Corrective Action Plans

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2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an...
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an instance of noncompliance with regard to the Special Tests and Provisions compliance requirement. Corrective Action Plan All tenant security deposits will be collected/supplied and deposited into the appropriate bank account. Furthermore, all monthly replacement reserve deposits will be made into an interest-bearing account. Responsible Person for Corrective Action Plan The AVP of Asset Management and the CFO of this organization. Implementation Date of Corrective Action Plan December 2025
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an...
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an instance of noncompliance with regard to the Special Tests and Provisions compliance requirement. Corrective Action Plan All tenant security deposits will be collected/supplied and deposited into the appropriate bank account. Furthermore, all monthly replacement reserve deposits will be made into an interest-bearing account. Responsible Person for Corrective Action Plan The AVP of Asset Management and the CFO of this organization. Implementation Date of Corrective Action Plan December 2025
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an...
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an instance of noncompliance with regard to the Special Tests and Provisions compliance requirement. Corrective Action Plan All tenant security deposits will be collected/supplied and deposited into the appropriate bank account. Furthermore, all monthly replacement reserve deposits will be made into an interest-bearing account. Responsible Person for Corrective Action Plan The AVP of Asset Management and the CFO of this organization. Implementation Date of Corrective Action Plan December 2025
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an...
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an instance of noncompliance with regard to the Special Tests and Provisions compliance requirement. Corrective Action Plan All tenant security deposits will be collected/supplied and deposited into the appropriate bank account. Furthermore, all monthly replacement reserve deposits will be made into an interest-bearing account. Responsible Person for Corrective Action Plan The AVP of Asset Management and the CFO of this organization. Implementation Date of Corrective Action Plan December 2025
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an...
2024-003: ALN# 14.181 Supportive Housing for Persons with Disabilities, June 30, 2024 – Special Tests and Provisions Condition Found The project did not collect tenant deposits and make the required monthly deposit of $1,144 into the reserve account during the year. We consider this finding to be an instance of noncompliance with regard to the Special Tests and Provisions compliance requirement. Corrective Action Plan All tenant security deposits will be collected/supplied and deposited into the appropriate bank account. Furthermore, all monthly replacement reserve deposits will be made into an interest-bearing account. Responsible Person for Corrective Action Plan The AVP of Asset Management and the CFO of this organization. Implementation Date of Corrective Action Plan December 2025
View Audit 365277 Questioned Costs: $1
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
View Audit 365271 Questioned Costs: $1
Implementation of plan of action - Management will review its internal controls and policies and procedures to ensure that requests for reimbursement are for appropriate program expenditures. Implementation date - Anticipated completion August 28, 2025. Persons responsible for the implementation -...
Implementation of plan of action - Management will review its internal controls and policies and procedures to ensure that requests for reimbursement are for appropriate program expenditures. Implementation date - Anticipated completion August 28, 2025. Persons responsible for the implementation - The Board of Directors and Head of School.
View Audit 365263 Questioned Costs: $1
Management recognizes the critical nature of enhanced internal control over review and approval of grant expenditures, including segregation of duties from the individual responsible for executing, reviewing and approving the expenditure. During 2024, management implemented a system where the progr...
Management recognizes the critical nature of enhanced internal control over review and approval of grant expenditures, including segregation of duties from the individual responsible for executing, reviewing and approving the expenditure. During 2024, management implemented a system where the program manager approves the expenditure based on the program needs and allowable cost standards, with review and sign off of the payment voucher by the Controller and, where required, the CFO. Further, management has put detailed approvals into place on all account payable items through vouchers required to be signed off on by the requesting party, and the related manager, as well as the appropriate C-Suite party. On a weekly basis, accounts payable detail by invoice is reviewed by the CEO, COO and CFO, approving payments to be made during that specific week. Once communicated, changes are made, if necessary, and approval is given to the Controller to have payments made via check, ACH or credit card.
COVID-19-Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21.027 Allowable Activities/Costs Recommendation: The Town should review and enhance controls and procedures where necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit fi...
COVID-19-Coronavirus State and Local Relief Funds (CSLRF)-Assistance Listing No. 21.027 Allowable Activities/Costs Recommendation: The Town should review and enhance controls and procedures where necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town will continue to review and enhance controls where necessary to ensure that all State and Local Fiscal Recovery Funds (SLFRF) expenditures support an eligible COVID-19 public health or economic response. Name(s) of the contact person(s) responsible for corrective action: Tyler Home, Director of Finance Planned completion date for corrective action plan: 07/01/2024
View Audit 365251 Questioned Costs: $1
2024-105 Lack of Payroll Review and Approval Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the ove...
2024-105 Lack of Payroll Review and Approval Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll, and the finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors’ approval of time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manger providing the final approval within ADP once all items are confirmed. This entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance initial off on the reviewed payroll items, ensuring a traceable record of the entire payroll approval process Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chie...
2024-104 Lack of Controls Related to Filing Reports Condition: The Organization did not maintain proper documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025 Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: Implemented
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale...
2024-101 Lack of Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Robert Thompson, Chief Executive Officer Anticipated Completion Date: October 2025
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center...
U.S. Department of Health and Human Services (HHS) SIGNIFICANT DEFICIENCY 2024-002 93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend that management hold additional training for front desk staff regarding the collection and verification of patient information for each patient. We also recommend enhancing your sliding fee status feature in your billing system to be completed for all patients to identify if the patient is insured, an application is pending, an application was received, an application was approved by finance for adjustment, and if an application was waived, to enable better tracking of the eligibility of each patient. We also recommend reviewing outstanding patient balances over 180 days to determine if follow up with a patient is required to collect the outstanding balance or to see if something has been collected by the front desk but not communicated to the finance team. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management agrees with the recommendations identified above. During April 2025, NHA started a project to review Self Pay balances with service dates prior to January 1, 2025 to follow up on why the balance is still outstanding. This would have caught the error identified above. In addition to this project, they have held additional trainings for front desk staff and will continue to do so and will continue to improve their methods of tracking patient eligibility. Name(s) of the contact person(s) responsible for corrective action: Doni Miller Planned completion date for corrective action plan: November 30, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Doni Miller, CEO at 419-720-7883.
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The ...
Clinic management team acknowledges that from the audit selection made of 60 patients, 14 were not recertified during the six-month period and the supporting documentation was not always obtained or retained related to income verification, household size, residency, and health insurance status. The corrective action plan as developed for CY 2023 will be continued to be reinforced and followed. The plan did result in lower findings than in prior years. A new bullet was added in the fourth quarter of 2024 to further assist in meeting the compliance guidance. The addition is the last bullet listed below. • Revamped the job titles and description to encourage better return on recruitment efforts of medical case manager positions. • A position of Certified Case Counselor (CCC) – Lead, was created and filled to provide direct oversight over the medical case managers that perform the bi-annual certifications, and other daily tasks. • Added a quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead is directly accountable to review the progress of the re-certification, and the process is monitored by the Assistant Manager of the clinic. The CCC-Lead and Assistant Manager monitor retention of all patients required supporting documentation in the patients’ medical records. • Patients that do not provide the required supporting documentation showing compliance with program eligibility as outlined in the grant agreement or are otherwise not able to be recertified six months after certification will be classified as inactive in the database used to submit invoices to the Ryan White HIV/AIDS Program. • CCC-Lead has been assigned to preview charts on the daily appointment book in EPIC and sending a list of the documentation required via email to case management staff as they meet with the patients. Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2025
Planned Corrective Action: 1. While LEAP was not solely responsible for delays in filing the Single Audit Report, it recognizes that it is ultimately the entity required to file timely and will do so. 2. At the beginning of the audit process, LEAP will establish an agreed timeline with its auditors ...
Planned Corrective Action: 1. While LEAP was not solely responsible for delays in filing the Single Audit Report, it recognizes that it is ultimately the entity required to file timely and will do so. 2. At the beginning of the audit process, LEAP will establish an agreed timeline with its auditors and LEAP will produce documentation consistent with that timeline. Planned Implementation Date of Corrective Action: September 1st, 2025. Person Responsible for Corrective Action: Shadine Alveranga, Managing Director of Finance
Methodist recognizes the current gap between Supply Chain Services and the Research Institute related to retaining documents for procurement activities. Supply Chain Services will develop processes to retain written documentation for procurement activities in accordance with regulatory standards. ...
Methodist recognizes the current gap between Supply Chain Services and the Research Institute related to retaining documents for procurement activities. Supply Chain Services will develop processes to retain written documentation for procurement activities in accordance with regulatory standards. As Methodist is in transition to a new ERP system in Quarter 1, 2026, Supply Chain Services will include strategies to address the needs in both the short term and long term.
View Audit 365182 Questioned Costs: $1
The District will implement a process to track the submission tine of the data collection form and audit package.
The District will implement a process to track the submission tine of the data collection form and audit package.
The District will assign the appropriate personnel to complete the reconciliations on a timely basis.
The District will assign the appropriate personnel to complete the reconciliations on a timely basis.
Finding 574901 (2024-005)
Significant Deficiency 2024
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognit...
The County agrees with this finding. The questioned costs are related to eligible payroll costs that were reported on the current year SEFA in error, rather than in the fiscal year in which they were incurred. The County recommends training for payroll and accounting staff related to proper recognition of expenses on the SEFA and documentation standards of the COVID-19 Coronavirus State and Local Fiscal Recovery Funds program.
View Audit 365155 Questioned Costs: $1
In Finding 2024-006, it was reported that the Organization did not comply with federal award requirements to submit an annual Federal Data Collection Form to the Federal Audit Clearinghouse, including audited financial statements, no later than nine months after the fiscal year ended November 30, 20...
In Finding 2024-006, it was reported that the Organization did not comply with federal award requirements to submit an annual Federal Data Collection Form to the Federal Audit Clearinghouse, including audited financial statements, no later than nine months after the fiscal year ended November 30, 2023. Management recognizes the importance of complying with federal grant requirement guidelines. In response to Finding 2024-006, Management concurs. The Organization has made a change in service providers for the completion of future audits.
In Finding 2024-004, it was reported that time and activity reports and/or I-9 forms were not maintained for certain employees. Although the Organization’s policies require that time records be maintained by employees, current operating procedures are not in place to ensure the time records are comp...
In Finding 2024-004, it was reported that time and activity reports and/or I-9 forms were not maintained for certain employees. Although the Organization’s policies require that time records be maintained by employees, current operating procedures are not in place to ensure the time records are completed. In response to Finding 2024-004, Management concurs. This was corrected after the audit for the fiscal year ended November 30, 2023, which was completed after the fiscal year ended November 30, 2024.
Communities In Schools of Georgia acknowledges the audit recommendation regarding enhancing internal controls over payroll allocation by establishing a formalized process for accurate completion and review of employee timesheets and integrating the timesheet functionality within our payroll platform...
Communities In Schools of Georgia acknowledges the audit recommendation regarding enhancing internal controls over payroll allocation by establishing a formalized process for accurate completion and review of employee timesheets and integrating the timesheet functionality within our payroll platform with our accounting system to facilitate accurate and efficient allocation of payroll costs to grants. Under the leadership of our newly hired CFO, we are improving our internal controls over the allocation of payroll costs and reporting by implementing the following measures: Establishing a Formalized Process for Accurate Completion and Approval of Timesheets Reconciling Timesheet Data in the Payroll Platform to the Salary Costs Captured in the General Ledger Training and Capacity Building During fiscal year 2025, we took the following actions to improve internal controls over the allocation of payroll costs and reporting processes: Engaged Senior Finance Contractor Completed a Search for Permanent full-time CFO Initiated and Completed a Search for an Accounting Manager
View Audit 365140 Questioned Costs: $1
August 15, 2025 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INT...
August 15, 2025 To: Clausell & Associates, P.C. From: Tabirus Lockhart, Chief Financial Officer of Enrichment Services Programs, Inc. Below is the Agency’s corrective action plan as it relates to the findings for the fiscal year ending July 31, 2024, Single Audit Act audit. Comment #2024-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL (Repeat) Views of Responsible Officials and Planned Corrective Actions: We concur with this finding - Management is in the process of assessing the organizational structure, capacity to provide adequate financial reporting. With Board review and approval of the Agency’s financial funding sources, the Agency will hire additional fiscal clerk to further support financial requirements and segregation of duties to ensure adequate internal controls are fully implemented. The CFO will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. The fiscal policies and procedures will be updated with the enhancements implemented within the fiscal department. Staff will be trained on revised policies and procedures and Uniform Guidance regulations. The new automated financial systems, will support financial reporting to meet GAAP requirements and to provide informative reports for Board and Management. All enhancements will be implemented by December 31, 2024. Concerning preparation of external reports required by various funding sources (i.e., SF-425, DHS’s reports for LIHEAP, LIHWAP, etc.), the Agency will ensure adequate training is performed to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action. Comment #2024-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION, GRANT CLOSE-OUT, AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED HEAD START AND EARLY HEAD START, LIHEAP, LIHWAP, CSBG, ASTHO, CACFP, and SLFRF FAL # 93.600, 93.568, 93.499, 93.569, 93.185, 10.558, 21.027 (Questioned Costs - Undetermined) Views of Responsible Officials and Planned Corrective Actions: We concur with the finding. Management and staff are in the process of assessing and updating the policies and procedures over the accounting and reporting of federal and state grants and contracts. In connection with training staff on the new and updated accounting system, we are providing ongoing training on the requirements of the Uniform Guidance and the specific requirements for each individual grant award as outlined in each applicable Compliance Supplement issued by Office of Management and Budget (OMB). We are currently reconciling all cash accounts and completing and amending, where necessary, all SF-425 reports and other external reports required by each funding source (state and federal). We anticipate completing this corrective action by December 31, 2025. See also the response to Comment #2024-001. Implementation Date: The plan correction date will be completed no later than December 31, 2025. Responsible Person: Tabirus Lockhart, CFO, will be responsible for the corrective action.
View Audit 365128 Questioned Costs: $1
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure that required supporting documentation is maintained when applicable. Auditee response: The Board agrees with the finding. Corrective ...
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure that required supporting documentation is maintained when applicable. Auditee response: The Board agrees with the finding. Corrective action planned: The Chief School Finance Officer, Federal Programs Director, and Assistant Superintendent/Special Education Director will ensure that all employees receive the semi-annual certification forms in order to comply with federal regulations. Anticipated completion date: September 30, 2025
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Auditee response: The Board...
Contact persons responsible for corrective action: Chief School Finance Officer Recommendation: The Board should review its current policies and procedures to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Auditee response: The Board agrees with the finding. Corrective action planned: The Chief School Finance Officer will ensure that all accounting policies and procedures are followed to ensure compliance with applicable regulations when federal funds are used to fund certain construction contracts. Anticipated completion date: September 30, 2025
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