduct the audit for the year ended December 31, 2024 and completed its audit and reporting requirements as of October 2025. Further, the Company intends to engage the same firm in future years to ensure timely submission of the data collection form to the Federal Audit Clearinghouse.
SNAP Cluster, Child Support Services and Medicaid Cluster – Assistance Listing No. 10.561, 93.563, 93.778 Recommendation: We recommend the County runs annual full user reports to ensure that access is being granted and terminated in a timely basis. Explanation of disagreement with audit finding: The...
SNAP Cluster, Child Support Services and Medicaid Cluster – Assistance Listing No. 10.561, 93.563, 93.778 Recommendation: We recommend the County runs annual full user reports to ensure that access is being granted and terminated in a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will develop and implement new policy and procedures. Names of the contact persons responsible for corrective action: Andrea Perea and Charles Lewis Planned completion date for corrective action plan: October 31, 2025
COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County follow their internal procurement policy procedures and keep documentation of such procedures to ensure compliance with the federal procurement requirements. E...
COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) – Assistance Listing No. 21.027 Recommendation: CLA recommends the County follow their internal procurement policy procedures and keep documentation of such procedures to ensure compliance with the federal procurement requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies and procedures to ensure that future awards or contracts with expenditures of American Rescue Plan (APRA) funds will follow the procurement guidelines outlined in the US Treasury rules and regulations as well as County procurement policies. Most of the 2024 expenditures were part of contracts that were already in place when the original findings came out in September 2023 so this could not be corrected. Name of the contact person responsible for corrective action: Craig McBrain, Deputy Director of Budget and Finance Planned completion date for corrective action plan: December 31, 2025
Food Distribution Cluster– Assistance Listing No. 10.565, 10.568, and 10.569 Recommendation: We recommend the County review controls and procedures surrounding the programs including review and record retention requirements. Explanation of disagreement with audit finding: There is no disagreement wi...
Food Distribution Cluster– Assistance Listing No. 10.565, 10.568, and 10.569 Recommendation: We recommend the County review controls and procedures surrounding the programs including review and record retention requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will develop and implement new policy and procedures to appropriate review and record retention. Names of the contact persons responsible for corrective action: Tanya Gurule Planned completion date for corrective action plan: December 31st, 2025
A procedure has been created for this and will be implemented and looked at 1/4ly so funds can be spent down during the school year. Immediate steps were taken to do a spenddown plan and the food serviced fund was used for the program to bring down the fund balance to less than the three-month avera...
A procedure has been created for this and will be implemented and looked at 1/4ly so funds can be spent down during the school year. Immediate steps were taken to do a spenddown plan and the food serviced fund was used for the program to bring down the fund balance to less than the three-month average expenditures.
View Audit 371424 Questioned Costs: $1
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