Corrective Action Plans

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Client has implemented staffing it is anticipated that the audit for 2025 and related forms will be issued within the allowable time period in the loan agreements.
Client has implemented staffing it is anticipated that the audit for 2025 and related forms will be issued within the allowable time period in the loan agreements.
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2...
St. John’s Lutheran Home of Albert Lea submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Lethert, Skwira, Schultz & Co. LLP, 170 E 7th Place, Saint Paul, MN 55101 Audit period: October 1, 2024 – September 30, 2025 The findings from the September 30, 2025 schedule of findings, questioned costs and recommendations. FINDINGS - FINANCIAL STATEMENT AUDIT Finding 2025-001 - Auditor Preparation of the Financial Statements Material Weakness Finding Summary: The Organization does not have an internal control system designed to provide for the preparation of the complete consolidated financial statements, including the accompanying footnotes, as required by GAAP. We were also requested to draft the financial statements and accompanying notes to the financial statements. Corrective Action Plan: It is not cost effective to have an internal control system designed to provide for the preparation of financial statements and accompanying notes. We requested that our auditors Lethert, Skwira, Schultz & Co. LLP, prepare the financial statements and the accompanying notes to the financial statements as a part of their annual audit. We have designated a member of management to review the drafted financial statements and accompanying notes. Responsible Individuals: Alice Marie, CFO 507-373-2040 Anticipated Completion Date: Ongoing
Management will strengthen controls over federal reporting by establishing documented procedures for the preparation, review, certification, and submission of all required federal reports. Responsibility for report preparation and certification will be formally assigned, with designated backup personn...
Management will strengthen controls over federal reporting by establishing documented procedures for the preparation, review, certification, and submission of all required federal reports. Responsibility for report preparation and certification will be formally assigned, with designated backup personnel identified to ensure continuity during staffing transitions. A reporting calendar and tracking system will be maintained to monitor filing deadlines, and all reports will be subject to documented review and approval by an authorized individual prior to submission. Management will periodically review compliance with reporting requirements to ensure reports are submitted accurately and timely.
III. Finding 2025-003 SEFA Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has implemented additional review procedures for preparation of the Schedule of Expenditures of Federal Awards (SEFA). Prior to issuance, grant contract numbers, amendment numbers,...
III. Finding 2025-003 SEFA Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has implemented additional review procedures for preparation of the Schedule of Expenditures of Federal Awards (SEFA). Prior to issuance, grant contract numbers, amendment numbers, award amounts, and expenditures reported on the SEFA will be reconciled to executed grant agreements, amendments, and supporting accounting records. Management review and approval of the completed SEFA will be documented prior to submission to the auditors. These procedures have been incorporated into CFILC's year-end financial reporting process to ensure the completeness and accuracy of federal award reporting. Contact Person: M. Lisa Hayes, Executive Director Projected Completion Date: September 30, 2026
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to...
II. Finding 2025-002 Lack of Documentation of Quarterly Reporting Statement of Concurrence: CFILC concurs with the finding. Corrective Action: CFILC has revised its reporting procedures to require that all quarterly reports required under the Assistive Technology Agreement be submitted in writing to the DOR Contract Administrator and retained electronically with evidence of timely submission. Documentation may include emailed reports, delivery confirmations, or other records demonstrating compliance with reporting deadlines. Management will maintain a centralized reporting file and review quarterly reporting requirements to ensure all required reports are submitted and retained in accordance with grant requirements. Although program activity associated with the Device Lending and Demonstration Centers and Reuse Centers is currently being procured through a competitive RFP process, CFILC will submit all required quarterly reports beginning with the next reporting cycle, including reports indicating limited or no activity when applicable. Contact Person: M. Lisa Hayes, Executive Director Projected Completion Date: July 30, 2026
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
Untimely Submission of Federal Financial Reports (SF 425) – Reporting – Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding – Significant Deficiency in Internal Control over Compliance Cause – Controls and procedures designed to ensure timely preparation,...
Untimely Submission of Federal Financial Reports (SF 425) – Reporting – Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding – Significant Deficiency in Internal Control over Compliance Cause – Controls and procedures designed to ensure timely preparation, review, and submission of required federal financial reports were not consistently followed, resulting in delayed submission of SF-425 reports. Corrective Actions: 1. Improvement of Data Entry and Documentation Management a. The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. b. Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: a. A regular internal review and audit process will be revisited to ensure that backup, storage and retention practices are followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. b. Any discrepancies or issues identified during audits will be addressed promptly, and corrective action will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: a. Training sessions will be conducted for all relevant staff on the updated backup, storage and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. b. Refresher training will be provided quarterly to ensure ongoing compliance and awareness.
Please accept this correspondence as the Alfred Saliba Family Services Center, Inc. 's formal corrective action response to Finding 2025-001: Reporting, related to the review and documentation process for Federal Financial Reports, including SF-425 reports. During the prior audit cycle, management b...
Please accept this correspondence as the Alfred Saliba Family Services Center, Inc. 's formal corrective action response to Finding 2025-001: Reporting, related to the review and documentation process for Federal Financial Reports, including SF-425 reports. During the prior audit cycle, management became aware of deficiencies related to the review and documentation process for Federal Financial Reports. While the 2024 audit was occurring and these deficiencies were being identified, the previous Grants Manager was relieved from her position. Following that personnel change, the Alfred Saliba Family Services Center undertook a reorganization of fiscal management responsibilities to strengthen oversight, accountability, and internal controls. As part of this corrective action, the organization reviewed, rewrote, and codified its Fiscal Policies and Procedures, which were formally adopted by the Board of Directors. These revised policies clarified reporting responsibilities, strengthened the review and approval process, and established clearer expectations for documentation, supervisory review, and retention of records related to grant reporting. The revised fiscal policies also include a new Federal Financial Report (SF-425) Review & Approval Form, located in Appendix X of Standard 2 - Fiscal Policies and Procedures, to ensure consistent documentation of management review prior to submission. Since the personnel and fiscal management changes were implemented, SF-425 reports have been prepared and provided to the Executive Director in a timely manner prior to submission. The Executive Director reviews the reports, verifies the information as appropriate, and signs the reports to document management review and approval. This process provides clear evidence that financial reports are revi_ewed before submission and that appropriate oversight is occurring. The Alfred Saliba Family Services Center believes these corrective actions have addressed the condition noted in the finding. The organization will continue to monitor this process as part of its ongoing fiscal management framework to ensure sustained compliance, timely reporting, and proper documentation of management review. Anticipated Completion: Immediately Responsible Party: Jim Hartnett, Executive Director
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognitio...
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognition Checklist for all new grant awards to identify conditional barriers, allowable costs, reporting requirements, and revenue recognition criteria. Maintain a centralized grant tracking schedule that identifies grant conditions, expenditures incurred, revenue recognized, refundable advances, and remaining deferred revenue. Perform monthly reconciliations between grant schedules and the general ledger. Implement a documented two-level review process whereby the preparer completes the reconciliation and a supervisory reviewer verifies the accuracy and completeness before month-end close. Provide additional training to finance and program management staff regarding ASC 958 revenue recognition requirements for conditional contributions. Update internal accounting procedures to document the review and approval process for recognizing grant revenue. These procedures will be incorporated into the monthly financial close process and monitored throughout FY2026. SERCAP has hired new staff for capacity and support • Contact Person: Charles Denny, Jr. - Finance & Operations • Contact Person: Beth Pusha - Loan Fund • Contact Phone Number: 540-345-1184 • Expected Completion Date: September 30, 2026
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
Condition: The Organization's SEFA for the year ended June 30, 2024 was not complete. Specifically, certain federal expenditures were omitted from the SEFA. Planned Corrective Action: In addition to current procedures, management will confirm with grantors directly when grant award agreements are si...
Condition: The Organization's SEFA for the year ended June 30, 2024 was not complete. Specifically, certain federal expenditures were omitted from the SEFA. Planned Corrective Action: In addition to current procedures, management will confirm with grantors directly when grant award agreements are silent on whether awards are sourced from federal funding and document the confirmations from grantors. Contact person responsible for corrective action: Jim Hagestad, CFO Anticipated Completion Date: July 1, 2026
Management acknowledges the finding. El Proyecto has implemented corrective actions, including tracking the FFR submission due dates separately from any closeout documentation submission due dates to help ensure both requirements are monitored and completed within the required timeframes. Person Res...
Management acknowledges the finding. El Proyecto has implemented corrective actions, including tracking the FFR submission due dates separately from any closeout documentation submission due dates to help ensure both requirements are monitored and completed within the required timeframes. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: June 1, 2026
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility f...
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility for tracking and ensuring timely submission of reports. Additionally, the Organization should conduct a root cause analysis to address any underlying issues and implement corrective actions to prevent future delays. Views of responsible officials and planned corrective actions: Management agrees with the finding and will implement processes to mitigate the risk of future late file reports. Anticipated Completion Date: June 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
The auditor recommends that the Village ensure compliance with the 9 month requirements and have the audits and single audit reporting package submitted by the end of February each year.
The auditor recommends that the Village ensure compliance with the 9 month requirements and have the audits and single audit reporting package submitted by the end of February each year.
Finding 1221502 (2025-003)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission...
Views of Responsible Officials: HIPS experienced significant delays in receiving approved budgets, Notice of grant awards (NOGAs) and Purchase Orders (POs) from the grantors. HIPS cannot submit reports without these documents. For these reasons, HIPS could not meet the requirement "timely submission of required reports". We hope that in the future, HIPS will receive the pre-requisite documentation on time. In addition, the grantors' systems are set in a chronological order and therefore even in instances where HIPS is ready to submit reports HIPS can only submit one month and wait for that month's report to be approved before HIPS can submit the next month. This system,albeit important in grant management, limits HIPS ability to fulfil "timely submission of required reports" requirements. HIPS will improve documentation on this issue.
Finding 1221501 (2025-002)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do...
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do not have the capacity to implement time tracking at this level of complexity. In FY 26, Supervisors will review and document review of proposed time allocations on the payroll allocations spreadsheets prior to month start to ensure that the allocation correctly matches the proposed schedule, and at month end to assess any changes needed based on actual time worked on various grant activities. We will also search for new software options to improve approval and entry process.
2025-002 Finding: Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) Responsible Individuals: Rusty Schmidt, General Manager Corrective Action Plan: Management of the District has reviewed the financial statements and schedule of expenditures of federal awards ...
2025-002 Finding: Preparation of Financial Statements and Schedule of Expenditures of Federal Awards (SEFA) Responsible Individuals: Rusty Schmidt, General Manager Corrective Action Plan: Management of the District has reviewed the financial statements and schedule of expenditures of federal awards prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the District. Management and the Board of Directors has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Anticipated Completion Date: Ongoing
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melen...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
Does the Agency Agree: Agree Planned Corrective Action: Processes are in place to identify and record accruals. Accruals are recorded on a regular basis. We will update our year-end checklist to include a new contract review for proper revenue and expense recognition. Contact Name and Title Responsi...
Does the Agency Agree: Agree Planned Corrective Action: Processes are in place to identify and record accruals. Accruals are recorded on a regular basis. We will update our year-end checklist to include a new contract review for proper revenue and expense recognition. Contact Name and Title Responsible for Corrective Action: Elizabeth Butchart, Controller Status: Resolved
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Authority should continue to review and accept both proposed adjusting journal ...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Authority should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. Authority’s Response: The Authority has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the Authority believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the Authority considers such assistance provided by the auditors to be the most cost-effective manner to prepare such information. The Authority will also ensure that in the future all transactions will be properly reflected in the accounting software.
The City will update its grant policy to strengthen internal controls for grant monitoring. The policy will establish the rules and procedures for how departments process, utilize, and monitory grant funding. With the updated policy, the City can ensure accountability, transparency and compliance. Q...
The City will update its grant policy to strengthen internal controls for grant monitoring. The policy will establish the rules and procedures for how departments process, utilize, and monitory grant funding. With the updated policy, the City can ensure accountability, transparency and compliance. Quarterly meeting with departments’ grants administrator will be set up to ensure grant drawdowns and other reporting are done timely. This will also require supervisor’s review and sign offs. Also, the grant accountant will familiarize themselves with the grant documents and deadlines even if the deadlines do not pertain to the finance department. Responsible Person: Sarby Munoz Expected Implementation Date: 07/01/2026
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant applica...
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant application process through closeout of a grant. This further ensures accurate and timely reporting going forward.
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
Finding Reference Number: 2025-001 Program: Assistance Listing 93.591 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-001 Program: Assistance Listing 93.591 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
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