Corrective Action Plans

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U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design and implement controls to ensure that time and effort related to federal programs is appropriately documented a...
U.S. Department of Health and Human Services Block Grants for Community Mental Health Services– Assistance Listing No. 93.958 Recommendation: It is recommended that the Organization design and implement controls to ensure that time and effort related to federal programs is appropriately documented and retained in accordance with Uniform Guidance requirements, regardless of contract type. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New Management is continuing advocacy to recover missing documentation from previous payroll provider. New payroll provider maintains all records and archives. For those employees who work on federal grants, attestations of time spent on programs are being produced. Name(s) of the contact person(s) responsible for corrective action: Kate Mombourquette Planned completion date for corrective action plan: Completed 12/31/2025
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WAU agrees with the recommendation to update our formal process to identify and maintain an inventory of data, devices, and systems that support or process customer f...
Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WAU agrees with the recommendation to update our formal process to identify and maintain an inventory of data, devices, and systems that support or process customer financial aid information. While we currently use the Spiceworks Inventory System to track hardware and software assets and Google Workspace to manage user cloud access and data storage, we acknowledge that a formal, documented inventory process covering all required categories has not yet been fully established. The IT Director has been assigned to develop and document this process within 30 days. We acknowledge this finding and the associated risk arising from the absence of an independent risk assessment. As of March 25, 2026, the University has engaged TeamLogic Cybersecurity to strengthen our managerial, technical, and operational controls and to (1) develop and document a formal, GLBA aligned risk assessment process; (2) conduct annual independent, comprehensive risk assessment of our information systems and data environment; and (3) provide written findings and recommendations. Based on these results, we will implement appropriate safeguards, and institutionalize an annual risk assessment cycle to ensure that risks are consistently identified, assessed, mitigated, and monitored in accordance with GLBA requirements. Name(s) of the contact person(s) responsible for corrective action: Rosalee Pedapudi, IT Director, Information Technology Services Planned completion date for corrective action plan: April 26, 2026
The Stoneham Public Schools are under new fiscal management as of October 29, 2025. As part of this change, grants are being initiated with an information sheet to all grant managers which provides start and end dates for eligible expenditures, as well as MUNIS budget codes for directly expensing re...
The Stoneham Public Schools are under new fiscal management as of October 29, 2025. As part of this change, grants are being initiated with an information sheet to all grant managers which provides start and end dates for eligible expenditures, as well as MUNIS budget codes for directly expensing reasonable and allocable expenses to the grant via a requisition/purchase order/ AP process used throughout the district. The grant budget codes are established in direct coordination with the approved grant budget at the time of award, and will be updated if amendments are required. The finance office will also receive these grant information sheets, and provide a cross check of the eligibility and coding requirements as requisitions are processed. No expenses shall be allowed in advance of an approved purchase order.
Finding: 2025-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with condu...
Finding: 2025-2 Name of contact person: Amanda Murphy, Economic Programs Administrator Corrective Action: Corrections to the proper verifications, documentation or computation, income and policy findings have been completed. Supervisors have reviewed with individual staff the errors along with conducting collective unit training on correct policy and keying procedures to ensure future accuracy. The Medicaid Supervisors. Lead Workers, and Quality Assurance team will continue to conduct monthly second party reviews as well as monthly policy/system training to improve quality in all areas. Proposed Completion Date: June 2026
Contact Person Stacy Grosse, Executive Director Corrective Action Plan The Authority is implementing a checklist and will continue random monthly file audits to be completed and documented by the Executive Director. Planned Completion Date for CAP Fiscal year beginning July 1, 2025.
Contact Person Stacy Grosse, Executive Director Corrective Action Plan The Authority is implementing a checklist and will continue random monthly file audits to be completed and documented by the Executive Director. Planned Completion Date for CAP Fiscal year beginning July 1, 2025.
Condition: The Program's Single Audit and reporting package was delayed for the year ended June 30, 2024 beyond the nine-month due date, as a result of turnover and delays in reconciling federal and state award activity with the Commonwealth. Criteria: Pursuant to the provisions of the Uniform Guida...
Condition: The Program's Single Audit and reporting package was delayed for the year ended June 30, 2024 beyond the nine-month due date, as a result of turnover and delays in reconciling federal and state award activity with the Commonwealth. Criteria: Pursuant to the provisions of the Uniform Guidance, under §200.512(a), the Program is required to complete and submit its Single Audit and related Data Collection Form within nine months of the end of its fiscal period (March 31) of the following year. Root Cause Analysis: The audit for the period ending June 30, 2024 was started in January 2025 and was completed and submitted in June 2025. In accordance with Uniform Guidance, the deadline is March 31st annually to have the audit completed and submitted. To meet this deadline, the year-end close and audit process needs to begin at least two months sooner to achieve this deadline. To address finding 2024-002, we began the audit in October 2025, one month ahead of schedule. Planned Corrective Action Steps: 1. Annually, begin the year-end close in September and start the audit in October. Responsible Party: MHDS Fiscal Director and MHDS Fiscal Unit Timeline for Completion: 1. Action Step #1 – September-November 2026
Supporting Services for Veteran Families Program – Assistance Listing No. 64.033 Recommendation: The Organization should enhance the design and controls to ensure that an exit date cannot be assigned to a veteran unless proper due diligence is achieved in accordance with their policies and procedure...
Supporting Services for Veteran Families Program – Assistance Listing No. 64.033 Recommendation: The Organization should enhance the design and controls to ensure that an exit date cannot be assigned to a veteran unless proper due diligence is achieved in accordance with their policies and procedures Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Retraining of managers that exit approval does not happen till 3 documented attempts are in HMIS record. Name(s) of the contact person(s) responsible for corrective action: Eleni Clark Planned completion date for corrective action plan: 3/31/2026
Contact Person: Duane Poitra, Business Manager Corrective Action Plan: The purchasing agent acquired verification that American Rescue Plan – Elementary and Secondary School Emergency Relief (ESSER III) may be used for IDEA B allowable special education purchases. Moving forward, prior approval will...
Contact Person: Duane Poitra, Business Manager Corrective Action Plan: The purchasing agent acquired verification that American Rescue Plan – Elementary and Secondary School Emergency Relief (ESSER III) may be used for IDEA B allowable special education purchases. Moving forward, prior approval will be acquired by District purchasing agents on the ND DPI Capital Expenditure Prior Approval For Use of Federal Funding form before capital purchase is made using federal funding. Anticipated Completion Date: Fiscal Year 2025-2026
Contact Person: Duane Poitra, Business Manager Corrective Action Plan: We will resolve these issues and ensure full compliance by training purchasing agents and business office staff to properly document federally funded purchase order expenditures, maintain supporting invoices, and verify that vend...
Contact Person: Duane Poitra, Business Manager Corrective Action Plan: We will resolve these issues and ensure full compliance by training purchasing agents and business office staff to properly document federally funded purchase order expenditures, maintain supporting invoices, and verify that vendor quotes reflect competitive market rates. Purchasing agents and approving administrators will also ensure staff travel requests are electronically filed; all related documentation for all related expenses will be collected. Additional training will be provided to relevant staff on federal expenditure guidelines to prevent future issues. These corrective actions will mitigate the risk of non-compliance and ensure that expenditures are reasonable and necessary for the federal award. Anticipated Completion Date: Fiscal Year 2025-2026
Corrective Action Plan Reporting Finding 2025-007 Roof Above will ensure the review of all grant invoices is documented through the signature of the reviewer on the grant cover sheet. Roof Above will institute a policy that grant invoices will not be submitted without the corresponding review signat...
Corrective Action Plan Reporting Finding 2025-007 Roof Above will ensure the review of all grant invoices is documented through the signature of the reviewer on the grant cover sheet. Roof Above will institute a policy that grant invoices will not be submitted without the corresponding review signature. Contact person responsible for corrective action: Tonya Frye, Chief Financial Officer Anticipated completion date: September 30, 2026
Corrective Action Plan Allowable Costs and Activities – Finding 2025-005 Roof Above will ensure payroll expenses will be allocated based on the allocation policy and job responsibilities of those working on the program. Allocations will be reviewed quarterly and reflected in the payroll system. Cont...
Corrective Action Plan Allowable Costs and Activities – Finding 2025-005 Roof Above will ensure payroll expenses will be allocated based on the allocation policy and job responsibilities of those working on the program. Allocations will be reviewed quarterly and reflected in the payroll system. Contact person responsible for corrective action: Tonya Frye, Chief Financial Officer Anticipated completion date: June 30, 2026
Corrective Action Plan Allowable Costs and Activities – Finding 2025-004 Roof Above will ensure administrative payroll expenses will be allocated based on the allocation policy and job responsibilities of those working on the program. Allocations will be reviewed quarterly and reflected in the payro...
Corrective Action Plan Allowable Costs and Activities – Finding 2025-004 Roof Above will ensure administrative payroll expenses will be allocated based on the allocation policy and job responsibilities of those working on the program. Allocations will be reviewed quarterly and reflected in the payroll system. Contact person responsible for corrective action: Tonya Frye, Chief Financial Officer Anticipated completion date: June 30, 2026
Corrective Action Plan Special Tests: Housing Quality Standards Finding 2025-003 Roof Above will document review of the inspection by sending an email to the grants administrator stating the inspection has been reviewed. Contact person responsible for corrective action: Katie Church, Vice President ...
Corrective Action Plan Special Tests: Housing Quality Standards Finding 2025-003 Roof Above will document review of the inspection by sending an email to the grants administrator stating the inspection has been reviewed. Contact person responsible for corrective action: Katie Church, Vice President of Scattered Site Housing Anticipated completion date: June 30, 2026
Corrective Action Plan Eligibility Finding 2025-002 Roof Above will add signature lines to current client eligibility checklist, to include the name, signature and date for both the person preparing and the person reviewing tenant eligibility. Contact person responsible for corrective action: Katie ...
Corrective Action Plan Eligibility Finding 2025-002 Roof Above will add signature lines to current client eligibility checklist, to include the name, signature and date for both the person preparing and the person reviewing tenant eligibility. Contact person responsible for corrective action: Katie Church, Vice President of Scattered Site Housing Anticipated completion date: June 30, 2026
OLD TOWNE SQUARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 AND 2024 Old Towne Square, Inc 609 SW F Avenue Lawton, OK 73501 Telephone: (580) 353-7392 Fax: (580) 353-6111 Corrective Action Plan Finding: 2025-001-Lack of Adequate Quality Control Regarding Tenant Procedures- Eligibility Cond...
OLD TOWNE SQUARE, INC. CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 AND 2024 Old Towne Square, Inc 609 SW F Avenue Lawton, OK 73501 Telephone: (580) 353-7392 Fax: (580) 353-6111 Corrective Action Plan Finding: 2025-001-Lack of Adequate Quality Control Regarding Tenant Procedures- Eligibility Condition: The quality of supervision over tenant file functions, such as calculating tenant rent and Housing Assistance Payments should be timely and sufficient to find errors in calculations or mis-application or mis-understanding of procedures. Corrective Action Planned: I am Rita Love, Executive Director. We will comply with the auditor’s recommendation. Person responsible for corrective action: Anna Richman, Executive Director Telephone: (580) 353-7392 Old Towne Square, Inc. Fax: (580) 353-6111 609 SW F Avenue Lawton, OK 73501 Anticipated Completion Date: June 30, 2026
None reported. Finding 2025-001 Name of contact person: Corrective Action: Staff will continue to receive training on the importance of maintaining complete and accurate files. Training will be focused on current resource audit findings as well as income calculation. Case file documentation should c...
None reported. Finding 2025-001 Name of contact person: Corrective Action: Staff will continue to receive training on the importance of maintaining complete and accurate files. Training will be focused on current resource audit findings as well as income calculation. Case file documentation should clearly outline the steps taken by caseworkers when determining eligibility. Checklists have been established to address errors cited during audits and are required at both applications and recertifications. As policies change or additional recommendations are issued by the State, these checklists will be updated to ensure staff remain aware of current requirements and procedures. BEAUFORT COUNTY Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings Section III - Federal Award Findings and Question Costs NORTH CAROLINA Amy Spring, Income Maintenance Administrator Supervisors will ensure that all staff complete the training required provided by the Division of Health Benefits. In addition, supervisors will offer supplemental training when needed to ensure staff maintain a thorough understanding of both current and riewly issued policies, as policy guidance is continually updated. Internal reviews of records will be conducted to ensure proper documentation is maintained for all cases. Our Quality Control Specialist has been completing second-party reviews for over a year. Policy changes throughout the year often requiring system updates. When this occurs, NCFAST training will also be provided to ensure that system procedures align with policy requirements. The Quality Control Specialist will continue to collaborate with supervisors to ensure staff are knowledgeable about common error trends to prevent recurring mistakes. Although errors are categorized as Significant Deficiencies, Beaufort County continues to show a steady decrease in errors across recent fiscal years. In fiscal year 2021-2022, there were 21 errors; in 2022-2023, there were 13; and in 2023-2024, there were 11. Currently, there are 6 errors for fiscal year 2024-2025 . Staff continue to prioritize accuracy in determining eligibility for the citizens of Beaufort County.BEAUFORT COUNTY Corrective Action Plan For the Year Ended June 30, 2025 NORTH CAROLINA BOARD OF COMMISSIONERS Frankie Waters, Chairman Jerry E. Langley, Vice Chairman Ed Booth Stan Deatherage John Rebholz Hood Richardson Randy Walker COUNTY OFFICIALS Brian M. Alligood, County Manager Katie Mosher, Clerk to the Board Anita Radcliffe, Finance Director David Francisco, County Attorney Proposed completion date: Corrective Actions for Finding 2025-001 also apply to State Award Findings. Section IV - State Award Findings and Question Costs Section III - Federal Award Findings and Question Costs (continued) Training was provided to all Medicaid staff on November 13, 2025, to review the findings and corrective action items. The agenda and sign-in sheets will be attached to the Corrective Action Plan. In addition, weekly training will continue to be held to review policy updates, NCF FAST changes, and common errors identified during second-party reviews. BEAUFORT COUNTY ADMINISTRATION BUILDING 121 West 3rd Street * Washington, North Carolina 27889 * Phone (252) 946-0079 * Fax (252)-946-7722 170 BOARD OF COMMISSIONERS Frankie Waters, Chairman Jerry E. Langley, Vice Chairman Ed Booth Stan Deatherage John Rebholz Hood Richardson Randy Walker COUNTY OFFICIALS Brian M. Alligood, County Manager Katie Mosher, Clerk to the Board Anita Radcliffe, Finance Director David Francisco, County Attorney BEAUFORT COUNTY ADMINISTRATION BUILDING 121 West 3rd Street * Washington, North Carolina 27889 * Phone (252) 946-0079 * Fax (252)-946-7722 169
10.553, 10.555, 10.559 - Child Nutrition Cluster 2025-002 Net Cash Resources Corrective Action Plan The School Lunch Fund continues to have excess fund balance on hand due to the additional reimbursements provided during the COVID-19 pandemic. The School District is currently reviewing the equipment...
10.553, 10.555, 10.559 - Child Nutrition Cluster 2025-002 Net Cash Resources Corrective Action Plan The School Lunch Fund continues to have excess fund balance on hand due to the additional reimbursements provided during the COVID-19 pandemic. The School District is currently reviewing the equipment used by the program and will create a plan to use these funds to support the program's infrastructure. Expected Completion Date June 30, 2026 Contact: Jolean Bliss, School Business Executive Mexico Academy and Central School District 16 Fravor Road, Suite A Mexico, NY 13114 (315) 963-8400
Name of Auditee: East Ramapo Central School District Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2025 CAP Prepared by: Eric Stark, Assistant Superintendent for Business Phone: 845-577-6000 (A) Current Findings on the Schedule of Findings and Questioned...
Name of Auditee: East Ramapo Central School District Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended June 30, 2025 CAP Prepared by: Eric Stark, Assistant Superintendent for Business Phone: 845-577-6000 (A) Current Findings on the Schedule of Findings and Questioned Costs (4) Audit Finding 2025-004 (a) Comments on the Finding and Recommendation: The District agrees with the finding. The District also agrees with the recommendation. See below for actions taken. (b) Actions Taken: Management will not approve expenditures or sign checks for cash disbursements that have not been approved by the claims auditor. (c) Anticipated Completion Date: Management anticipates this finding will be resolved by June 30, 2026.
Finding 1205216 (2025-002)
Material Weakness 2025
Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: Significant Deficiency in Internal Control over Compliance and Other Matters Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to findi...
Significant Deficiency in Internal Control over Compliance and Other Matters Recommendation: Significant Deficiency in Internal Control over Compliance and Other Matters Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management believes the issue resulted from timing overlap with the prior year audit, as the transactions occurred in July and August 2024, shortly after the fiscal year-end June 30, 2024. To address this matter, management has retrained existing staff and is in the process of training the new CFO. In addition, management has performed a re-review of accounting records to confirm that no other instances of sales tax misclassification have occurred. Name of the contact person responsible for corrective action: Karen Harshman Planned completion date for corrective action plan: June 30, 2026
Student Financial Assistance Cluster Federal Direct Loans - Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate controls around monitoring return of Title IV funds to determine changes, either on the electronic processes or review processes that should be made to prope...
Student Financial Assistance Cluster Federal Direct Loans - Assistance Listing No. 84.268 Recommendation: We recommend the University evaluate controls around monitoring return of Title IV funds to determine changes, either on the electronic processes or review processes that should be made to properly capture return of Title IV funds on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Planned corrective action: Currently, the return of Title IV calculations are done manually and a second person within Financial Aid reviews the calculation. The University is working on a training engagement for the Financial Aid office which will explore the ability to perform the return of Title IV calculations within the ERP system. A second person would continue to review the calculation. Name(s) of the contact person(s) responsible for corrective action: Patrick Michael, Director of Financial Aid If the United States Department of Education has questions regarding this plan, please call Shari Keffer, Vice President for Administration & Finance at 618-537-6838.
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town of West Warwick’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence Management concurs...
Significant Deficiency in Internal Control over Compliance, Other Matters Description of Finding The Town of West Warwick’s procurement standards do not include the essential elements as outlined in 2 CFR sections 200.318 through 200.326. Statement of Concurrence or Nonconcurrence Management concurs with the finding. Corrective Action The error will be corrected as of the beginning for fiscal year ending June 30, 2027. We will add the paragraph to our existing purchasing policy. This must be done by resolution and given the timeline that takes, we anticipate having this implemented the end of June 2026. Name of Contact Person Kristen Benoit, Finance Director Projected Completion Date 7/1/2026
Views of Responsible Officials: SCC’s implementation of Student First on August 10, 2026, will help rectify the enrollment reporting issues.
Views of Responsible Officials: SCC’s implementation of Student First on August 10, 2026, will help rectify the enrollment reporting issues.
Corrective Action: SNMCAC will monitor administrative cost percentages against grant thresholds to ensure compliance. Person Responsible: Tracey Young, Fiscal Director Completion Date: March 31, 2026
Corrective Action: SNMCAC will monitor administrative cost percentages against grant thresholds to ensure compliance. Person Responsible: Tracey Young, Fiscal Director Completion Date: March 31, 2026
Finding #2025-001: #84.048 -Career and Technical Education - Basic Grants to States Federal Grantor Agency: U.S. Department of Education Compliance Requirement: Subrecipient Monitoring Condition: During our audit procedures, we noted that the District does not have formal, written procedures governi...
Finding #2025-001: #84.048 -Career and Technical Education - Basic Grants to States Federal Grantor Agency: U.S. Department of Education Compliance Requirement: Subrecipient Monitoring Condition: During our audit procedures, we noted that the District does not have formal, written procedures governing subrecipient monitoring. Although the District reviews supporting documentation—such as invoices—submitted by subrecipient schools prior to submitting claims to the Department of Public Instruction (DPI), these practices are not documented in an established policy or procedure. Criteria: Uniform Guidance (2 CFR 200.331–200.332) requires pass-through entities to establish and implement written procedures for monitoring subrecipients to ensure compliance with federal program requirements and achievement of performance goals. Cause: The District has not developed or implemented formal written policies and procedures for subrecipient monitoring. Effect: In the absence of formalized procedures, the District’s monitoring practices may be applied inconsistently, increasing the risk of unallowable costs, noncompliance with federal requirements, or misunderstandings between the District and its subrecipients. This could lead to questioned costs or administrative issues during oversight by DPI or other regulatory bodies. Recommendation: We recommend that the District develop and adopt formal written procedures outlining its subrecipient monitoring activities. These procedures should clearly describe monitoring responsibilities, required documentation, review steps, communication expectations, and follow-up actions. Implementing a formalized process will help ensure consistent oversight and compliance with federal regulations. Grantee Response: The District will develop and implement written procedures that outline the required monitoring steps, documentation standards, communication protocols, and follow-up expectations for subrecipient oversight. These procedures will align with the requirements of Uniform Guidance and DPI expectations.
JCCA CORRECTIVE ACTION PLAN March 23, 2026 Health Resources and Services Administration Jewish Child Care Association of New York (d/b/a JCCA) and Affiliated Organization respectfully submits the following corrective action plan for the year ended June 30, 2025. _____________________________________...
JCCA CORRECTIVE ACTION PLAN March 23, 2026 Health Resources and Services Administration Jewish Child Care Association of New York (d/b/a JCCA) and Affiliated Organization respectfully submits the following corrective action plan for the year ended June 30, 2025. ____________________________________________________________________________________ CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: June 30, 2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FINANCIAL STATEMENT FINDINGS Finding 2025-001 – Account Analyses MATERIAL WEAKNESS Recommendation We recommend that the Agency implement policies, procedures and controls to ensure that all accounting records are analyzed and reconciled on a monthly basis. Action Taken BTQ Financial is spearheading a comprehensive stabilization project to refine the chart of accounts and reconstruct historical tracking for the permanent endowment fund. BTQ already has in place a rigorous monthly closing schedule. This includes establishing automated reconciliation protocols for program service revenue, endowment tracking, and inter-company accounts to ensure GAAP compliance and timely board reporting. These policies, procedures, and controls to ensure that all accounting records are analyzed and reconciled on a monthly basis have already been incorporated into FY2026 monthly close process. Finding 2025-002 – Information Technology – General Control Activities SIGNIFICANT DEFICIENCY Recommendation We recommend the Agency follow their policy for password age. We also recommend the Agency perform a risk assessment over the information technology environment. We recommend a written risk assessment and penetration test to be performed annually and vulnerability scans to be performed quarterly. Action Taken The Agency has configured NetSuite and Active Directory to programmatically enforce password aging and complexity requirements that strictly mirror our established IT Security Policy. Furthermore, we have moved beyond interview-based assessments to an annual cadence of formal, written risk assessments and penetration testing, supported by continuous monthly vulnerability monitoring through our Security Operation Center (SOC). An interview-based risk assessment was performed in Q3 2025, and monthly vulnerability scans are managed by Arctic Wolf, our Security Operation Center (SOC) service provider. To further strengthen our posture, we will initiate an annual cadence of formal external and internal penetration tests starting in Q2-Q3 2026. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, Unaccompanied Alien Children Program (Assistance Listing Number 93.676), FAIN # 90ZU0603, 90ZU0567, and 90ZU0536, for FY 2025 - Significant Deficiency Finding 2025-003 – Reporting Recommendation We recommend that management of the Agency implement procedures to track all federal reporting deadlines and ensure that reports are reviewed and submitted timely. This could include maintaining a centralized grant reporting calendar and implementing supervisory review prior to submission. Action Taken With the outsourcing to BTQ now fully operational, a centralized Federal Grant Reporting Calendar has been established. This calendar includes automated alerts for all 30/60/90-day deadlines. BTQ has also implemented a dual-level supervisory review process to ensure that all future reports are validated against the general ledger and submitted well in advance of federal deadlines. This protocol has been strictly applied to all federal reporting for the FY2026 cycle. U.S. Department of Health and Human Services, Unaccompanied Alien Children Program (Assistance Listing Number 93.676), FAIN # 90ZU0603, 90ZU0567, and 90ZU0536, for FY 2025 - Significant Deficiency Finding 2025-004 – Cash Management Recommendation We recommend that management of the Agency implement formal controls over the drawdown process that includes establishing procedures requiring documented supervisory review and approval of all drawdown requests and ensuring drawdowns are based on immediate cash needs so that federal funds are expended within a reasonable amount of time. Action Taken The Agency, in collaboration with BTQ Financial, has implemented a formalized "Drawdown Authorization Protocol." This new workflow improves upon the existing, and adds a standardized approach to every drawdown request, documented supporting schedules (showing immediate cash needs), and formal approval from BTQ’s PM, SVPF, VPF, or AVPF. This ensures a clear audit trail and prevents the accumulation of excess federal cash on hand. If the Health Resources and Services Administration has questions regarding this plan, please call Kenneth Shieh, Chief Administration Officer at (718) 747-4367. Sincerely yours, Kenneth Shieh, Chief Administrative Officer
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