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Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully subm...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2023-004 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management ensure that the data collection forms are submitted electronically to the FAC each fiscal year going forward. Action Taken: We agree with Finding 2023-004 and the recommendation described in the accompanying schedule of findings and questioned costs. The project was unable to pay the prior audit fees timely due to limited available cash flow causing a delay in the audits. Management will work to improve cash flow for timely payment of the required annual audits. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
• Monitor submission of SF-425 reports quarterly via staff meetings to ensure timely and accurate filing. • Enhance file maintenance for deeper reviews and accessibility. • Note: Re-review located 100% of cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 ...
• Monitor submission of SF-425 reports quarterly via staff meetings to ensure timely and accurate filing. • Enhance file maintenance for deeper reviews and accessibility. • Note: Re-review located 100% of cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 Ms. Senny Phillip, Asst. Secretary of Investment & International Financing Email: senny.phillip@gov.fm
• Strengthen monitoring controls to verify period of performance, including obligation/incurrence and liquidation timelines. • Collaborate with grantors to clarify and document allowable liquidation periods for drawdowns. • Implement systematic filing of supporting documents for easy retrieval. • No...
• Strengthen monitoring controls to verify period of performance, including obligation/incurrence and liquidation timelines. • Collaborate with grantors to clarify and document allowable liquidation periods for drawdowns. • Implement systematic filing of supporting documents for easy retrieval. • Note: Drawdowns conducted in close collaboration with grantors, confirming compliance with agreed terms. 9/30/2026 Ms. Senny Phillip, Asst. Secretary of Investment & International Financing Email: senny.phillip@gov.fm
• Train compliance officers on reporting processes and monitor submissions quarterly. • Improve file maintenance system with deeper reviews for easy retrieval. • Note: Re-review located all cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 Ms. Christina E...
• Train compliance officers on reporting processes and monitor submissions quarterly. • Improve file maintenance system with deeper reviews for easy retrieval. • Note: Re-review located all cited "missing" reports; underlying support was available. Tagging is not mandatory. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury Email: christina.elnei@dofa.gov.fm
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Re...
Disagree with adverse compliance opinion and findings, as auditors applied Uniform Guidance (2 CFR Part 200) requirements, which are inapplicable to Compact sector grants (ALN 15.875) governed exclusively by the Compact of Free Association, as amended, and the Fiscal Procedures Agreement (FPA). • Request U.S. Department of the Interior, Office of Insular Affairs, to disregard these findings for grant administration and questioned costs resolution, as they do not reflect noncompliance with Compact/FPA standards. • Maintain commitment to accountability under Compact/FPA standards. 9/30/2026 Ms. Christina Elnei, Asst. Secretary of National Treasury (primary contact) Email: christina.elnei@dofa.gov.fm
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; ...
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Coronavirus State and Local Fiscal Recovery ALN 21.027; passed through the Commonwealth of Pennsylvania Department of Community and Economic Development. Condition The Authority did not submit the Single Audit reporting package and Data Collection Form to the Federal Audit Clearinghouse within the required timeframe of nine months after the end of the audit period. The 2022 reporting package was submitted on May 7, 2025, which was after the one month due date of September 30, 2023. In addition, the 2023 reporting package was not submitted by the September 30, 2024 due date. Recommendation We recommend that the Authority continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse. Management Response The Authority will continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse.
2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income ...
2023-002 PROGRAM INCOME - MATERIAL WEAKNESS Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks and HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Condition/Cause During our testing of program income received during 2023, it was noted that the Authority did not report all program income received into IDIS. As a result of not entering all program income into IDIS, our testing indicated that new entitlement funds were drawn down prior to utilizing all available program income on hand. The Authority utilizes a separate general ledger account in the financial reporting software to record all program income received for each federal grant program. The Fiscal Officer enters the program income into IDIS. No internal control existed to ensure the completeness or accuracy of the program income information entered into IDIS. Recommendation We recommend the Authority develop and implement an internal control procedure to ensure that all program income is entered timely within the IDIS system. Prior to drawing down new entitlement funding, the program income general ledger account associated with the grant program should be reviewed and compared to the program income reported within IDIS to ensure all program income is recorded and fully utilized before drawing down additional entitlement funding. Management Response The Authority implemented a new policy to track and document program income: a. Upon receipt of program income, it shall be entered individually into IDIS and assigned to an activity or activities within fifteen (15) calendar days of receipt. b. At the next request for funds for an activity which includes funding from program income, program income shall be used prior to requesting federal funds for the activity. c. The request for federal funds shall be prepared by the Fiscal Officer and reviewed by one of the Assistant Fiscal Officers to determine if program income is being used prior to the request of federal funds. d. If it has been determined and documented that program income is being used prior to the request for federal funds, the request shall be forwarded to the Executive Director for approval. Current Status of Corrective Action Plan This finding has been resolved by management. The new policy was implemented on April 1, 2025.
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.
Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the fi...
Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (Compliance) We recommend that management establish and enforce procedures to ensure all required federal financial and progress reports are submitted by the applicable due dates. Management's Response: The County concurs with the findings; Responsible Individual: Nicole Reinert, Public Health Director; Corrective Action Plan: Administrative staff will schedule out all required report dates in the Outlook calendar at least three weeks before the due date to keep responsible parties informed of deadlines. These set reminders will ensure timely submissions. The Department Head will review the submission process to eliminate congested workflow to ensure efficiency and identify any tasks that can be automated or improved. Regular check-ins will take place to discuss the status of ongoing reports.; Anticipated Completion Date: June 30, 2026.
Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Manageme...
Schools and Roads - Grants to States (Compliance) We recommend that the County establish internal control procedures to ensure that required certifications for Title III expenditures and unobligated funds are completed, reviewed, and submitted timely in accordance with federal requirements. Management's Response: The County concurs with the findings. Responsible Individual: Allen Hisky, Clerk of the board of Supervisors; Corrective Action Plan: The Clerk of the Board will ensure that sufficient internal controls are in place for proper notification of Certification Title III Expenditures and Unobligated Funds by statutory deadline. This process should include clear assignment to responsibilities and retention of documentation as part of grant compliance records.; Anticipated Completion Date: June 30, 2026.
Schools and roads - Grants to States, Highway Planning and Construction, Coronavirus State and Local Fiscal Recovery Funds, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Foster Care - Title IV-E, and Medical Assistance Program. We recommend that the County departments provide t...
Schools and roads - Grants to States, Highway Planning and Construction, Coronavirus State and Local Fiscal Recovery Funds, Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), Foster Care - Title IV-E, and Medical Assistance Program. We recommend that the County departments provide the County Auditor with accurate Federal expenditure information prior to the beginning of audit fieldwork. Management's Response: The County concurs with the findings. Responsible Individuals: 10.665 and 20.205: Rob Thorman, Director of Public Works and Damien Frank, Administrative Services Officer; 10.665: Kevin Goss, Chairman of the Board of Supervisors; 21.027 and 93.323: Nicole Reinert, Director of Public Health and DeLena Jones, Administrative Services Officer; 93.658 and 93.778: Jennifer Bromby, Interim Social Services Director/Staff Service Manager. Corrective Action Plan: Each department will be required to run a trial balance report and identify the federal expenditures by program. The departments will be required to track each program and either within the financial system or on an Excel spreadsheet and at the end of the fiscal year use the method of backing out expenses from previous SEFA reporting and adding any expenses from the subsequent fiscal year to the prior fiscal year up to 60 days. The department tis required to maintain the reconciliation spreadsheet on a monthly or quarterly basis depending on the volume of the program. The department fiscal officer will be required to review with the department head, and both the department fiscal officer and department head will need to sign off on the SEFA information provided to the Auditor-Controller, along with proper back and the program trial balance at the end of the fiscal year prior to start of the external auditor fieldwork. Anticipated Completion Date: The Auditor-Controller will hold a mandatory training course in January of 2026 for fiscal officers and department heads of the above-mentioned findings.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Finding 1166097 (2023-006)
Material Weakness 2023
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionall...
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionally, reasonably and in a timely manner to secure our 2022 audit within the required timeline. Despite our diligence, the previous auditing company and their representatives were grossly non-responsive and ultimately, we had to dispute our payment that was made in full for not receiving the 2022 audit services in a timely manner. This impacted our 2023 audit not being completed as indicated in the finding. Corrective Action: The Organization chose a new audit company that is responsive, professional and highly experienced in non-profit audits. The Organization continues to have a process in place to ensure that required audits are completed in accordance with established guidelines. In advance, we seek at least three bids from reputable audit companies; our finance team provides documentation in a timely manner; we utilize a designated person to ensure the audit process is not delayed including conducting routine follow-ups or check-ins and ensuring any issues are resolved quickly; and we pay our bills on time. Our corrective action plan is in place to ensure timely audits in the future as applicable.Name of Contact Person Sophia Nash – HR-Business Manager; 229-854-3660; hr.fwocga@gmail.com Projected Completion Date: December 31, 2025
Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training...
Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training to staff on SLFRF reporting requirements and deadlines, implement written policies and procedures to ensure timely submission of all reports, including establishing a compliance calendar with automated reminders and maintaining a reporting log to track submission dates. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Katie Eviston, Finance Director, (937) 324-7700
Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to sta...
Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Borough’s Response: Eldred Borough has board oversight and will continue to do so. The Borough employees do cover duties of the other employee when necessary and will continue to do so. Bank Reconciliations will be signed by Council. Pay Requisitions are signed by Council and will continue to do so.
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. A calendar of all federal reporting...
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. A calendar of all federal reporting requirements will be developed and maintained. This calendar will be reviewed monthly to ensure all federal compliance timelines are met. A federal program grant activity report will be shared monthly with the district leadership team. This report will keep financial monitoring to the forefront of the leadership team. All federal program reporting will be reviewed with the Business Office prior to submission. Business Office will complete federal program management and reporting training by December 31st by working with the federal program specialists at the State Department of Education and reading and retaining for future reference any grant specific guidance.
Condition: The Organization did not submit required program reports within the timeframes stipulated in the Community-Based Violence Intervention and Prevention Initiative grant agreement. Criteria: Per the grant agreement and financial reporting compliance requirements, recipients must submit perfo...
Condition: The Organization did not submit required program reports within the timeframes stipulated in the Community-Based Violence Intervention and Prevention Initiative grant agreement. Criteria: Per the grant agreement and financial reporting compliance requirements, recipients must submit performance and financial reports timely. Cause of condition: The delay was due to internal administrative challenges and competing priorities during the reporting period. Potential effect of condition: Late reporting may hinder the grantor’s ability to monitor program performance and compliance, potentially affecting future funding decisions. Recommendation: Implement stronger internal controls and calendar-based tracking to ensure timely submission of all required reports. Management response: The Organization is working to catch up on the outstanding invoices and have implemented adjustments to their process to help ensure timely submission going forward. Action Taken: The Organization has implemented process adjustments to its workflow to catch up on outstanding invoices and ensure timely submission of current invoices. As of November 14, 2025, all outstanding invoices have been submitted.
Description: Management should ensure that Uniform Guidance regarding time tracking related to federal grants is fully implemented. Auditors review of employee timesheets lacked evidence of review and approval, and certain employees did not prepare timesheets. Recommendation: Management should revie...
Description: Management should ensure that Uniform Guidance regarding time tracking related to federal grants is fully implemented. Auditors review of employee timesheets lacked evidence of review and approval, and certain employees did not prepare timesheets. Recommendation: Management should review the requirements of CFR 200.430 and ensure that current processes, whether digital or hard-copy driven, are consistent with the requirements of the Uniform Guidance. In addition, management should consider adding additional staff to its accounting and/or grants management team. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management will evaluate systems and processes to ensure time tracking procedures meet the standards outlined in the Uniform Guidance. Anticipated Completion Date: December 31, 2025
Person Responsible: Fiscal Administrator (Grants and Budget) Deadline: CUC agrees to develop and create a more refined tracking system and staffing for compliance purposes. A tracking system is in place as of this writing.
Person Responsible: Fiscal Administrator (Grants and Budget) Deadline: CUC agrees to develop and create a more refined tracking system and staffing for compliance purposes. A tracking system is in place as of this writing.
Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025
Management will review its current policies and the grant requirements set forth by its grant agreements as well as review the CFR requirements and adopt numerous policies in FY2025
Finding 2023-006 – Timely Submission of the Single Audit Responsible official: Executive Director Corrective action planned: Management has acknowledged the delay in the submission of prior audits and has begun implementing stronger scheduling and monitoring controls to prevent recurrence. A complia...
Finding 2023-006 – Timely Submission of the Single Audit Responsible official: Executive Director Corrective action planned: Management has acknowledged the delay in the submission of prior audits and has begun implementing stronger scheduling and monitoring controls to prevent recurrence. A compliance calendar has been created listing all federal and financial reporting deadlines, including the nine-month requirement for Single Audit submissions. The Executive Director will coordinate with the external accountants within the first quarter following fiscal year-end to initiate audit planning and fieldwork early. The Board will monitor progress to ensure that financial closing and audit engagement activities are completed in sufficient time to meet the next federal submission deadline. Monitoring: Management will review the audit timeline audit process in order to remains on schedule. Target completion date: For the 2025 audit – submission to the Federal Audit Clearinghouse by September 30, 2026. Status: Corrective action in process. Controls have been established but were not fully effective for the 2024 audit cycle. Management is applying the revised procedures for the 2025 audit to ensure timely completion and submission.
Finding No. 2023-003 Area: Reporting Views of Auditee and Planned Corrective Action: We agree with this finding. Kosrae Project Management Office hired a Finance Officer in FY2024 and started preparing SF-425 reports for its infrastructure projects. The Office of Finance consolidates all SF-425 form...
Finding No. 2023-003 Area: Reporting Views of Auditee and Planned Corrective Action: We agree with this finding. Kosrae Project Management Office hired a Finance Officer in FY2024 and started preparing SF-425 reports for its infrastructure projects. The Office of Finance consolidates all SF-425 forms for all Compact sector grants and sends them to the FSM National Government on a quarterly basis. Anticipated Completion Date: Ongoing Name of Contact Person: Mr. Palokoa George Finance Officer Kosrae Project Management Office Email: psgeorge@kosrae.gov.fm
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