Corrective Action Plans

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Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service ...
Special Tests and Provisions Significant Deficiency in Internal Control over Compliance and Instance of Noncompliance Department of Agriculture Federal Financial Assistance Listing #10.766 Community Facilities Loans and Grants Finding Summary: The Hospital did not maintain the required debt service coverage ratio for the year ended December 31, 2025. Additionally, the Hospital does not have a control process in place to ensure that the monitored debt service coverage ratio is accurate and non-compliance is reported timely. Responsible Individuals: Eric J. Price, CFO Corrective Action Plan: Management has enhanced internal control policies and processes to monitor compliance with debt covenants, including the periodic calculation of debt service coverage ratio, documentation of management review and approval, and timely communication with the lender if noncompliance is identified. Anticipated Completion Date: September 30, 2026
PLANNED CORRECTIVE ACTION The Division will communicate to all units conducting USDA Foods inventory counts the requirement that inventory reports must include documented evidence of review prior to submission. The Division's Social Services department will incorporate verification of documented inv...
PLANNED CORRECTIVE ACTION The Division will communicate to all units conducting USDA Foods inventory counts the requirement that inventory reports must include documented evidence of review prior to submission. The Division's Social Services department will incorporate verification of documented inventory review into its quarterly internal oversight process to ensure compliance with this requirement on an ongoing basis. ANTICIPATED COMPLETION DATE 10/1/26 RESPONSIBLE CONTACT PERSON Julie Luft, NW Social Services Director
PLANNED CORRECTIVE ACTION The Division will contact each unit distributing TEFAP assistance to reinforce the requirement to retain documentation regarding the determination of client eligibility and will review and strengthen existing policies and procedures related to form completion and retention....
PLANNED CORRECTIVE ACTION The Division will contact each unit distributing TEFAP assistance to reinforce the requirement to retain documentation regarding the determination of client eligibility and will review and strengthen existing policies and procedures related to form completion and retention. The Division's Social Services department will implement a quarterly internal review process to provide increased oversight and monitoring across all distributing units. ANTICIPATED COMPLETION DATE 10/1/26 RESPONSIBLE CONTACT PERSON Julie Luft, NW Social Services Director
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization continues to make improvements to processes and procedures to ensure the accurate documentation and application of sliding fee discounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Matt Morrill, CFO, at 970-871-7635.
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: April 2026
Section 202 HUD-Insured Mortgage– Assistance Listing No. 14.157 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place t...
Section 202 HUD-Insured Mortgage– Assistance Listing No. 14.157 The Project is required to make a deposit into the residual receipts account within 90 days after year end in the amount of any surplus cash. Recommendation: We recommend management ensure they have the controls and processes in place to make the residual receipts deposit timely. Action taken in response to finding: Management will review procedures to ensure they have the process in place to ensure timely deposit going forward. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: October 2025
Finding 1219022 (2025-002)
Material Weakness 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.157 Management is responsible for maintaining required monthly deposits into the Replacement Reserve account in accordance with the form HUD-9250. Recommendation: The Project should establish and follow a consistent monthly review process t...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.157 Management is responsible for maintaining required monthly deposits into the Replacement Reserve account in accordance with the form HUD-9250. Recommendation: The Project should establish and follow a consistent monthly review process to ensure all deposits are made on a timely basis. Action taken in response to finding: Management continues to review and establish processes related to review and approval to ensure monthly replacement reserve deposits are made. The missed July payment was made April of 2026. The Project currently does not have the funds to make the deposit and is working with HUD to resolve. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: December 31, 2026
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The security deposit liability needs to be funded by a security deposit asset equal to or greater than the liability. Recommendation: We recommend management ensure they have controls and processes in place to ensure the security deposi...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.155 The security deposit liability needs to be funded by a security deposit asset equal to or greater than the liability. Recommendation: We recommend management ensure they have controls and processes in place to ensure the security deposit liability account is properly funded at all times. Action taken in response to finding: The property sold on November 30, 2025, and the security deposit cash was transferred to the new owners at that point. The $342 shortage in cash was considered in the sale but was not transferred from operating to the security deposit cash before the sale took place. Name of the contact person responsible for corrective action: Thomas Krolak Planned completion date for corrective action plan: November 30, 2025
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Distributions and payments on surplus cash notes must be within amounts permitted based upon semi-annual surplus cash calculations. Recommendation: Recommend that management account for surplus cash note payments when determining how mu...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Distributions and payments on surplus cash notes must be within amounts permitted based upon semi-annual surplus cash calculations. Recommendation: Recommend that management account for surplus cash note payments when determining how much cash is available for distribution in accordance with the semi-annual surplus cash calculations and review those calculations for accuracy prior to distributions being made. There is no disagreement with the audit finding. Action taken in response to finding: We have surplus cash remaining at December 31, 2025, subsequent to the distributions being made, therefore the finding has corrected itself. Future distributions and payments on surplus cash notes will be monitored closely to ensure they are limited to amounts permitted. Name of the contact person responsible for corrective action: Doug Harrison Planned completion date for corrective action plan: December 31, 2026
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that manage...
Section 232 HUD-Insured Mortgage– Assistance Listing No. 14.129 Management is required to retain the HUD approved management agreement to ensure payments made are in accordance with HUD requirements. The Project does not have a HUD approved management agreement. Recommendation: Recommend that management work with HUD to have the current management agreement approved. There is no disagreement with the audit finding. Action taken in response to finding: We have contacted HUD to obtain an approved management agreement. Name of the contact person responsible for corrective action: Doug Harrison Planned completion date for corrective action plan: December 31, 2026
The Alabama Department of Public Health will ensure all expenditures are adequately documented, based on true and accurate invoices, and allowable under the federal award. • The Immunization Division continues to reorganize with the new leadership team. Staff reviews grant guidance semi-annually, or...
The Alabama Department of Public Health will ensure all expenditures are adequately documented, based on true and accurate invoices, and allowable under the federal award. • The Immunization Division continues to reorganize with the new leadership team. Staff reviews grant guidance semi-annually, or when updated, with program grant monitoring staff to ensure compliance. • Invoices and supporting documentation are being reviewed for source documents against grant guidance by program staff and approved by Operations Manager or Division Director to ensure costs to the grant are reasonable, allowable, allocable, and consistently applied before forwarding to Finance. • Grant monitoring staff use the Risk Assessment and Subrecipient monitoring policy to ensure that all reimbursements of expenses are adequately documented, based on true and accurate invoices, and costs are allowable under the federal award. • ADPH Bureau of Financial Services has developed and required the use of a Subrecipient Field Voucher form to include certification statement referencing 2 CFR200 in regard to invoices, along with conducting ffirther reviews of invoices before uploading into STAARS for payment. • All program grant staff have access to attend all available Finance and Grant training courses. • ADPH Bureau of Financial Services has created a Grant Management Centralized Guidance Repository in the ADPH Document Library for access by all ADPH staff • ADPH Bureau of Financial Services is developing an ADPH Grant Manual. • ADPH Bureau of Financial Services will develop policies and procedures related to media usage, college awareness campaigns, and sponsorships to ensure adequate documentation is available to verify the allowability of the expenditures in relation to various programs.
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION, PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION, HIGHWAY PLANNING AND CONSTRUCTION 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF TRANSPORTATION, PASSED THROUGH MINNESOTA DEPARTMENT OF TRANSPORTATION, HIGHWAY PLANNING AND CONSTRUCTION 2025-001 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR § 180 requires the City of Prior Lake (the City) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements applicable to the highway planning construction grant. The City did not have sufficient controls in place within its highway planning and construction grant to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned – The City will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible – The City’s Finance Director, Nicole Klekner. Planned Completion Date – December 31, 2026. Disagreement With or Explanation of Finding – The City agrees with this finding. Plan to Monitor – The City’s Finance Director, Nicole Klekner, will ensure appropriate controls are in place to verify that any vendor with which the City contracts for federal program goods or services exceeding $25,000 is not listed as suspended or debarred on the federal Excluded Parties List System website.
Finding 1218974 (2025-101)
Material Weakness 2025
PAYROLL CONTROLS Criteria: In accordance with the documentation standards of 2 CFR section 200.430(a), costs of compensation for personal services are allowable to the extent the total compensation for individual employees is reasonable for the services rendered, conforms to the established written ...
PAYROLL CONTROLS Criteria: In accordance with the documentation standards of 2 CFR section 200.430(a), costs of compensation for personal services are allowable to the extent the total compensation for individual employees is reasonable for the services rendered, conforms to the established written policy of the recipient or subrecipient and is determined and supported as provided in 2 CFR section 200.430(g), which states that charges to federal awards for salaries and wages must be based on records that accurately reflect the work performed. Condition: Payroll testing was completed for a sample of 40 individuals for which time and expenses were charged to R&D grants. Within that selection, we noted instances where payroll controls did not function properly in regard to percentage of time allocated to a grant, proper pay code inclusion, fringe benefit calculation and timely and supervisor level review of time sheets. Context: Management was able to isolate the time allocation error to 20 employees for which the time and costs charges to the grants were in excess of actual time allocation. This resulted in $87,831.53 in excess charged to the grants. Additional control deficiencies did not result in significant improper grant expenditures. Cause: A new payroll system was implemented in fiscal 2025. Grant allocation percentages were not accurately established in the payroll system upon conversion. Effect: Time charged to grant efforts by certain individuals exceeded actual time worked. Recommendation: Review controls should be enhanced to ensure grant expenditures accurately reflect payroll costs. Corrective Actions Taken or Planned: Management identified the issue early following implementation of the new payroll system and performed a detailed review to isolate the impacted population. Corrections were made to payroll allocations for the affected employees, and reimbursement adjustments were processed as appropriate. To prevent recurrence, management has implemented the following control enhancements: - Standardized procedures for establishing and validating grant allocation percentages within the payroll system; - Enhanced supervisory review requirements for time reporting and payroll approvals; - Periodic monitoring and reconciliation of payroll charges to grant budgets; - Additional training for payroll and grant accounting personnel on system configuration and compliance requirements. Responsible Parties: VP of Accounting and Controller and VP of Audit & Compliance. Anticipated Completion Date: Completed in fiscal year 2025; ongoing monitoring procedures are in place.
Finding: 2025-002 Reportable finding considered a material weakness-Expenses incurred outside of the period of performance Effect: The organization claimed and was reimbursed for unallowable costs under 2 CFR 200.458. Failure to maintain effective controls over cost allowability increases the risk o...
Finding: 2025-002 Reportable finding considered a material weakness-Expenses incurred outside of the period of performance Effect: The organization claimed and was reimbursed for unallowable costs under 2 CFR 200.458. Failure to maintain effective controls over cost allowability increases the risk of noncompliance questioned costs, and potential repayment of federal funds. Questioned costs: Known questioned costs of $403,805 were identified by reviewing each transaction prior to the date and for the month after the award began to ensure there are no likely questioned costs. Recommendation for the organization from the auditor: • Formalize and implement written policies and procedures governing identification, approval, and accounting for pre-award costs. • Require documented written approval from the federal awarding agency prior to charging any pre-award costs to federal awards. • Provide training to program and finance personnel on Uniform Guidance cost allowability requirements, including 2 CFR 200.458 and 2 CFR 200.403. • Implement supervisory review controls to ensure costs charged to federal awards are incurred within the approval period of performance or have documented prior approval. Corrective Action Plan for Pre-award costs Management acknowledges the audit finding that pre-award costs were charged to multiple federal awards for expenses incurred before the approved period of performance beginning October 1, 2024. The costs were incurred without the required written prior approval from the Maryland Department of Labor (MD DOL), the pass-through entity. As a result, unallowable costs were reimbursed and later removed from the Schedule of Expenditures of Federal Awards (SEFA). Management determined that the issue resulted from insufficient internal controls, the absence of formal written procedures for pre-award costs, and gaps in staff understanding of Uniform Guidance requirements. To address these root causes, the organization adopted a formal written policy governing the identification, approval, documentation, and accounting of pre-award costs. The policy requires written prior approval from MD DOL before any pre-award costs may be incurred or charged to a federal award and establishes documentation, retention, and accounting standards to support compliance with 2 CFR 200.458 and 2 CFR 200.403. Third, the organization also implemented a mandatory written approval workflow requiring program and grants staff to prepare and submit a formal request to MD DOL whenever pre-award costs are anticipated. No costs may be incurred until written approval is received. Approval documentation must be retained in both the official grant file and the accounting system. This workflow is now part of the grant start-up process for all federal awards. Fourth, the organization strengthened supervisory review controls to ensure that all costs charged to federal awards fall within the approved period of performance or have documented prior approval. These controls include a pre-posting cost allowability checklist, supervisory review and approval of all federal charges, and accounting system alerts that flag costs incurred outside the period of performance. Additionally, the Compliance Officer will conduct quarterly internal compliance reviews to verify adherence to federal requirements and internal policies. Finally, the organization implemented preventive measures to ensure long-term compliance. These include maintaining a centralized grant calendar with period-of-performance dates, requiring dual review of costs charged during the first 90 days of new awards, and conducting semi-annual internal audits of federal expenditures. Any discrepancies identified will be reported to senior leadership within five business days. Management is committed to ensuring full compliance with Uniform Guidance and MD DOL requirements. All corrective actions described above have been implemented or will be fully implemented by July 31, 2026. The organization believes these actions sufficiently address the audit findings and significantly strengthen internal controls over federal award management. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Develop and implement formal Pre-award Cost Policy Finance Director June 1, 2026 Final approved policy; distribution email; policy posted to shared drive Establish mandatory written prior approval workflow Finance Director June 30, 2026 Completed approval request template; sample approval documentation; updated grant file checklist Conduct Uniform Guidance training Compliance Officer July 31, 2026 Training materials; attendance logs; post-training assessments Implement supervisory review controls Finance Director June 30, 2026 Completed checklists; system screenshots; supervisor sign-offs Perform quarterly internal compliance reviews Compliance Officer Quarterly, ongoing Quarterly review reports; corrective action memos (if applicable) Maintain centralized grant calendar Director of Performance and Compliance June 30, 2026 Updated grant calendar; access logs or distribution email Conduct semi-annual internal audits Compliance Officer Semi-annual, ongoing Internal audit reports; follow-up documentation Dual review of early-period charges Finance Director; Grants Manager July 1, 2026 Dual-review sign-off forms; documented approvals
Management Response: Management acknowledges Finding 2025-004 and agrees that weaknesses in the review and approval of expenses represent a material weakness in internal control over compliance. The reimbursement of personal credit card expenses and the charging of those transactions to federal awar...
Management Response: Management acknowledges Finding 2025-004 and agrees that weaknesses in the review and approval of expenses represent a material weakness in internal control over compliance. The reimbursement of personal credit card expenses and the charging of those transactions to federal awards resulted in unallowable costs and demonstrated a breakdown in the review process for employee reimbursements and supporting documentation. Although the known questioned costs total only $46, the broader risk is that additional unallowable, unsupported, or improperly coded expenses could be charged to federal awards if review controls are not strengthened. Management determined that the root causes included insufficiently detailed procedures for reviewing employee reimbursement requests, inconsistent verification of business purpose and allowability before reimbursement, and inadequate supervisory review of expense documentation before costs were posted to federal awards. Existing controls were not precise enough to identify personal or otherwise unallowable charges embedded within reimbursement activity, particularly when descriptions were incomplete or reviewers did not independently confirm that the expense was necessary, reasonable, properly documented, and allowable under Uniform Guidance. To address this material weakness, management is implementing a corrective action plan focused on strengthening pre-payment and pre-posting review of employee reimbursements and other expense transactions charged to federal awards. The plan includes four key actions: revising reimbursement and accounts payable procedures to require detailed support for every request; requiring documented secondary review by supervisory or finance personnel independent of the submitter; implementing exception-based review procedures for higher-risk transactions; and performing periodic post-payment monitoring to confirm that review procedures are operating effectively and that unallowable costs are promptly identified and corrected. Under the revised process, no employee reimbursement or expense charged to a federal award will be approved unless the request includes sufficient supporting documentation to allow the reviewer to determine that the cost is necessary, reasonable, allocable as applicable, consistently treated, and adequately documented in accordance with Uniform Guidance cost principles. Reviewers will be required to confirm the business purpose of the transaction, assess whether the type of cost is allowable under the terms of the award and applicable federal regulations, and verify that no personal items, duplicate charges, sales tax errors, or unsupported amounts are included. If documentation is incomplete or a charge appears questionable, the transaction will be held pending clarification, recoded to a non-federal source, or denied reimbursement as appropriate. Any unallowable expense identified after reimbursement will be promptly removed from the applicable federal award and reported through management’s corrective follow-up procedures. Management will also reinforce accountability through targeted training and oversight. Employees who prepare, review, approve, or process reimbursements and expense reports affecting federal awards will receive training on allowable cost principles, documentation expectations, and the importance of careful review under 2 CFR Part 200, including the requirement that costs be adequately documented and necessary and reasonable for the performance of the federal award. In addition, Finance will generate periodic exception reports highlighting reimbursement activity charged to federal awards, personal credit card reimbursements, and other transactions meeting defined risk criteria. These reports will be reviewed by management to identify trends, address control failures, and implement additional corrective measures when needed. Management believes these corrective actions directly address the auditors’ recommendations and strengthen controls over the review and approval of expenses charged to federal awards without repeating the corrective actions already established for pre-award costs, allocation methodology, or broader financial close procedures. Responsibility for implementation will rest primarily with the Finance Director, in coordination with accounts payable, grants, and program leadership. Management expects enhanced documentation standards, independent review requirements, exception-based oversight, and monitoring activities to reduce the risk of personal or otherwise unallowable expenses being reimbursed and charged to federal awards in future periods. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written expense reimbursement and accounts payable review procedures requiring itemized receipts, documented business purpose, funding source identification, and explicit confirmation that requested costs are not personal in nature. Finance Director; Accounts Payable Supervisor June 30, 2026 Approved procedures; updated reimbursement forms; staff distribution records. Implement a standardized reimbursement review checklist requiring reviewer validation of allowability, Accounts Payable Supervisor; July 15, 2026 Completed checklist template; sample reviewed reimbursement business purpose, receipt support, coding accuracy, and identification of any personal or unsupported charges before reimbursement or posting to a federal award. Finance Director packages; approval signoff documentation. Require independent supervisory review and approval for all employee reimbursements and any expense transaction charged in whole or in part to a federal award, including personal credit card reimbursement requests. Finance Director Effective immediately Supervisor approval records; signed reimbursement packages; workflow evidence showing independent review. Provide targeted training for employees, supervisors, accounts payable, and grants personnel on allowable cost principles, documentation standards, and reviewer responsibilities for expenses affecting federal awards. Compliance Officer; Finance Director August 31, 2026 Training materials; attendance logs; completed acknowledgements or knowledge checks. Create periodic exception reports for reimbursement activity charged to federal awards, missing receipt transactions, unusual merchants, and other higher-risk expense patterns, and require documented management review of the results. Accounting Manager; Finance Director September 30, 2026 Exception report format; monthly or quarterly review logs; documented follow-up on exceptions. Perform quarterly post-payment monitoring of a sample of reimbursed expenses charged to federal awards to verify compliance with documentation, Compliance Officer; Finance Director Quarterly, beginning September 30, 2026 Quarterly monitoring reports; exception logs; evidence of recoding, recovery, or corrective follow-up. approval, and allowability requirements and to ensure prompt correction of any identified exceptions.
Finding NO. 2025-003 Wage Rate Requirements View of the University of Guam and Corrective Action Plan: During the first half of fiscal year 2025, the University was in the process of implementing corrective actions related to the prior-year finding. While procedures were in place to address the requ...
Finding NO. 2025-003 Wage Rate Requirements View of the University of Guam and Corrective Action Plan: During the first half of fiscal year 2025, the University was in the process of implementing corrective actions related to the prior-year finding. While procedures were in place to address the requirements, improvements to the retention of certified payroll documentation and related compliance support were still being implemented during the period under review. The University's Capital Projects team continues to monitor certified payroll submissions from the Contractor and applicable Subcontractors. Through ongoing coordination with the Contractor, the University has strengthened its oversight procedures to help ensure certified payroll documentation is obtained, reviewed, and retained in accordance with applicable requirements. The University will continue to enhance its monitoring and documentation practices as part of its ongoing corrective action efforts. Name of Contact Person: Zenon Belanger, Interim Director, Facilities Management and Services Proposed Completion date: Ongoing
2025-002 - Eligibility: Public Housing Operating Fund (FALN #14.850) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the ...
2025-002 - Eligibility: Public Housing Operating Fund (FALN #14.850) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the collection and retention of certain tenant information to document the eligibility determination for each recipient. Condition The results of our testing indicated that certain items were not completed in a timely matter as follows: • In fifteen instances, the income verification form was not found in the file or not performed timely. Questioned Costs Not determinable. Context We selected a sample of 60 files for review. Our sample was a statistically valid sample. Effect or Possible Effect The tenant income verification form was not performed timely. Cause The cause is unknown. Identification as a Repeat Finding This finding is a repeat finding (see prior year finding number: 2024-002). Recommendation We recommend that Park City continue to improve its internal processes to ensure tenant income verification is performed timely. Park City's Response A Compliance Manager has been hired to randomly review resident files to make sure all documentation is maintained. An email reminder is sent monthly to managers to insure that EIV for move-ins is done on a timely basis. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900
2025-001 – Eligibility and Special Tests and Provisions: Housing Voucher Cluster (FALN #14.871) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (2...
2025-001 – Eligibility and Special Tests and Provisions: Housing Voucher Cluster (FALN #14.871) Criteria HUD regulations of Annual Income (24 CFR § 5.609), Eligible Family Status (24 CFR § 5.403), Citizenship and Eligible Immigrant Status (24 CFR § 5.506) and Disclosure of Social Security Numbers (24 CFR § 5.216) require the collection and retention of certain tenant information to document the eligibility determination for each recipient. Condition The results of our testing indicated that certain items were unable to be located in the file, as follows: • In five instances, supporting documentation (Form HUD-52580) was not available to verify that HQS inspections were completed and passed • In five instances, social security verification was missing from the tenant file. • In six instances, income verification form was missing from the tenant file or performed timely. • In fourteen instances, signed HAP contracts were not maintained in the tenant file for review. • In one instance, income was incorrectly calculated on Form HUD-50058. Questioned Costs Not determinable. Context We selected a sample of 60 files for review. Our sample was a statistically valid sample. Effect or Possible Effect The tenant file documentation was incomplete and tenant income verification was not performed timely. Cause The cause is unknown. Identification as a Repeat Finding This finding is a repeat finding (see prior year finding number: 2024-001). Recommendation We recommend that Park City continue to improve its internal processes to ensure tenant files contain the required documentation and tenant income verification is performed timely. Park City's Response Income verification: PCC has implemented software tracking of income verification attempts. Inspections: An SOP was issued to staff to review/compare lines 5I and 5H on the 50058 to inspection result history, to confirm dates populating are accurate. HAP Contracts and Social Security Card Documentation: Implemented internal tracking review of ongoing executions are in place and monitored. HAP payments are not released until HAP contract is executed by both parties. Automated process to perform a review of electronically indexed files will be put into place to identify active units that may not display an indexed document relevant to HAP contract. A request for submission of the documents will be made. Contact: Jillian Baldwin Email & Phone Number : jbaldwin@oarkcitycommunities.org (203) 337-8900
The District will implement proper control over program expenditures. Expenditures for other programs will be paid directly from those program funds, if possible.
The District will implement proper control over program expenditures. Expenditures for other programs will be paid directly from those program funds, if possible.
The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major,...
The Division is in the process of designing and implementing a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and that such evidence is maintained. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.
The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Com...
The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, and also applies to Expanded Food and Nutrition Education Programs, whic...
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, and also applies to Expanded Food and Nutrition Education Programs, which is not a cluster Sponsoring Agency: National Aeronautics and Space Administration and Department of Agriculture Award Names: NASA 90NSSC24K0999 and NI22eFNEPXXXG004-0003 Award Numbers: 208905 and 385076 Assistance Listing Title: Mission Support and Expanded Food and Nutrition Education Program Assistance Listing Number: 43.009 and 10.514 Award Year: 2024 – 2025 Management notes 2025-001 is a repeat finding of 2024-001, but given the timing of the finding last year, our 2024 CAP was anticipated to be completed as of October 1, 2025. To ensure Auburn University is in compliance with 2CFR 200.324, Auburn University has implemented the following corrective action plan: In addition to our current policies that required three quotes for purchases between $15,000-$75,000 and a formal competitive bid for purchases greater than $75,000, Auburn University revised our policies to require a cost or price analysis for items greater than $250,000, documenting that the purchase is reasonable. For items greater than $250,000, we will include a certification on the Professional Services Contracts and the Sole Source request forms indicating an analysis of cost or price has occurred and that the purchase is reasonable. As part of the cost or price analysis, we will utilize available data points. In addition to our analysis, we will ensure that our reviews have been appropriately documented and included in our files. Prior to the implementation date noted below, we will review any purchases greater than $250,000 in fiscal year 2026 and ensure proper cost or price analysis is completed and documented. The corrective actions noted herein have been implemented as of October 1, 2025. Contact: Missty Kennedy Chief Procurement Officer and Executive Director Procurement and Payment Services Amy Douglas Associate VP Financial Services/Controller Completed Date: October 1, 2025
Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm....
Item 2025.003 - Cash Management Recommendation The Organization should develop written procedures to review all drawdowns that occur in order to ensure accuracy. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting, a grant and contracts consulting firm. A drawdown policy will be established for the July 2026 Board Meeting for approval.
Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Heal...
Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Health Center converted the payroll system from Paycom to Paylocity which has capacity for grant hours tracking. We should have compliance in three months after implementation. The first pay date using Paylocity will be 7/2/2026 covering the pay period from 6/14/2026 to 6/27/2026. In addition, The Health Center's new GL system, Sage lntacct, also has grant accounting capability. With these two systems conversions, we should be able to track time and effort compliance.
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly appli...
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly applied a sliding fee discount to a patient account, resulting in a discount that was not consistent with the Organization's sliding fee discount policy. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: The identified error resulted from a contracted third-party billing company applying a sliding fee discount that was inconsistent with Little Rivers Health Care's Sliding Fee Discount Program policy. Upon identification of the finding, the account was reviewed and corrected to ensure the patient received the appropriate discount. To prevent future occurrences, Little Rivers Health Care re-instituted its monthly monitoring and review procedures in May 2026. These monitoring activities had been conducted consistently through the fall of 2025 and include periodic audits of patient accounts receiving sliding fee discounts, verification of discount calculations, and oversight of third-party billing activities. Findings from these reviews are documented, and corrective action is taken promptly when discrepancies are identified. In addition, the contracted billing company has been reminded of the organization's sliding fee discount requirements and expectations for compliance. To provide ongoing oversight and validation of compliance with the Sliding Fee Discount Program, Little Rivers Health Care has also implemented quarterly review meetings involving the Billing Manager, Controller, and Chief Executive Officer. These meetings have been formally scheduled, with the first occurrence set for July 20, 2026. The quarterly reviews will evaluate monitoring results, validate adherence to policy requirements, identify trends or potential risks, and ensure continuous compliance with program requirements. Anticipated Completion Date: May 20, 2026 (Corrective action completed), for reinstatement of monthly monitoring procedures. Quarterly compliance review meetings with the Billing Manager, Controller, and CEO are scheduled to commence on July 20, 2026, and will continue on an ongoing basis as part of the Organization's continuous compliance monitoring process.
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