Corrective Action Plans

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The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved acco...
The audit noted that federal awards and expenditures were not adequately tracked by grant in the general ledger. Corrective action has already been taken: the general ledger has been updated to ensure that federal awards are now tracked by the grant program. This enhancement allows for improved accountability, accurate reporting, and compliance with federal requirements.
Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. ...
Planned Corrective Action: To ensure compliance with federal reporting standards, the Organization will require a secondary review of all federal reports submitted to granting agencies. The designated secondary reviewer shall be an individual that has strong knowledge of the reporting requirements. Additionally, the Organization will implement policies and procedures surrounding file retention of the underlying data that supports federal reports submitted. Anticipated Completion Date: 12/31/2025 Responsible Contact Person: Meghann Ackley, Chief Financial Officer
Management understands that the Cooperative must provide data for the proper periods when filing its quarterly reports. The Controller, Steve Malay, has implemented a review process to ensure that financial reports align with the periods specified in the grant agreements whenever possible. In instan...
Management understands that the Cooperative must provide data for the proper periods when filing its quarterly reports. The Controller, Steve Malay, has implemented a review process to ensure that financial reports align with the periods specified in the grant agreements whenever possible. In instances where complete information is not available within the required reporting window (due timing of information and required deadlines), management will provide the most reliable and available data at the time of reporting. This will be clearly documented to ensure transparency with granting agencies.
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (3) Finding 2024-003 (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 establish internal tracking and reminder systems to ensure all required reports, including the final P&E and AMCC, are completed and submitted to HUD by the required due dates. Grant reporting responsibilities will be clearly assigned, and submission deadlines will be monitored by the Director of Finance to prevent future delays. These procedures will be implemented immediately. (c) Planned implementation date - The Authority plans to implement procedures during the year ending December 31, 2025 to resolve the reported finding.
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (...
Name of Auditee: Amsterdam Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2024 CAP Prepared by: Damaris Carbone, Executive Director Phone: (518) 842-2894 (A) Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (4) Finding 2024-004 (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 strengthen procedures to ensure all interfund accounts are reconciled and settled monthly before completing the HUD-52681-B report. Accounting staff will review and verify key line items (including Unrestricted Net Position and Cash in 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.
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting document...
Finding 2024-001 WIC Special Supplemental Nutrition Program for Women, Infants, and Children (ALN 10.557) Advocate Aurora Health, Inc., follows a paperless system as supported by the State of Wisconsin and the U.S. Department of Agriculture. The state does not require third-party supporting documentation of eligibility determinations to be retained. As a result, no corrective action will be taken. Contact Person - Responsible for Corrective Action: Jen Agnello, Program Manager Anticipated Completion Date: N/A
Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 369054 Questioned Costs: $1
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children an...
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children and Families State Agency: Wisconsin Department of Children and Families State Program ID Number and Title: 435.560100 ADRC 435.000561/000681 Basic County Allocation State Agency: Wisconsin Department of Health Services State Program ID Number and Title: 395.168 Specialized Transit County Operating Aids (Elderly & Disabled) State Agency: Wisconsin Department of Transportation State Program ID Number and Title: 435.000283 IMAA State Share State Agency: Wisconsin Department of Health Services Award Numbers: Unknown Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with federal laws, regulations and program compliance requirements. The State Single Audit Guidelines (SSAG) require that local entities receiving State awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including appropriate review and approval of expenditures. Condition/Context: During our testing, we were unable to view approval for the following number of payroll expenditures in each program: • 93.778: 13 out of 20 expenditures tested. • 435.000561/000681, 437.3561/3681: 7 out of 40 expenditures tested. • 435.560100: 14 out of 20 expenditures tested. For programs 395.168 and 435.000283, these are carried over from the prior year as controls have not changed within the system. These samples were not statistically valid. Corrective Action Plan Corrective Action Planned: In response to Finding 2024-004 regarding Internal Control Over Financial Reporting, note that the County is aware that there is lack of controls over its year-end financial reporting process. The County will endeavor to evaluate the need to increase additional staff to meet the deficiencies noted in the finding. However, due to its size, the County does not feel it is cost-effective to hire the number of employees needed to complete these task in house at this point in time and will rely on an outside audit firm. Administration is aware the current payroll and financial system allows to only go back to view payroll approvals within one year. Name(s) of Contact Person(s) Responsible for Corrective Action: Ron Barger, Marquette County Administrator Anticipated Completion Date: Administration will examine the lack of internal financial reporting on a yearly ongoing basis.
Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will implement procedures to ensure accurate reporting. Completion Date – 9/30/2025
Contact Person – Bruce Starkey, County Administrator Corrective Action Plan – The County will implement procedures to ensure accurate reporting. Completion Date – 9/30/2025
Management’s Views and Corrective Action Plan 2024-001 – Non-compliance with Enrollment Reporting Requirements Grantor: U.S. Department of Education Program Name: Student Financial Assistance Cluster Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Year: 1/1/2024 - 12/3...
Management’s Views and Corrective Action Plan 2024-001 – Non-compliance with Enrollment Reporting Requirements Grantor: U.S. Department of Education Program Name: Student Financial Assistance Cluster Award Names: Federal Pell Grant Program and Federal Direct Student Loans Award Year: 1/1/2024 - 12/31/2024 Award Number: Not applicable Assistance Listing Numbers: 84.063 and 84.268 Management’s Response Management agrees with the finding as it relates to the improper reporting to NSLDS of enrollment reporting for one student. The improper reporting was due to a human clerical error. As of the date of this report, management notes that the identified student’s enrollment status has been updated to NSLDS. Currently all financial aid aspects of the AHN Schools of Nursing are completed by one personnel. Management has communicated reminders of the student enrollment change requirements, as well as the AHN Schools of Nursing policies and procedures to the personnel to ensure that changes are reported accurately and timely. In addition, management is in process of recruiting an additional Financial Aid Officer, who will act as an additional layer of review and cross-checks to ensure that data is being reported for enrollments accurately and timely. Anticipated Completion Date As of the date of this report, the noted student’s enrollment status has been updated. Management is actively recruiting for an additional Financial Aid Officer and is working to fill the open position as soon as possible. Responsible Parties • Amy Stoker, Director of AHN Schools of Nursing • Sarah Loomis, Director of Financial Aid of AHN Schools of Nursing
Housing Voucher Cluster-Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action t...
Housing Voucher Cluster-Assistance Listing No. No. 14.871 and 14.879 Recommendation: We recommend that the Authority implements controls to ensure HUD-50058 recertifications are uploaded to PIC. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HAKC will monitor the monthly SEMAP Indicator report and monitor the PIC dashboard to ensure all 50058 errors are corrected and uploaded in a timely manner. HAKC will also pull the ADHOC from PIC to verify the records. HAKC will continue working with the HUD PIC coach monthly to correct all errors. HAKC will complete the initial process and complete ongoing compliance reviews. Name(s) of the contact person(s) responsible for corrective action: Lisa Earnest, Director of Housing Choice Voucher Program Planned completion date for corrective action plan: 4/30/2026
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of ...
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of Responsible O􀆯icials: We concur with the findings. Description of Corrective Action Plan: The Grant Administrator will monitor all claims that will be used for the quarter and send them to the reporting agent to report after the quarter ends. She will be diligent to track any claims coming in outside of that quarter so that reporting is accurate. She will provide the reporting agent with all claims relevant to that quarter’s report. Anticipated Completion Date: This will be done quarterly starting with the quarter ending on September 30th, 2025. The Grant Administrator will submit these claims to the reporting agent one week after the quarter ends. The Financial Administrator will sign o􀆯 on the LOW report to verify the claims match.
On behalf of Bebashi – Transition to Hope, I am submitting this corrective action plan in response to the material weakness finding identified in our recent federal audit. The finding noted a lack of effective internal controls over the maintenance of accurate accounting records, including the trial...
On behalf of Bebashi – Transition to Hope, I am submitting this corrective action plan in response to the material weakness finding identified in our recent federal audit. The finding noted a lack of effective internal controls over the maintenance of accurate accounting records, including the trial balance, general ledger, and the Schedule of Expenditures of Federal Awards (SEFA) and state financial assistance. These deficiencies resulted in material audit adjustments to the current year’s financial statements, multiple versions of the trial balance due to reconciling issues, and audit delays related to unreconciled supporting documentation. We take these findings with the utmost seriousness. As stewards of federal funds, it is our fiduciary duty to maintain strict compliance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR Part 200), as well as applicable state financial requirements. Corrective Action Plan 1. Strengthening Internal Controls o We are implementing enhanced internal control procedures to ensure timely reconciliation of the trial balance and general ledger. o Monthly reconciliations will now be prepared by the Finance Department, reviewed by the Chief Operating Officer, and formally approved by the President & Chief Executive Officer prior to closing. o Quarterly oversight reporting will also be provided to the Bebashi Board of Directors. 2. Accounting System Improvements o We will establish a standardized process to ensure one official version of the trial balance is maintained, with all adjustments tracked and documented in accordance with Generally Accepted Accounting Principles (GAAP). o We are upgrading our financial reporting system to include automated reconciliation checks, audit trails, and controls that will minimize the risk of discrepancies. 3. Staff Training and Accountability o Finance staff will undergo mandatory annual training on federal compliance, SEFA preparation, and reconciliation best practices. o Roles and responsibilities will be clearly defined, with a segregation of duties to prevent misstatements and errors. 4. Audit Readiness and Documentation o A comprehensive audit binder will be prepared and maintained to ensure that supporting documentation reconciles with the trial balance prior to submission. o A compliance calendar will be developed to track critical deadlines, reconciliation reviews, and reporting requirements. 5. Board and Executive Oversight o The Bebashi Board of Directors, through its Finance and Audit Committees, along with the President & CEO, will provide governance oversight of this corrective action plan. o Quarterly progress reports will be submitted to the Board, and the CEO and Board will formally document oversight in meeting minutes to ensure accountability and compliance. Responsible Party: The Finance Director, in collaboration with the Chief Operating Officer and with final accountability to the President & CEO as well as the Bebashi Board of Directors, will be responsible for implementing and monitoring this corrective action plan. Anticipated Completion Date: All corrective measures will be completed within ninety (90) days of the date of this letter, with ongoing monitoring and governance oversight by the CEO and Board of Directors to ensure sustainability. We regret the deficiencies that led to this finding and are committed to taking the corrective actions necessary to strengthen our financial management systems. Bebashi – Transition to Hope is dedicated to full compliance with federal and state requirements and to safeguarding the integrity of public funds entrusted to us. Respectfully submitted, Sincerely, Sebrina Tate President & Chief Executive Officer Bebashi – Transition to Hope On behalf of the Bebashi Board of Directors
Management agrees with the finding and is working on submission of the federal reporting package for the year ended December 31, 2023. The submission of the December 31,2024 federal reporting package will be completed prior to its due date.
Management agrees with the finding and is working on submission of the federal reporting package for the year ended December 31, 2023. The submission of the December 31,2024 federal reporting package will be completed prior to its due date.
Action taken in response to finding: The County will identify all federal awards that FFATA reporting is required. Once all the requirements are identified, the County will then determine if there are eligible subrecipients or contracts that need to be reported on the FFATA website.
Action taken in response to finding: The County will identify all federal awards that FFATA reporting is required. Once all the requirements are identified, the County will then determine if there are eligible subrecipients or contracts that need to be reported on the FFATA website.
The District acknowledges that the size of the accounting staff limits the District’s ability to prepare the financial statements in accordance with U.S. generally accepted accounting principles and implement the proper segregation of duties among who performs the billing, receives cash receipts, po...
The District acknowledges that the size of the accounting staff limits the District’s ability to prepare the financial statements in accordance with U.S. generally accepted accounting principles and implement the proper segregation of duties among who performs the billing, receives cash receipts, posts receipts to customer accounts, and makes deposits at the bank. . While there is an outsourced bookkeeper, the Office Manager performs three of these functions in the normal course of performing her duties. Additionally,the District acknowledges that the size of the accounting staff limits the District’s ability to prepare the Schedule of Expenditures and Federal Awards in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). The Board of Trustees plans to remain involved in the financial activities of the District to provide oversight by performing a monthly review of the financial information of the District to provide mitigating controls over the lack of segregation of duties over these functions. Responsible party: Dale Clark, Superintendent, (207) 696-5211 Anticipated Completion Date: Ongoing
Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and perf...
Views of Responsible Officials and Planned Corrective Action: To the extent possible, monitoring of federal compliance information by management and the board of trustees will continue at ACHD. When possible with limited staff, ACHD will conduct a documented review of reimbursement requests and performance reports.
Finding 2024-003: Emergency Rental Assistance Program (ERAP). Contact Person: Duane K. McMullen Jr., Director of Fiscal Affairs. Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the H...
Finding 2024-003: Emergency Rental Assistance Program (ERAP). Contact Person: Duane K. McMullen Jr., Director of Fiscal Affairs. Recommendation: The County should establish internal controls procedures over reporting requirements. Response: The County agrees with the finding and will work with the Human Services Director and Human Services Financial Manager to revise and, where necessary, establish procedures to ensure proper approval by all required parties prior to submission of said reports. Action Planned: Post-audit submission, the County Director of Fiscal Affairs will meet and discuss with the Human Services Director and Human Services Financial Manager all upcoming reporting requirement, and implement reporting procedures that require multiple signatures and approvals, including those required under the reporting guidelines and requirements, and the initials of the County Director of Fiscal Affairs, prior to submission of the subject reports. Date for Completion: December 31, 2025.
Views of Responsible Officials: We acknowledge this lapse. We have already updated procedures to ensure that we are registering subgrants correctly.
Views of Responsible Officials: We acknowledge this lapse. We have already updated procedures to ensure that we are registering subgrants correctly.
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could includ...
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends that additional emphasis of documentary evidence of approvals be made, and such evidence obtained and retained by SFP as proof of oversight of expenditure of federal funds. This could include: signatures on reports, emails indicating review and approval from appropriate individuals, retention of meeting agendas and minutes to corroborate that review occurred during the meetings, etc. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, the COO (or the Director of Finance, once hired) will conduct a documented review and written approval of all federal draw requests prior to submission to USAID. This review will be evidenced by either1. A signed and dated approval on the draw request form, or 2. A saved electronic record (e.g., email approval) in the grant’s shared compliance folder. SFP will also retain relevant meeting minutes or other supporting documentation demonstrating review in accordance with 2 CFR §200.303(a) requirements for internal controls. Name(s) of the contact person(s) responsible for corrective action: Anna Gabis Planned completion date for corrective action plan: October 31, 2025
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
2. In response to Finding 2024-002: Reporting – significant deficiency in internal controls over compliance Economic Development Initiative, Community Project Funding and Miscellaneous grants, please note the following: Cause of Internal Control Issue: Transform 1012’s grant reporting procedures inc...
2. In response to Finding 2024-002: Reporting – significant deficiency in internal controls over compliance Economic Development Initiative, Community Project Funding and Miscellaneous grants, please note the following: Cause of Internal Control Issue: Transform 1012’s grant reporting procedures included a verbal approval of reports and therefore, management approval could not be confirmed or reperformed. The effect of this is that bi-annual reporting was not fully documented in accordance with internal control procedures over compliance. Actions To Rectify Internal Control Issue: Management’s Response: Carlos Gonzalez-Jaime, Executive Director, will ensure his written documentation of review and approval of all grant reports is kept on file by using electronic signature to indicate review and approval and storing signed copies of the documentation. • This will be completed by October 31, 2025, for 2025 reports through October 31, 2025. Going forward, signed documentation will be stored within seven days of the report being issued.
Finding 1156477 (2024-002)
Material Weakness 2024
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.
Finding 1156474 (2024-001)
Material Weakness 2024
Rent Reasonableness forms for rental payments made with CoC funds were not always completed in a timely fashion. Additionally, there was inadequate evidence of internal review and approval. In late 2024, LifeWire’s Controller began requiring Rent Reasonableness forms to be provided with every rental...
Rent Reasonableness forms for rental payments made with CoC funds were not always completed in a timely fashion. Additionally, there was inadequate evidence of internal review and approval. In late 2024, LifeWire’s Controller began requiring Rent Reasonableness forms to be provided with every rental payment request made with public funds. LifeWire’s AP approval process requires review and approval by members of the Director team before payments can be issued. In 2025, all rental payments made with CoC funds now have documented evidence of internal approval and review. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: The new process was rolled out in November 2024.
Finding 2024-002: Internal Control Environment Condition The Federal Financial Report was submitted by the original preparer without review before submission. Corrective Action Plan Corrective Action Planned: The Finance Director will review and approve submittals of the annual grant applications an...
Finding 2024-002: Internal Control Environment Condition The Federal Financial Report was submitted by the original preparer without review before submission. Corrective Action Plan Corrective Action Planned: The Finance Director will review and approve submittals of the annual grant applications and reports, including from third-parties in the event of any pass-through grants the City facilitates. Name(s) of Contact Person(s) Responsible for Corrective Action: Josh Solinger Anticipated Completion Date: Immediate and ongoing
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