Corrective Action Plans

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We acknowledge this finding, and we believe the finding reflects a transitional issue rather than a systemic weakness. The errors noted in the SEFA were directly tied to turnover in key finance personnel at the time, and those conditions no longer exist. We have since stabilized the team, centralize...
We acknowledge this finding, and we believe the finding reflects a transitional issue rather than a systemic weakness. The errors noted in the SEFA were directly tied to turnover in key finance personnel at the time, and those conditions no longer exist. We have since stabilized the team, centralized grant reporting responsibilities, and are implementing a new accounting system that will automate federal grant tracking.
The Organization is increasing its efforts to ensure that its policies and procedures are in place to ensure timely submission of reports. Completion Date: Estimated December 2025. Contact Person: Daniel Kevin Finney - Chief Financial Officer - 3529 7th Avenue South Birmingham, AL 35222 205-324-9822...
The Organization is increasing its efforts to ensure that its policies and procedures are in place to ensure timely submission of reports. Completion Date: Estimated December 2025. Contact Person: Daniel Kevin Finney - Chief Financial Officer - 3529 7th Avenue South Birmingham, AL 35222 205-324-9822 finney@aidsalabama.org
The Organization is increasing its efforts to ensure that its policies and procedures are in place to ensure timely submission of reports. Completion Date: Estimated December 2025. Contact Person: Daniel Kevin Finney - Chief Financial Officer - 3529 7th Avenue South Birmingham, AL 35222 205-324-9822...
The Organization is increasing its efforts to ensure that its policies and procedures are in place to ensure timely submission of reports. Completion Date: Estimated December 2025. Contact Person: Daniel Kevin Finney - Chief Financial Officer - 3529 7th Avenue South Birmingham, AL 35222 205-324-9822 finney@aidsalabama.org
2024 – 001 Reporting (Compliance, Internal Controls Over Compliance) Material Weakness – ALN 10.767 Intermediary Relending Program Condition: Testing of the reporting requirements disclosed that the quarterly and semiannual IRP reports were not submitted to USDA Rural Development. Corrective Action ...
2024 – 001 Reporting (Compliance, Internal Controls Over Compliance) Material Weakness – ALN 10.767 Intermediary Relending Program Condition: Testing of the reporting requirements disclosed that the quarterly and semiannual IRP reports were not submitted to USDA Rural Development. Corrective Action Plan: BASEC management and staff has taken USDA Rural Development provided LINC training on September 30, 2025 and has been in contact with Clark Guthmiller, IRP specialist with USDA Rural Development. BASEC has implemented a procedure with IRP reporting to be done the month following the quarter end (April, July, October and January). The procedure includes the following steps: 1. In Porfol (loan software), Executive Director will review the Master Loan List for IRP Direct and IRP Revolved for quarter end to ensure all IRP loans are listed and all payment information is current as of month end. 2. Executive Director will then pull the Delinquency report to ensure IRP (revolved and direct) delinquency statuses. 3. Executive Assistant will review that all IRP loans are up to date and payment information is accurate and return to Executive Director 4. Executive Director will log into LINC (USDA system for loan reporting) and update the loan information and submit each month after quarter end. BASEC’s IRP approaching year budget will be submitted to USDA Rural Development by October 31st to allow time for any questions or corrections to ensure an approval from USDA prior to the new year. Emily Rodgers Executive Director
Recommendation Quivira should implement procedures and controls to ensure that the federal reports are reconciled, reviewed for accuracy and completeness before submission. Views of Responsible Officials and Planned Corrective Action Management agrees that, despite regular reviews of SF-425 reports ...
Recommendation Quivira should implement procedures and controls to ensure that the federal reports are reconciled, reviewed for accuracy and completeness before submission. Views of Responsible Officials and Planned Corrective Action Management agrees that, despite regular reviews of SF-425 reports for accuracy and completeness, current steps were not adequate to ensure federal reports are reconciled and reviewed for accuracy and completeness before submission. This finding is directly connected to 2024-001, and the same action steps will address this finding. To correct for this significant deficiency, Quivira Coalition will: Action Step Detail Date Responsible Party Develop a new, compliant method to allocate personnel costs for federal billing and reporting. Stop using the timekeeping system (Harvest) for allocation. The new method must properly reflect actual paid salaries, paid fringe, and actual time spent. 12/31/2025 Accounting Firm Update reporting process to reconcile all costs reported on the SF-425 to the general ledger (instead of the timekeeping system) using the new federal grants billing process. Keep detailed records of the reconciliation. 12/31/2025 Accounting Firm Implement a monthly reconciliation process between the time and expense system (Harvest) and the QuickBooks general ledger to reconcile all non-personnel expenses. 1/30/2026 Operations Director Document the grant management process, including new reporting processes, required reconciliations, monitoring policies, and allowable cost management to ensure consistency across the organization. 2/28/2026 Operations Director Update policies and procedures to require that expenses reported on the SEFA form come directly from the accounting system to ensure this continues. 1/30/2026 Operations Director Update policies and procedures to require an annual reconciliation between the SF-425 and SEFA reports to ensure this continues. This occurs before submitting the SEFA report. 1/30/2026 Operations Director Reconcile all grant programs active in 2024 using updated processes and resolve any discrepancies with federal reports or billing. 1/30/2026 Initial Review - Operations Director & Grants Manager Secondary Review & Corrections (if needed) - Accounting Firm Develop a plan to ensure regular and sufficient training on Uniform Guidance tracking regulatory changes, and how to implement changes. Update policies and procedures. 11/30/2025 Operations Director & Executive Director Update policies and procedures to require an additional level of review and approval for SF-425 and SEFA reports and reconciliations for accuracy and completeness before they are submitted. 12/31/2025 Operations Director with final approval from the Executive Director
Views of responsible officials and planned corrective actions Quivira Coalition has made efforts to fully comply with federal allowable cost rules, including implementing a compliant time and expense system, implementing a compliant accounting system, consulting with federal program officers, and re...
Views of responsible officials and planned corrective actions Quivira Coalition has made efforts to fully comply with federal allowable cost rules, including implementing a compliant time and expense system, implementing a compliant accounting system, consulting with federal program officers, and requesting budget revisions when necessary. However, management agrees that despite its efforts it did not correctly attribute allowable non-personnel and personnel costs to the grants, resulting in errors on the Schedule of Expenditures of Federal Awards (SEFA). Management has analyzed the errors and determined the root causes. Management agrees that the root cause of finding 2024-001 is the discrepancy between the accounting system and time and expenses software system, and that this is material to grant management. After reconciling these discrepancies, as discussed below, management believes the estimated amount for Beginning Farmer and Rancher Development Program; Award: BFRDP - 2023 - 49400 - 40894 (AL 10.311) to be $7,002 and for Partnerships for Climate-Smart Commodities; Award: USDA/NR243A750004G005 (AL 10.937) to be $10,169. Non-Personnel Costs Discrepancies in non-personnel costs were primarily caused by human errors. Management conducted a post-audit reconciliation between the expense tracking system (Harvest) and the general ledger (QuickBooks) which identified the 2024 discrepancies, and Quivira has corrected them. Personnel Costs Discrepancies in labor costs were due to three factors: 1) Quivira Coalition personnel are paid for holidays and paid time off (PTO) and therefore personnel costs include PTO and holiday costs in QuickBooks. However, Quivira’s timekeeping system (Harvest) does not burden federal award personnel costs with PTO and holiday costs making it difficult to reconcile. 2) To allocate personnel costs to a grant, Quivira used the Harvest system. This system calculates a fixed cost rate for each person based on their total annual compensation and expected work capacity and then multiplies this fixed cost rate by the number of hours worked on each grant (as recorded in the Harvest System). However, using fixed cost rates can result in misallocation in situations where personnel work over capacity (e.g. overtime) or under capacity. The appropriate cost allocation approach for salaried employees is to allocate actual personnel costs for a task based on the percentage of total hours worked. 3) Quivira calculated personnel fringe costs based on an estimated hourly fringe rate rather than identifying and allocating actual fringe expenses from QuickBooks. To correct for this material weakness, Quivira Coalition will: Action Step Detail Date Responsible Party Develop a new, compliant method to allocate personnel costs for federal billing and reporting. Stop using the timekeeping system (Harvest) for allocation. The new method must properly reflect actual paid salaries, paid fringe, and actual time spent. 12/31/2025 Accounting Firm Update reporting process to reconcile all costs reported on the SF-425 to the general ledger (instead of the timekeeping system) using the new federal grants billing process. Keep detailed records of the reconciliation. 12/31/2025 Accounting Firm Implement a monthly reconciliation process between the time and expense system (Harvest) and the QuickBooks general ledger to reconcile all non-personnel expenses. 1/31/2026 Operations Director Document the grant management process, including new reporting processes, required reconciliations, monitoring policies, and allowable cost management to ensure consistency across the organization. 2/28/2026 Operations Director Update policies and procedures to require that expenses reported on the SEFA form come directly from the accounting system to ensure this continues. 1/31/2026 Operations Director Update policies and procedures to require an annual reconciliation between the SF-425 and SEFA reports to ensure this continues. This occurs before submitting the SEFA report. 1/31/2026 Operations Director Reconcile all grant programs active in 2024 and 2025 using updated processes and resolve any discrepancies with federal reports or billing. 2/28/2026 Initial Review - Operations Director & Grants Manager Secondary Review & Corrections (if needed) - Accounting Firm Develop a plan to ensure regular and sufficient training on Uniform Guidance tracking regulatory changes, and how to implement changes. Update policies and procedures. 11/30/2025 Operations Director & Executive Director Update policies and procedures to require an additional level of review and approval for SF-425 and SEFA reports and reconciliations for accuracy and completeness before they are submitted. 12/31/2025 Operations Director with final approval from the Executive Director
View Audit 369852 Questioned Costs: $1
2024-003 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants...
2024-003 Federal Procedure Manual Condition: Internal controls over federal grants should be in place to provide reasonable assurance that misstatement in the schedule of expenditures of federal awards would be prevented or detected. Criteria: Non-federal entities who receive federal or state grants or have grant programs should have documented policies and procedures in place over grants and grant expenditures. Cause: The Village does not have documented policies and procedures in place over grants and grant expenditures. Effect: Without documented policies and procedures, the internal control over federal grants is low, and the risk of misstatement in the schedule of expenditures of federal awards is high. Auditor’s Recommendation: We recommend that the Village works on written policies and procedures over grants and grant expenditures. Management Response: The Village will work with their auditor to develop and adopt written grant procedures that are in accordance with the Uniform Guidance. Contact Person: Lee Kucher Anticipated Completion: June 30,2025
Recommendation: Block grant reports should be completed prior to the accounting record close process to ensure the expenditures reported are supported by the underlying accounting records. Controls over reporting should include records for the basis of reporting submissions should be reviewed as par...
Recommendation: Block grant reports should be completed prior to the accounting record close process to ensure the expenditures reported are supported by the underlying accounting records. Controls over reporting should include records for the basis of reporting submissions should be reviewed as part of the report approval process prior to submission. Supporting documentation and reconciliations should be filed for reference purposes. Action Taken: The Department of Human Services received approval from the PA DHS in February 2025 for its 2021–2022 HSBG Income & Expenditure (I&E) Report, Revision 3, which had been submitted in January 2025. At the State’s request, the Agreed Upon Procedures report was submitted in August 2025 for fiscal year 2021-2022 and has since been approved. The journal entries reconciling the underlying expenditure detail in the County’s accounting system to the expenditures reported have been submitted, and the final reconciliation is in process. Retained Earnings Plans were submitted to the State in February and March 2024. The County completed submission of the 2022–2023 HSBG I&E Report in March 2025, with a revised version submitted in September 2025. The State is currently reviewing the report. Upon approval, the AUP will be completed, and the County will reconcile the detailed expenditures in the accounting system to the amounts reported, ensuring accuracy and compliance. The 2023–2024 HSBG I&E Report was submitted in September 2025. The County is finalizing the 2024–2025 HSBG I&E Report and anticipates submission by October 2025. Responsible Individual for Corrective Action: Gaston Gonzalez, County of Delaware Department of Human Services Chief Financial Officer Completion Date: December 31, 2025
Management agrees with the recommendation. Beginning in October 2024, the Organization adopted the use of a federal reporting portal that facilitates the tracking of federal revenues and expenditures and is expected to improve the accuracy of federal expenditure reporting going forward. Management w...
Management agrees with the recommendation. Beginning in October 2024, the Organization adopted the use of a federal reporting portal that facilitates the tracking of federal revenues and expenditures and is expected to improve the accuracy of federal expenditure reporting going forward. Management will continue to monitor controls for their effectiveness throughout the year.
2024-007 - Significant Deficiency in Internal Control and Non-material Noncompliance - Schedule of Expenditures of Federal Award Awareness and Preparation WPHW understands this finding and will be implementing further steps to ensure full compliance with this finding. The follow process has been put...
2024-007 - Significant Deficiency in Internal Control and Non-material Noncompliance - Schedule of Expenditures of Federal Award Awareness and Preparation WPHW understands this finding and will be implementing further steps to ensure full compliance with this finding. The follow process has been put in place to ensure compliance: 1) Director of Accounting and Grants Director will ensure they have appropriate training and work collaboratively to develop documentation process a. The Grant Director will update all grants as they are received, to ensure an accurate list of grants b. The Director of Accounting will update all the financial data for each grant 2) The Director of Accounting will be responsible for the review and submitting document to the auditing firm For FY25, the Director of Accounting and Grant Director will jointly build the document and review to ensure completeness and accuracy. Person(s) Responsible: Beth McLean, Director of Accounting Timing for Implementation: FY25-FY26
2024-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections were not completed FY24, but have been implemented, as stated in the FY23 Corrective Action Plan. WPWH implemented the following process: 1) Full year-end check list is distributed and review ...
2024-002 - Material Weakness - Year End Cutoff WPHW understands this finding and recognizes the corrections were not completed FY24, but have been implemented, as stated in the FY23 Corrective Action Plan. WPWH implemented the following process: 1) Full year-end check list is distributed and review by staff (Accounting Specialists, Accountants, and AR/AP Specialists) prior to year-end for review and training, conducted by the Director of Accounting and Accounting Manager a. Review each step with staff and provide training on the expectation for each step 2) Accounting Specialists and Accountants complete necessary year-end tasks 3) Accounting Manager reviews all completed tasks to ensure accuracy and completeness 4) Director of Accounting conducts a final review and signs off at the end of the year With this clear process in place, we anticipate this issue being fully resolved in FY25.
2024-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and has corrected this error, but the correction was not fully completed for FY24 due to the timing of receiving the FY23 audit. In October 2024, we transitioned back to QuickBooks fully, we also made sig...
2024-001 - Material Weakness - Material Adjusting Journal Entries WPHW understands this finding and has corrected this error, but the correction was not fully completed for FY24 due to the timing of receiving the FY23 audit. In October 2024, we transitioned back to QuickBooks fully, we also made significant staff role changes. Our accounting department now has a Director of Accounting and a new manager, Accounting Manager. With these new positions, we have developed the following procedures for adjusting journal entries: 1) Accounting Director, Accounting Manager or Accountant Specialist identifies need for a journal entry 2) Accounting Specialist pulls the supporting documentation for the required entry, creates journal entry template in Excel or hand writes on supporting document, and prepares journal entry packet with supporting documentation for entry into QB. 3) Accounting Manager/Director of Accounting reviews packet and determines who can enter journal a. If reviewed by Director of Accounting, entry is entered QuickBooks by Accounting Specialist/Accounting Manager b. If reviewed by Accounting Manager, entry is entered into QuickBooks by Accountant Specialist 4) Once journal entry is entered into QuickBooks, entry is printed from QB system and added to packet. The packet is returned to the preparer to ensure all elements were completed corrected and signed off on 5) Completed packet goes to filing and are scanned into our electronic file system All adjustments must go through three different individuals to ensure separation of duties. This process was implemented during Q4 of FY24. The Director of Accounting will go back over all the journals completed before this date to review how each were completed and delegate additional review to the Accounting Manager and Accounting Specialist to ensure each journal entry had appropriate review and support. With this process in place, we anticipate this issue being fully resolved in FY25.
Partnerships for Climate-Smart Commodities – Assistance Listing No. 10.937 Recommendation: We recommend the Organization implement a formal control where someone other than the preparer documents their review of the financial and performance reports prior to submitting to the federal agency. This re...
Partnerships for Climate-Smart Commodities – Assistance Listing No. 10.937 Recommendation: We recommend the Organization implement a formal control where someone other than the preparer documents their review of the financial and performance reports prior to submitting to the federal agency. This review would include comparing the amounts in the report to the general ledger or other supporting documents. This review should be supported by documenting the signature and date prior to submission Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is finalizing the Federal Grant Report Review and Submission Protocol whose purpose is to ensure that all federal funding programmatic reports and FFRs are accurate, complete, and compliant with grant requirements and federal regulations before they are submitted to the funding agency. This form will be filed in the project folder.
Explanation: We acknowledge the oversight and would like to provide context to better understand the circumstances that led to the delay. We faced internal challenges when our previous management company departed, leaving us with incomplete files and late recertifications or recertifications that ne...
Explanation: We acknowledge the oversight and would like to provide context to better understand the circumstances that led to the delay. We faced internal challenges when our previous management company departed, leaving us with incomplete files and late recertifications or recertifications that never commenced, making it nearly impossible to catch up promptly. Next, staff staffing issues contributed to the delays because staff members were not adequately trained. Despite these challenges, we recognize the importance of adhering to HUD regulations and are committed to taking corrective measures. Corrective Actions Taken: We initiated immediate corrective actions to rectify the situation as stated in our 2023 corrective action plan. Upon discovering the late recertifications, we instituted the following measures to prevent the recurrence of late annual recertifications, 1. Created a recertification schedule and calendar with the annual recertification date, specific dates to notify residents that their annual recertification is due, and dates for submitting the information to CMS and to trac. The schedule and calendar are submitted to the executive director every two weeks to monitor progress. A meeting is also scheduled with staff every two weeks to review recertification issues. 2. We hired a consultant specializing in certification to train the staff and work with the staff daily to answer questions concerning our certification. This is not a one-and-done process; our recertification consultant is available on a permanent basis to address certification issues and provide ongoing staff training. These measures are designed to ensure timely compliance with HUD regulations and to strengthen our internal processes.
Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsib...
Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsible Fatherhood Grants Award Period: September 30, 2023 – September 29, 2024 Award Period: September 30, 2024 – September 29, 2025 Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Teen Pregnancy Prevention Education Assistance Listing Number: 93.297 Assistance Listing Program Title: Adolescent Health Programs Award Period: July 1, 2023 – June 30, 2024 Award Period: July 1, 2024 – June 30, 2025 Management response to 2024-002: In response to the auditors’ recommendation, management has addressed this deficiency by assigning appropriate personnel to review and approve all Federal reporting before submission. Additionally, management has implemented specific procedures for review and approval of drawdown requests, which include reviewing the indirect cost rate applied in all drawdown requests.
Name of Auditee: Newton Housing Authority EFPR Group, CP As, PLLC December 31, 2024 Name of Audit Firm: Period Covered by the Audit: CAP Prepared by: Michael Lara, Executive Director Phone: (718) 382-5332 (A)Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Fin...
Name of Auditee: Newton Housing Authority EFPR Group, CP As, PLLC December 31, 2024 Name of Audit Firm: Period Covered by the Audit: CAP Prepared by: Michael Lara, Executive Director Phone: (718) 382-5332 (A)Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2024-002 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for additional comments and action taken. (b) Action taken - The Authority will review and verify key line items (including restricted net position, unrestricted net position and cash and investments) against the general ledger prior to VMS submission. Supervisory review will be required to confirm accuracy. ( c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.
2024-002 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: E - Eligibility Internal Control Impact: Material Weak...
2024-002 Program: Crime Victim Assistance Federal Agency: Department of Justice AL #: 16.575 Federal Award Identification Number and Year: Various – See SEFA Pass-through Entity: Missouri Department of Social Services Type of Compliance Finding: E - Eligibility Internal Control Impact: Material Weakness Finding: When a participant arrives at the Shelter, the admission checklist, procedures, and forms must be completed by program staff. During our audit of the Organization’s fiscal year ended December 31, 2024 federal award program, we noted the Organization did not have necessary supporting documentation, such as admission checklists for eligibility, to evaluate twenty-one out of twenty- five participants in their files. Corrective Action Plan: All supporting documentation for client eligibility will be maintained for the period required by the grant. Person(s) Responsible for Implementation: Danielle Brown, CEO, dbrown@ywcasj.org, 816-232-4481
Corrective Action Taken or Planned: The Commission will adopt a policy whereby the Executive Director or a designee will review all future reports prior to submission. Contact person(s) responsible for correction action: Kristi Kane, Executive Director Anticipated Completion Date: Immediately
Corrective Action Taken or Planned: The Commission will adopt a policy whereby the Executive Director or a designee will review all future reports prior to submission. Contact person(s) responsible for correction action: Kristi Kane, Executive Director Anticipated Completion Date: Immediately
Corrective Action: Procedures will be created as part of the subaward monitoring process to ensure that subrecipient information is received in a timely manner. Deadlines will be created to ensure that the subaward information is entered as part of FFATA reporting in Sam.gov with deadlines outlined ...
Corrective Action: Procedures will be created as part of the subaward monitoring process to ensure that subrecipient information is received in a timely manner. Deadlines will be created to ensure that the subaward information is entered as part of FFATA reporting in Sam.gov with deadlines outlined in 2 CFR 170.
Choice Neighborhood Incentive Grants – Assistance Listing No. 14.889 Recommendation: We recommend that HABC staff review the controls in place to ensure that required FFATA reporting documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There i...
Choice Neighborhood Incentive Grants – Assistance Listing No. 14.889 Recommendation: We recommend that HABC staff review the controls in place to ensure that required FFATA reporting documentation is complete, accurate, and available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Public Law 109-282, known as the Federal Funding Accountability and Transparency Act of 2006 (FFATA), mandates the public disclosure of all entities and organizations receiving federal funds through a single accessible website. Any subcontract exceeding $30,000 must be reported by the prime recipient of federal funds. However, this reporting requirement does not apply to the Housing Authority of Baltimore City (HABC), similar to the Moving to Work (MTW) block grants and their sub-recipient reporting to the Baltimore Regional Housing Partnership (BRHP). Both awards, the Choice Neighborhood Initiative (CNI) grant awards are not available in the dropdown menu for fulfilling this monthly reporting requirement. This issue was noted because HABC could not demonstrate to the auditors that we had made several unsuccessful attempts to meet this requirement. In response, HABC Finance has established a monthly workflow process to regularly check the website to document the attempts. In addition, we are currently awaiting a formal response from the Department of Housing and Urban Development (HUD) regarding the unavailability of these grants for sub-contracting monitoring & reporting on the SAMs website. Name(s) of the contact person(s) responsible for corrective action: Anu Francis, Chief Financial Officer. Planned completion date for corrective action plan: 12/31/2025
Sentara Health and Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: PBMares, LLP 701 Town Center Drive, Suite 900 Newport News, VA 23606 Audit period: Year ended December 31, 2024 The ...
Sentara Health and Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: PBMares, LLP 701 Town Center Drive, Suite 900 Newport News, VA 23606 Audit period: Year ended December 31, 2024 The finding from the year ended December 31, 2024 schedule of findings and questions costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FEDERAL AWARDS FINDING A. Significant Deficiency in Internal Control over Compliance Finding 2024-001: Student Financial Assistance Cluster - Federal Assistance Listing Number 84.268 - Significant Deficiency in Internal Control over Enrollment Reporting to National Student Loan Data System (NSLDS) Recommendation: Internal controls should be implemented to ensure that all enrollment status changes, including withdrawals occurring outside of standard roster cycles, are reported to NSLDS within the required timeframe. This should include submitting out-of-cycle enrollment updates to the Clearinghouse when necessary. This is not a repeat finding. Corrective Action Plan: 1. The Registrar will create a report that captures students who withdrew from the college to include all students in all program cycles. This report will capture withdrawal activity that occurs within and falls outside of each reporting period. 2. The report will be manually cross-referenced with enrollment data in the student information system. The responsible parties for ensuring this corrective action is employed are the Registrar and the Assistant Registrar of the College. They will be overseen by Cindy Mabie, Assistant Dean for Student Services. Timeline for Completion: The new process will go into effect October 1, 2025. If there are questions, please contact Cindy Mabie, Assistant Dean for Student Services at Cmabie@sentara.edu.
Finding No. 2024-002 Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Completion Date: January 31, 2025 Corrective Action Plan: We take the proper review and documentation of review of our Housing Quality Standards (HQS) inspections prior to their timely submiss...
Finding No. 2024-002 Significant Deficiency Personnel Responsible for Section 8 Director Corrective Action: Completion Date: January 31, 2025 Corrective Action Plan: We take the proper review and documentation of review of our Housing Quality Standards (HQS) inspections prior to their timely submission to the Public and Indian Housing Information Center (PIC) very seriously. We acknowledge the importance of this process and the need for consistent implementation. To address this finding, we will implement the following measures: 1. Documentation: A new documentation protocol will be established to provide clear proof that this process is occurring regularly. This will include date-stamped review logs and signatures from responsible staff members. We will institute a monthly review of 3 to 5 initial failed inspections. This review will: • Determine if repairs have occurred in a timely manner • Assess whether abatement letters should be sent • Be documented and included in our regular reporting 2. Training: We will conduct refresher training for all relevant staff to ensure they understand the importance of this process and their role in maintaining it. 3. Automated Reminders: We will implement an automated reminder system to alert staff when reviews and submissions are due. 4. Internal Review: Internal quarterly reviews will be conducted to ensure compliance with this process and to identify any potential issues early.
View Audit 369736 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: We agree with the recommendation and have implemented the recommendation as noted.
Views of Responsible Officials and Planned Corrective Action: We agree with the recommendation and have implemented the recommendation as noted.
With the addition of personnel, the finance team has been restructured to allow for a more streamlined month-end process. As part of the month-end process we have implemented more collaborative and robust communication between the grants management and finance teams to ensure accuracy in our grant m...
With the addition of personnel, the finance team has been restructured to allow for a more streamlined month-end process. As part of the month-end process we have implemented more collaborative and robust communication between the grants management and finance teams to ensure accuracy in our grant management process.
Finding #2024-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: All programs. Condition and context: The SEFA originally provided by management erroneously included a program that was not subject to Uniform Guidance and did not include two programs that w...
Finding #2024-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: All programs. Condition and context: The SEFA originally provided by management erroneously included a program that was not subject to Uniform Guidance and did not include two programs that were subject to Uniform Guidance. Additionally, an adjustment of approximately $165,000 was required to properly report the value of commodity expenditures in accordance with KCM’s valuation policy. Recommendation: Strengthen policies and procedures to ensure all federal grant expenditures subject to Uniform Guidance are properly recorded and classified in the general ledger system by class code. Reconcile federal expenditures to the SEFA using the class code reports. Planned corrective action: An internal audit performed in January 2025 identified deficiencies in internal controls for the calendar year 2024 primarily due to elevated personnel turnover. In response, corrective measures were implemented in April 2025, including the establishment and documentation of formal internal controls and procedures. New management has assumed oversight responsibilities and is actively monitoring compliance to ensure sustained effectiveness of these controls. All federal expenditures are segregated in the general ledger system and will be used to prepare the SEFA for calendar year 2025. Responsible officer: Virginia Gonzalez, Chief Executive Officer. Estimated completion date: Completed as of April 30, 2025.
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