Corrective Action Plans

Finding 1159769 (2022-010)

Material Weakness 2022

NY

Reporting

PAX will establish appropriate policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed timely. The primary deliverable will be timely audit completion and submission.

View Audit 370331

Finding 1159767 (2022-008)

Material Weakness 2022

Program of Academic Exchange

NY

Questioned Costs Allowable Costs / Cost Principles Reporting

In a previous period and by previous auditors, PAX was told that because we were using a percentage of effort calculation in budgeting that time sheets were no longer needed for this purpose. At that time, we abandoned the time sheet process (which was arduous). Based upon current auditor’s advice, ...

In a previous period and by previous auditors, PAX was told that because we were using a percentage of effort calculation in budgeting that time sheets were no longer needed for this purpose. At that time, we abandoned the time sheet process (which was arduous). Based upon current auditor’s advice, PAX established an effort verification reporting system. This system was launched in FY23 and enhanced in FY24. It will accurately capture the effort spent by each employee on specific grants, ensuring proper documentation of allocation of wages and salaries to the respective federal awards.

View Audit 370331 Questioned Costs: $1

Finding 1157886 (2022-083)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. A process related to financial and performance report preparation and submission will be formalized, and clear roles/responsibilities will be outlined. The Disaster Program Account Supervisors will be responsible for preparing t...

The Government concurs with the auditor's findings and recommendations. A process related to financial and performance report preparation and submission will be formalized, and clear roles/responsibilities will be outlined. The Disaster Program Account Supervisors will be responsible for preparing the reports on a quarterly basis and submitting them to the Territorial Hazard Mitigation Officer for review. The review process will include thorough reconciliation between the reports and other supporting data, such as accounting records.

View Audit 369907

Finding 1157884 (2022-081)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. The formalized process related to financial and performance report preparation and submission is now in place with clear roles and responsibilities outlined. The Disaster Program Financial Specialist is responsible for preparing...

The Government concurs with the auditor's findings and recommendations. The formalized process related to financial and performance report preparation and submission is now in place with clear roles and responsibilities outlined. The Disaster Program Financial Specialist is responsible for preparing the reports quarterly and submitting them to the Territorial Public Assistance Officer for review. The review process includes thorough reconciliations between the reports and other supporting data, such as accounting records.

View Audit 369907

Finding 1157879 (2022-076)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. As Medicaid staffing shortages are addressed, reports are submitted for review via email. The Department has implemented a shared folder to ensure copies of the approval emails and any time extension requests are now stored in s...

The Government concurs with the auditor's findings and recommendations. As Medicaid staffing shortages are addressed, reports are submitted for review via email. The Department has implemented a shared folder to ensure copies of the approval emails and any time extension requests are now stored in said folder to ensure access for audit purposes as the submission portal does not allow for attachments.

View Audit 369907

Finding 1157878 (2022-075)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Eligibility Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. DHS staff will work with PMO, hired to assist with the Public Health Emergency Unwind and establish Standard Operating Policies and Procedures (SOPPs) on certification and recertification processes and procedures. DHS is also in...

The Government concurs with the auditor's findings and recommendations. DHS staff will work with PMO, hired to assist with the Public Health Emergency Unwind and establish Standard Operating Policies and Procedures (SOPPs) on certification and recertification processes and procedures. DHS is also in the process of hiring a Program Integrity Director and Medical Eligibility Quality Control (MEQC) staff, whose responsibility will be to review completed case files.

View Audit 369907

Finding 1157869 (2022-073)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Reporting Internal Control / Segregation of Duties § 200.303

The Government concurs with the auditor's findings and recommendations. Presently, there is a collaboration with our Federal Partners to consolidate the reporting in the Payment Management System portal as there is no one report for the SSBG as required. Presently, report requests are not consistent...

The Government concurs with the auditor's findings and recommendations. Presently, there is a collaboration with our Federal Partners to consolidate the reporting in the Payment Management System portal as there is no one report for the SSBG as required. Presently, report requests are not consistent with one consolidated grant. Additionally, the pre and post expenditures are submitted through the portal with a log of submission.

View Audit 369907

Finding 1157865 (2022-068)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

The Government concurs with the auditor's findings and recommendations. While DHS remains in compliance with this finding from previously audited years, the untimely submission resulted in this finding. Moving forward, a shared file will be established to ensure that the requisite information for ea...

The Government concurs with the auditor's findings and recommendations. While DHS remains in compliance with this finding from previously audited years, the untimely submission resulted in this finding. Moving forward, a shared file will be established to ensure that the requisite information for each year is readily available for audit purposes.

View Audit 369907

Finding 1157864 (2022-067)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. A Federal Grants Financial Analyst specific to the CCDF program has been onboarded with responsibility for the accuracy and submission of the financial reports. Internal controls have been implemented whereas final review and ap...

The Government concurs with the auditor's findings and recommendations. A Federal Grants Financial Analyst specific to the CCDF program has been onboarded with responsibility for the accuracy and submission of the financial reports. Internal controls have been implemented whereas final review and approval is required by a supervisor.

View Audit 369907

Finding 1157841 (2022-061)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. The Governing Board transitioned to virtual meetings due to the Pandemic with pre-empted the FY22 training and has incorporated electronic voting from board members into its procedures. Therefore, regular trainings occur that en...

The Government concurs with the auditor's findings and recommendations. The Governing Board transitioned to virtual meetings due to the Pandemic with pre-empted the FY22 training and has incorporated electronic voting from board members into its procedures. Therefore, regular trainings occur that enable the governing body to perform its legal, fiscal and oversight responsibilities.

View Audit 369907

Finding 1157839 (2022-059)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. Program is collaborating with the Director of Asset Management and the Fiscal Analyst to include SOPP verbiage to ensure that completion of said forms are timely and submitted as required. Efforts are being supported by the Fede...

The Government concurs with the auditor's findings and recommendations. Program is collaborating with the Director of Asset Management and the Fiscal Analyst to include SOPP verbiage to ensure that completion of said forms are timely and submitted as required. Efforts are being supported by the Federal Office of Head Start Grants Office.

View Audit 369907

Finding 1157828 (2022-056)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Allowable Costs / Cost Principles Reporting Subrecipient Monitoring § 200.303 § 200.403 § 200.430

The Government concurs with the auditor's findings and recommendations. DOH fully acknowledge and accept the auditor’s finding regarding DOH’s inability to reconcile the payroll expenses listed in the SEFA with those documented in the payroll register. This discrepancy arose because payroll adjustme...

The Government concurs with the auditor's findings and recommendations. DOH fully acknowledge and accept the auditor’s finding regarding DOH’s inability to reconcile the payroll expenses listed in the SEFA with those documented in the payroll register. This discrepancy arose because payroll adjustments were not completed in time to reflect accurately in the FY2022 SEFA. To address this, DOH team has received thorough training, and staff members now have the necessary access to make payroll adjustments in the Government Financial Management System as of FY2024. Moving forward, DOH will strengthen our SOPs by conducting monthly reconciliation meetings with all relevant program teams to ensure timely adjustments and continuous monitoring. Additionally, DOH will update procedures to guarantee that all new fiscal staff are granted complete financial system access and are trained on reconciliation and adjustment processes within two weeks of starting.

View Audit 369907

Finding 1157823 (2022-053)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the deficiencies identified in the reporting processes for the COVID-19 Education Stabilization Fund (ESF-SEA). VIDE is committed to enhancing our reporting practices to ensure compliance with federal requireme...

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the deficiencies identified in the reporting processes for the COVID-19 Education Stabilization Fund (ESF-SEA). VIDE is committed to enhancing our reporting practices to ensure compliance with federal requirements and to prevent future occurrences. VIDE will implement a structured review and approval process for all performance and special reports, ensuring that each report is vetted by the appropriate officials. Training will be provided for all staff involved in report preparation and submission.

View Audit 369907

Finding 1157812 (2022-050)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit finding concerning the failure to comply with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements for first-tier subawards. VIDE plan will prioritize the development...

The Government concurs with the auditor's findings and recommendations. VIDE acknowledges the audit finding concerning the failure to comply with the Federal Funding Accountability and Transparency Act (FFATA) reporting requirements for first-tier subawards. VIDE plan will prioritize the development and implementation of detailed reporting policies and procedures, with a focus on FFATA requirements. These policies will include clear procedures for identifying and tracking all subawards subject to FFATA reporting, specific guidelines for collecting and reporting required data elements, and established timelines for data submission. Roles and responsibilities for all involved personnel, including program staff, grants management staff, and the Federal Grants Office, will be clearly defined within these policies. To enhance our subaward tracking capabilities, VIDE will implement a dedicated system for tracking subawards and collecting the required data. This may involve enhancing our existing grants management system or implementing a new system specifically designed to capture all necessary data elements for FFATA reporting. Comprehensive training on the use of this system will be provided to all relevant staff. VIDE will also strengthen its data verification and validation procedures. This will include establishing a formal process for reviewing and verifying the accuracy and completeness of subaward data before submission. Data quality checks will be implemented within the tracking system, and regular reconciliations will be conducted between subaward data and other relevant records to ensure consistency and accuracy. To ensure that all relevant personnel are well-versed in the new policies and procedures, VIDE will conduct mandatory training sessions. These sessions will cover FFATA reporting requirements in detail, VIDE's new policies and procedures for subaward reporting, and proper data collection and submission procedures.

View Audit 369907

Finding 1157804 (2022-044)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Allowable Costs / Cost Principles Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. OMB has established a reporting approval memo in which the OMB Director signs acknowledging the review and approval of the Treasury reports starting in calendar year 2024 reporting. OMB has improved the collection and storage of...

The Government concurs with the auditor's findings and recommendations. OMB has established a reporting approval memo in which the OMB Director signs acknowledging the review and approval of the Treasury reports starting in calendar year 2024 reporting. OMB has improved the collection and storage of underlying supporting financial information for all projects being reported in the quarterly reports and can provide the necessary support upon request as of FY23.

View Audit 369907

Finding 1157800 (2022-040)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Reporting Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. An analyst will be assigned to track reporting schedules, grant activity and store documents. The analyst will regularly monitor the reporting schedule for each grant award to ensure that all reports are submitted in a timely ma...

The Government concurs with the auditor's findings and recommendations. An analyst will be assigned to track reporting schedules, grant activity and store documents. The analyst will regularly monitor the reporting schedule for each grant award to ensure that all reports are submitted in a timely manner.

View Audit 369907

Finding 1157798 (2022-038)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Special Tests & Provisions Subrecipient Monitoring Eligibility § 200.303

The Government concurs with the auditor's findings and recommendations. VIDOL will be implementing a RESEA case management system for reporting and program services. This case management system is currently in configuration phase of the project. Live production is expected by the 2nd quarter 2025. T...

The Government concurs with the auditor's findings and recommendations. VIDOL will be implementing a RESEA case management system for reporting and program services. This case management system is currently in configuration phase of the project. Live production is expected by the 2nd quarter 2025. This system will be the official system of record for recording all services for RESEA claimants that participate in the program.

View Audit 369907

Finding 1157796 (2022-036)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.303

The Government concurs with the auditor's findings and recommendations. VIDOL has obtained a federal grant award from USDOL, to assist in updating and redesigning of UI reporting and accounting system. This award is intended to rebuild the current reporting structure to assist with having complete, ...

The Government concurs with the auditor's findings and recommendations. VIDOL has obtained a federal grant award from USDOL, to assist in updating and redesigning of UI reporting and accounting system. This award is intended to rebuild the current reporting structure to assist with having complete, accurate, and timely processes in place. VIDOL has commenced work on preparing scope of works for the projects, and it is anticipated by 4th quarter of FY2026.

View Audit 369907

Finding 1157788 (2022-033)

Material Weakness 2022

The Virgin Islands Hsg Finance Authority - Paradise Mills Apartments

FL

Subrecipient Monitoring Reporting § 200.303

The Government concurs with the auditor's findings and recommendations. The Government will conduct a high-level review of internal control policies and closely monitor reports for completeness, accuracy, timeliness, and consistency with the guidelines, policies, and procedures established by the Co...

The Government concurs with the auditor's findings and recommendations. The Government will conduct a high-level review of internal control policies and closely monitor reports for completeness, accuracy, timeliness, and consistency with the guidelines, policies, and procedures established by the Cognizant Agency. Additionally, to support this effort, an analyst will be assigned to track reporting schedules, oversee grant activity, and manage document storage for individual agencies. The analyst will regularly monitor the reporting schedule for each grant award to ensure timely submission of all required reports.

View Audit 369907

Finding 1156135 (2022-001)

Material Weakness 2022

Ward Memorial Hospital A Compnent Unit of Ward County, Texas

TX

Internal Control / Segregation of Duties Reporting

Corrective Action Plan for Finding 2022-001 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting.. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to...

Corrective Action Plan for Finding 2022-001 We are in receipt of the finding required to be reported by Uniform Guidance, regarding other instance of noncompliance with respect to Reporting.. Management agrees with the finding. Policies and procedures over federal grant reporting will be modified to ensure reports are prepared using complete and accurate information. We will increase compensating controls for introducing additional oversight and review for future federal funding reporting. Leticia Rodriguez, CEO, will be responsible to ensure this is accomplished. The District had sufficient lost revenues that the error determined in Finding 2021-003 will not result in a conflict with funding received, but controls will be implemented to reconcile data in reporting prior to submission. The Corrective Action Plan will be implemented by December 31, 2025.

View Audit 368553

Finding 1155421 (2022-008)

Material Weakness 2022

Headquarters Kansas, Inc.

KS

Cash Management Material Weakness Reporting § 200.302 § 200.400

2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be ...

2022‐008 Grant Expenditures (Material Weakness) Recommendation: The Organization’s accounting system should be modified to accommodate expense tracking by individual grant and policies and procedures should be implemented to require direct expenses be assigned to specific grants. A method should be established to allocate indirect costs in accordance with federal regulations. Policies and procedures are also needed to provide appropriate oversight of all grant accounting including reporting. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. A review process and coding within the accounting system was completed in January 2025. All invoices and staff time are evaluated for the level of effort towards each grant.

View Audit 367706

Finding 1155420 (2022-007)

Material Weakness 2022

Headquarters Kansas, Inc.

KS

Material Weakness Reporting § 200.430

2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Acti...

2022‐007 Payroll (Material Weakness) Recommendation: Procedures should be implemented to require appropriate contemporaneous documentation to support time and effort reporting under 2 CFR Part 200. In addition, procedures should also be implemented to require the review and approval of payroll. Action Taken (Unaudited): Management has updated its control procedures to include proper written policies for the internal control over financial reporting to ensure conformity with U.S. GAAP. Dan Watkins is responsible for this corrective action. The Organization hired a Human Resource Manager June of 2024, moved to ADP for payroll in January 2025 and updated policies and process for review in May 2025. Procedures are in place for review and approval of each payroll.

View Audit 367706

Finding 1155271 (2022-003)

Material Weakness 2022

Comanche County Medical Center

TX

Questioned Costs Allowable Costs / Cost Principles Subrecipient Monitoring § 200.303

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hosp...

We are in receipt of the Findings Required to be Reported by Government Auditing Standards, regarding Reporting and Activities Allowed/Unallowed and Cost Principles. Management agrees with the finding. After correcting the calculation of expenses to include reimbursement from other sources, the Hospital still has sufficient lost revenues and expenses to cover the amount of provider relief funding received. Management will perform a detailed analysis of the reporting requirements in accordance with the final guidelines set by HRSA for future reporting periods. As deemed necessary, the Hospital will modify policies and procedures over federal grant reporting The CFO, Hong Wade, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

View Audit 367503 Questioned Costs: $1

Finding 1155084 (2022-002)

Material Weakness 2022

Hill Country Community Clinic, Inc.

CA

Reporting

Management acknowledges the finding. We will enhance our internal policies and procedures to ensure accurate financial reporting and compliance with federal grant requirements. A detailed reporting checklist will be developed to prevent errors and improve the accuracy of UDS and FFR submissions. Add...

Management acknowledges the finding. We will enhance our internal policies and procedures to ensure accurate financial reporting and compliance with federal grant requirements. A detailed reporting checklist will be developed to prevent errors and improve the accuracy of UDS and FFR submissions. Additional layers of review will be implemented to verify the accuracy of financial data before submission. Designated personnel will cross-check program income and financial data to ensure proper classification and reporting. To mitigate the impact of staff turnover, we will implement a structured training program for all employees responsible for grant reporting. A documented succession plan will be established to ensure continuity in key financial and reporting roles. We will evaluate opportunities for automation and financial system improvements to reduce manual errors. Enhanced documentation and reconciliation procedures will be implemented to ensure accurate tracking of program income. Internal compliance reviews will be conducted quarterly to assess reporting accuracy and address potential issues before submission. Management will conduct periodic training sessions and refresher courses to keep staff informed of reporting requirements and best practices. The above corrective actions are currently being implemented.

View Audit 367389

Finding 1155016 (2022-009)

Material Weakness 2022

Ulster County Community Action Committee, Inc.

NY

Reporting Significant Deficiency § 200.508 § 200.510

UCCAC has retained services of an outside service provider who will ensure schedule of expenditures of federal awards is reconciled to general ledger and includes all federal and pass-through federal grants awarded. The schedule will also be reviewed by program director for accuracy and completeness...

UCCAC has retained services of an outside service provider who will ensure schedule of expenditures of federal awards is reconciled to general ledger and includes all federal and pass-through federal grants awarded. The schedule will also be reviewed by program director for accuracy and completeness. Responsible Person: Controller and program directors Timeline: 30-60 days

View Audit 367339

Corrective Action Plans

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