Corrective Action Plans

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U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monit...
Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monitoring plan for all identified subrecipients, ensuring that required monitoring activities (including review of reports and Single Audits, where applicable) are performed and documented throughout the period of performance.  Ensure the SEFA accurately reflects subrecipient relationships and amounts passed through.  This monitoring plan has already been implemented.
Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Feder...
Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Federal Financial Report was not submitted timely and required performance reporting was not completed during the year. Questioned Costs - N/A Context - The Federal Financial Report for the reporting period end September 29, 2024 was due December 28, 2024, however, this was not submitted until February 25, 2025. Additionally, two (2) performance reports were due during the year, however, neither were completed. The first was for the period September 30, 2023 - March 31, 2024 and was due April 30, 2024, and the second was for the period April 1, 2024 - September 30, 2024 and was due October 30, 2024. Effect - The Company did not comply with federal reporting requirements. Cause - Management turnover caused uncertainty in assigned responsibilities, including this reporting requirement. Identification as a Repeat Finding - N/A Recommendation - The Company should review reporting requirements in grant award documents for all federal awards to ensure compliance. Client Planned Action: Benson Hospital agrees to the finding. The issue was identified in February of 2025 and the required reporting was completed and submitted. Going forward we have established a protocol by which reports for such Congressional Funding shall be submitted timely. Client Responsible Party: Mark Nellis, CFO; (520) 586-1873 Completion Date: February 22, 2025
Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate...
Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate time to prepare quarterly reports for submission to the USDA. Once the quarterly financials are finalized, the USDA report will be submitted no later than the last day of the month. This plan will also be added to the calendar with reminders set for the Administor to ensure timely review and submission.
Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.
Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.
As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are prop...
As previously stated, NCAAA has hired another Finance Director coupled with a Consultant an expert in the Accounting system being utilized to ensure full use. In addition, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account ...
NCAAA has hired a full-time Finance Director coupled with a Consultant who is an expert in the Accounting system being utilized to ensure the system is being for its full intent. Inclusive of financial activities. As previously mentioned, procedures will be implemented to formalized monthly account reconciliations and year end closed to ensure transactions are properly recorded in the appreciate account and correct period.
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation ...
No. 2024-004 Subject: Reporting - Significant deficiency in internal control over compliance Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: Management will implement internal controls related to documentation of approval for all monthly NSLP claims for reimbursement prior to submission. We will establish a formalized procedure to ensure that all monthly claims for reimbursement undergo documented management review and approval before submission. This procedure will clearly define the review process and designate responsible personnel for each step to maintain accountability. All reviewed and approved claims will be accompanied by signed documentation as evidence of compliance. All Food Service personnel involved in the reimbursement submission process will receive training on the new procedure to ensure understanding and adherence to the documentation requirements.
No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage i...
No. 2024-003 Subject: Allowable costs - Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Ingmar Berg, CFO Phone Number: (480) 270-5438 x1091 Anticipated Completion Date: June 30, 2025 Corrective Action: We will review the funding percentage in the accounting system to the approved percentages in the semi-annual time and effort logs to verify accuracy. These improved internal procedures will provide proper compliance over allowable costs. Annual audit of all grant-funded employee positions at the start of each school year, reviewed by grants team, HR, and accounting to verify accuracy of all employee costing allocations to grants.
Finding Reference Number: 2024-001 Management Agent's Certification Description of Finding: The Project is required to obtain a Management Agent's Certification approved by the USDA-RD. The Project did not obtain an approved Management Agent's Certification for the year ended December 31, 2024. Stat...
Finding Reference Number: 2024-001 Management Agent's Certification Description of Finding: The Project is required to obtain a Management Agent's Certification approved by the USDA-RD. The Project did not obtain an approved Management Agent's Certification for the year ended December 31, 2024. Statement of Concurrence or Nonconcurrence: The Project agrees with the audit finding. Corrective Action: The management certification from 3560-13 has been sent to the board president for signature on September 24, 2025, and will be submitted to USDA once received back. Name of Contact Person: Paula Tracy, President, 860-398-5425 ext. 511# paulat@wildwoodmgt.com Projected Completion Date: Management certifications have been e-mailed to the board president on September 24, 2025 and once received back will forward to USDA for final signature.
September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an...
September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an unusual reallocation of funding by the Washington State Department of Commerce. The award was originally awarded and recorded as state funds. In September 2024, the Washington State Department of Commerce reallocated a portion of its funding and amended the grant terms to designate the award as being funded under the Coronavirus State and Local Fiscal Recovery Funds (21.027). Because the reallocation and revised terms were communicated late in the fiscal year, management did not identify the change in time to ensure that the award was correctly reported as federal on the SEFA. The adjustment was therefore an oversight and not an intentional misclassification. 2024-001 Preparation of the Schedule of Expenditures of Federal Awards CCAP Executive Leadership understands the function and necessity of preparing a complete and accurate SEFA. 1. Policy and Procedures Development: By November 15, 2025, management will develop and adopt written policies and procedures requiring formal review of all grant amendments, reallocations, and correspondence from pass-through entities to determine whether funding sources have changed and whether SEFA reporting is affected. 2. Internal Control Implementation: Management will implement a dual-review process in which both the Finance Director and Grants Manager verify the funding source and assistance listing number for all awards and amendments before SEFA preparation. 3. Training: Staff responsible for grants management and financial reporting will complete training on Uniform Guidance financial management and SEFA preparation requirements by November 15, 2025, with refresher training annually thereafter. 4. Ongoing Monitoring: Management will conduct a pre-audit SEFA review each year, reconciling all awards and amendments to source documentation, including grant agreements, amendments, and communications from pass-through entities. Responsible Party: Lucy Machowek, CFO Planned Completion Date: November 15, 2025
Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving lim...
Management acknowledges the finding and concurs with the auditor’s recommendation. The challenges identified were primarily the result of a major transition in accounting personnel during 2024. In August 2024, CRMSDC’s long-serving in-house accountant of nine years resigned unexpectedly, leaving limited time for an adequate transfer of knowledge and responsibilities. To preserve continuity in financial operations, CRMSDC immediately engaged outsourced accounting support. Looking ahead, CRMSDC will undertake a full review of its financial management structure and secure a highly qualified accountant or financial professional with specialized expertise in nonprofit accounting and federal grant compliance. Combined with strengthened procedures and enhanced supervisory oversight, these actions will build organizational capacity, reinforce internal controls, and ensure accurate and timely financial reporting. Name of the contact person responsible for corrective action: Sharon R. Pinder, President, 301.593.5861 Planned completion date for corrective action plan: Assessment and Correction – 4th Quarter 2025
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.
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: Angelita Thomas, Chief Financial Officer
Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm...
Corrective Action Plan Cognizant or Oversight Agency for Audit: U.S. Department of Health and Human Services Center for Asbestos Related Disease, Inc respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Rudd & Company, PLLC 3805 Valley Commons Drive, Ste. 7 Bozeman, MT 59718 Audit Period: January 1, 2024 – December 31, 2024 The findings from the 2024 schedule of findings and questioned costs are discussed below: Federal Award Findings and Questioned Costs Finding 2024-001 Department of Health and Human Services Libby, Montana’s Public Health Emergency, Asbestos Health Screening, CFDA #93.534 5NU61TS000295-05 Finding Summary: Final Financial report for the grant period end was not submitted by the due date. Responsible Individuals: Executive Director, Tracy McNew and Financial Officer, Janine Price Corrective Action Plan: Management has added all report due dates to their calendars beginning two weeks before the due dates to ensure reports are filed in a timely manner even if difficulties are encountered with the filing process. In addition, case numbers with PMS’s help desk will be recorded and other communications will be saved to ensure that proper documentation is maintained for any reports rejected and refiled at a later date. Anticipated Completion Date: Ongoing
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting
Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not c...
Finding 2024-006 L. Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding that FISAP was not correctly populated. Management has since corrected the data and submitted a revised FISAP. Management notes there was turnover in the PSON’s Office of Student Financial Aid during the year and an employee was not properly trained on the FISAP preparation. Training has since been implemented and new employees in the department will be trained accordingly. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org Projected completion date: The project is expected to complete by December 31, 2025.
Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management ag...
Finding 2024-004 N. Special Tests and Provisions - Enrollment Reporting Information on the federal program: Grantor: Department of Education Program Name: Student Financial Assistance Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. PSON and ISSMS’ Offices of Student Financial will ensure that all NSLDS submissions are made timely and with the correct status of each student. The respective Offices are implementing enhanced monitoring, staff training, and periodic internal reviews to confirm compliance. Names of responsible official: Denis Donegan Vice President of Finance, Mount Sinai Health System Denis.donegan@mountsinai.org LaVerne Walker Director of Student Financial Services, Icahn School of Medicine at Mount Sinai Laverne.walker@mssm.edu Projected completion date: The project is expected to complete by December 31, 2025.
Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities...
Management acknowledges the audit finding regarding deficiencies in the reporting of student status changes to COD. These discrepancies were primarily due to limitations in our staffing and review procedures. We are revising our enrollment reporting policies to clearly define roles, responsibilities, and timelines for processing student status changes. This includes an additional layer of review to verify the accuracy of effective dates prior to COD submission. These additional policies and procedures will be implemented by December 31, 2025.
Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying an...
Management acknowledges the findings related to Common Origination and Disbursement (COD) reporting as identified. These discrepancies were primarily due to limitations in our current review procedures. We are revising our internal policies and procedures to include detailed guidance on verifying and documenting disbursement and enrollment dates, academic year parameters, and cost of attendance calculations prior to COD submission. This will include additional layers of review to ensure timely and accurate reporting. These policies and procedures will be implemented by December 31, 2025.
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.
Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the sub...
Federal Funding Accountability and Transparency Act (FFATA) Filing for Subawards. Assistance Listing No. 93.493 Congressional Directives: Kupuna Support Navigator Program (KSNP) The KSNP project manager and senior management reviewed and submitted the FFATA required reporting, which included the subrecipient's name, subaward date, and subaward amount on SAM.gov website prior to the completion of this federal grant, which ended on June 30, 2025. The funder confirmed receipt of our reporting and did not specify any implications for late submission. As recommended by the auditors, HIPHI has developed a process to help identify the subawards subject to the FFATA reporting requirements prior to the start of the grant, and to ensure that reporting is reviewed, approved for completeness and accuracy, and filed in a timely manner. The Director of Finance, Finance and Accounting Manager, Program Managers and contract signers will be responsible for implementing these corrective actions by the end of 2025.
Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balan...
Finding 2025-002: Untimely Paid Credit Balance Comments on Finding and Recommendation: Statement of Concurrence: We concur with the finding of Untimely Paid Credit Balance The delay in issuing the credit balance was due to a timing oversight related to the award year dates. Although the Credit Balance Authorization Form was on file, the refund was processed after the award year had ended, rather than within the required timeframe. In the past, students were always allowed to keep funds in their Populi accounts for future use regardless of the loan award year, and it had not previously been indicated that this practice was not allowed. Actions Taken or Planned: We have reviewed our internal procedures and will strengthen oversight of award year deadlines to ensure that all credit balances are refunded within the required timeframe. Moving forward, the financial aid and accounting teams will implement a compliance checklist and establish calendar reminders to prevent similar delays. Additionally, we will revise the wording on our Credit Balance Authorization Form to read: “Leave the funds in my account and any remaining funds from the current award year in my account up to the end of the loan period.” Completion Date: Ongoing 9/26/2025 Dong-Hua Yang MD, PhD Date Title: Administrative Dean Telephone: 516-739-1545 Email: administrative_dean@nyctcm.edu
View Audit 370123 Questioned Costs: $1
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