Corrective Action Plans

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U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
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
Recommendation: We recommend that the Corporation file the MINC reports timely. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: March 31, 2026
Recommendation: We recommend that the Corporation file the MINC reports timely. Action Taken: We agree with the auditor and will take under advisement. Anticipated Date of Completion: March 31, 2026
Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will impl...
Recommendation: While we do recognize that the Corporation is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Corporation be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional controls where possible. Anticipated Date of Completion: December 31, 2025
Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was d...
Federal Program: Head Start – ALN 93.600 / 93.356 Awarding Agency: U.S. Department of Health and Human Services (DHHS), Administration for Children and Families (ACF) Finding Reference Number: 2024-001 Condition The SF-425 Federal Financial Report for the period ending December 31, 2024, which was due on January 30, 2025, was submitted late on February 7, 2025. Corrective Action Plan Christian Military Academy, Inc. acknowledges this finding and has implemented corrective measures to ensure compliance with future reporting deadlines: 1. Enhanced Monitoring of PMS Submissions – A reporting calendar with reminders has been established to track all SF-425 deadlines and submission confirmations through the Payment Management System (PMS). 2. Secondary Reviewer – A second staff member has been assigned to review and confirm timely report submissions before each deadline. 3. System Contingency Plan – In the event of PMS malfunctions or access issues, management will immediately notify DHHS/ACF program officers in writing and retain evidence of the communication on or before the due date. 4. Staff Training – Fiscal staff responsible for federal reporting have been trained on the importance of timely submission and the procedures to follow in case of technical issues. Responsible Official Maribel Batista Marrero Christian Military Academy, Inc. Anticipated Completion Date The corrective actions have been implemented as of October 2025 and will remain in place on an ongoing basis.
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reconciled with the FDS. Anticipated completion date - Within the nex...
Corrective Action Plan - VMS not reconciled with FDS. Contact person - Executive Director, Melba White. Phone 806-293-4160. Corrective action planned - The current year VMS will be adjusted as needed and future VMS reports will be reconciled with the FDS. Anticipated completion date - Within the next fiscal year.
FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for t...
FINDING 2024-001 – Reporting; Significant Deficiency in Internal Control Over Compliance and Noncompliance Condition and context: Supporting documentation for the quarterly financial reports required by the grant did not include documentation of a review process or filing could not be verified for timely submission. We noted for two of the three reports selected; submission support was not retained by the client. The grantor confirmed submission of all required reports however, the date of submission could not be verified. As such, both reports were determined to have been submitted late. Views of responsible officials and planned corrective actions: Management agrees with the assessment and has implemented corrective action. The Organization has implemented a review and documentation control surrounding the timely submission of all quarterly reports. Calendar reminders will be added to the task list for the compiler of the report information as well as the reviewer/signer of the report. These reminders will be implemented in the work calendars of the employees responsible at the onset of the grant. Reports required by the grant must be submitted timely and must have two levels of documented review. The bookkeeper and project manager will compile the information needed for the grant. The project manager and executive director will review and sign off on the grant report prior to each reporting date. Additionally, report backup and proof of timely submission will be retained by the bookkeeper and project manager. Contact Persons: Phil Champlin – Executive Director Mary Pat Davoren – Bookkeeper
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-010: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. has already started the process to file the reports with HRSA to resolve this request
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-006: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City H...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2024-006: • Heart City Health Center, Inc. continues to focus on the controls related to both the filing and review process of these required reports before final submission • Heart City Health Center, Inc. started the discussion with HRSA on this funding and will continue to work with them on this funding
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR...
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2025
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
Lincoln County Clerk and Lincoln County Treasurer will review the fiscal report prepared by the third party administrator prior to its submission to the U.S. Treasury.
The Organization will review all of its grant agreements to properly ensure that all federal awards have been identified and included in the SEFA.
The Organization will review all of its grant agreements to properly ensure that all federal awards have been identified and included in the SEFA.
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
The Center has subsequently engaged with a third-party organization to help review the Center's monthly vouchers submitted for reimbursement to help ensure proper and timely vouchering.
The Center is implementing reconciliations of the grant expenditures to the general ledger.
The Center is implementing reconciliations of the grant expenditures to the general ledger.
Finding number 2024-004, significant deficiency in internal controls over compliance – reporting. Recommendation: We recommend that the Organization implement and document procedures to ensure that all required federal financial reports are prepared, reviewed and submitted within the required timefr...
Finding number 2024-004, significant deficiency in internal controls over compliance – reporting. Recommendation: We recommend that the Organization implement and document procedures to ensure that all required federal financial reports are prepared, reviewed and submitted within the required timeframes. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: KRJC has now developed a clear procedure for ensuring that all program expenses are received and/or accrued for the period so that reporting can be completed and submitted no later than 30 days after the end of the quarter. All FFY2025 required financial and narrative reporting has been submitted within the required time frame. Planned completion date for corrective action plan: November 30, 2024.
Corrective Action Plan – Single Audit Finding Entity Name: Journey’s End Refugee Services, Inc. Audit Period: For the year Ended December 31, 2024 Finding Reference Number: 19.510 Federal Program: U.S. Refugee Admissions Program 1. Audit Finding Summary (Describe the audit finding and the specific n...
Corrective Action Plan – Single Audit Finding Entity Name: Journey’s End Refugee Services, Inc. Audit Period: For the year Ended December 31, 2024 Finding Reference Number: 19.510 Federal Program: U.S. Refugee Admissions Program 1. Audit Finding Summary (Describe the audit finding and the specific noncompliance identified by the auditor.) Failure to Submit monthly financial reports by the 15th of each month following, resulting in noncompliance with grant agreement. 2. Root Cause (Explain the underlying reasons for the finding, such as process gaps, training issues, or lack of controls.) Lack of process, including a tracking mechanism that identifies due dates and completion dates of all reports due. 3. Corrective Actions: A) Create a report in excel to track grant reports deadlines. B) Weekly review of the report by the Grants and Finance committee. C) Purchase and implementation of grants monitoring software. 4. Monitoring Plan (Describe how the implementation of corrective actions will be monitored and evaluated.) New Chief Financial Officer will review the action items and monitor the progress with the Chief Operating Officer monthly.
Security Deposit Funding Auditee agrees that the security deposit liability account is underfunded. We recommend that management funds the shortfall and created a better system of controls to ensure no future occurrences. Auditee plans to evaluate its internal controls and implement policies to miti...
Security Deposit Funding Auditee agrees that the security deposit liability account is underfunded. We recommend that management funds the shortfall and created a better system of controls to ensure no future occurrences. Auditee plans to evaluate its internal controls and implement policies to mitigate underfunding of the security deposit account and has funded the shortfall. Transfer of $1,271 to security deposit account was made to fully fund the account.
Timely Submission of Required Reporting Management understands the need to be in compliance with the filing requirements and will ensure that these reports are filed timely. The filings have been subsequently completed with the FAC system.
Timely Submission of Required Reporting Management understands the need to be in compliance with the filing requirements and will ensure that these reports are filed timely. The filings have been subsequently completed with the FAC system.
Finding 2024-001 – Material Weakness – Accounting Discipline and Recordkeeping Condition During the audit of the fiscal year ending June 30, 2024, Impact Services Corporation and Affiliates‘ (the “Corporation's”) management was unable to provide timely year-end trial balances in accordance with U.S....
Finding 2024-001 – Material Weakness – Accounting Discipline and Recordkeeping Condition During the audit of the fiscal year ending June 30, 2024, Impact Services Corporation and Affiliates‘ (the “Corporation's”) management was unable to provide timely year-end trial balances in accordance with U.S. GAAP. An accurate year-end trial balance was not provided in a timely manner, and management continued to make a significant number of adjustments after the year-end trial balance had been provided to the auditors, resulting in significant time by management and the auditors to complete the audit. As a result, the fiscal year 2024 financial statements were not finalized in time to meet the deadlines noted in 2 CFR Section 200.512(a)(1). In addition, during the audit it was discovered that certain account balances and transactions were not properly recorded in the prior year, resulting in a prior period adjustment to correct the beginning balances as of July 1, 2023. While reconciling accounts payable and accrued expenses as of June 30, 2024, management discovered that the accounts payable balance was incorrect dating back to 2023. The Corporation changed accounting software packages during the year ended June 30, 2023 and during the transition of accounting packages, an accounts payable balance totaling $390,229 transferred into the new software. The invoices representing this balance were also entered into the accounts payable module and transferred into the general ledger module, resulting in a double recording of the accounts payable balance and overstatement of expenses by $390,229 in fiscal year 2023. Recommendation We recommend that management continue to review and update the Corporation's policies and procedures to ensure that the trial balance is accurate throughout the year. Account reconciliations and supporting schedules should be prepared and reviewed on a monthly basis. The accounting books and records should be closed timely at year end and thoroughly reviewed. Management’s Corrective Action Plan In February 2025, a new Chief Financial Officer was hired and immediately launched a full evaluation of the Accounting and Finance department. Her efforts have included restructuring staff, restarting the fiscal year 2024 audit, implementing new financial policies, and launching a credit card purchasing system with embedded controls. Within six months, she has established new internal controls, enhanced financial reporting, and introduced staff training protocols. To remediate the material weakness, the Corporation has implemented the following initiatives: • Month-End Close Process: July 2025 marked the first successful month-end close, anticipated to be completed on August 22, 2025. This included key reconciliations, journal entries, and revenue-expense reporting. • Department Structure and Documentation: We are refining processes and documentation using technology and talent to promote transparency and accountability. • Leveraging Technology: o Ramp: Enables real-time spend controls, customizable virtual cards, and automated receipt matching. It enforces policy compliance, prevents unauthorized purchases, and supports audit readiness. o NetSuite ERP: Streamlines operations and decision-making through automated, real-time reporting, ensuring consistent and accurate insights across departments. We affirm our alignment with the auditor's recommendations to ensure trial balance accuracy, monthly account reconciliations, and timely year end closings. These practices are now embedded in our financial operations and supported by enhanced review protocols. The Corporation is confident that these corrective actions will fully address the material weakness and position the Corporation for sustained financial health, transparency, and compliance. Contact Person: Richonda Pelzer, Chief Financial Officer Anticipated Completion Date: March 31, 2026
Significant Deficiency in Internal Control over Compliance, Other Matters U.S. Department of the Treasury U.S. Department of Housing and Urban Development Coronavirus State and Local Fiscal Recovery Funds Community Development Block Grants/Entitlement Grants 21.027 14.218 Recommendation: We recommen...
Significant Deficiency in Internal Control over Compliance, Other Matters U.S. Department of the Treasury U.S. Department of Housing and Urban Development Coronavirus State and Local Fiscal Recovery Funds Community Development Block Grants/Entitlement Grants 21.027 14.218 Recommendation: We recommend that the Authority implements controls to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2025 Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2025
Actions Taken: The institution has implemented an automated process for Exit Counseling to ensure compliance with Title IV requirements. As of August 2025, the system has been configured to automatically send an exit counseling notification to students when they enter one of the following statuses: ...
Actions Taken: The institution has implemented an automated process for Exit Counseling to ensure compliance with Title IV requirements. As of August 2025, the system has been configured to automatically send an exit counseling notification to students when they enter one of the following statuses: • Withdrawal • Graduation • Less than half-time enrollment System Workflow: When a student’s status changes, the system immediately generates and sends an email alert containing exit counseling instructions and the necessary links for completion. This ensures timely notification without requiring manual tracking by staff. Monitoring and Compliance: • Reports will be reviewed monthly to confirm that all required students received the exit counseling notifications. • Any discrepancies will be immediately investigated and resolved. Outcome: This automation eliminates the manual process previously in place, ensuring 100% notification compliance and greatly reducing the likelihood of future deficiencies in this area.
Corrective Action Plan: The ARC of Delaware will ensure that there are appropriate procedures in place to ensure that the required calculation of surplus cash is completed with 60-days of year end. ARC of Delaware will also ensure that individuals have appropriate access to HUD Reporting tools to en...
Corrective Action Plan: The ARC of Delaware will ensure that there are appropriate procedures in place to ensure that the required calculation of surplus cash is completed with 60-days of year end. ARC of Delaware will also ensure that individuals have appropriate access to HUD Reporting tools to ensure timely calculation. Contact Person Responsible for Correction Action: Stanley Kihara, Controller Completion Date:
Internal Control over Compliance and Other Matters Recommendation: We recommend that the Organization implement adequate controls to ensure the timely submission of the required granter reports. If delays, with the submission of a report, occur, we recommend that the Organization notifies its grante...
Internal Control over Compliance and Other Matters Recommendation: We recommend that the Organization implement adequate controls to ensure the timely submission of the required granter reports. If delays, with the submission of a report, occur, we recommend that the Organization notifies its granter and obtains an extension of the report due date. There is no disagreement with the audit finding. Action planned in response to finding: Essex-Newark Legal Services Project, Inc agrees that it will timely advise granters when a delay in the timely submission of a report is anticipated. Name of the contact person responsible for corrective action: Felipe Chavana, Executive Director Planned completion date for corrective action plan: Effectively Immediately.
Corrective Action Plan: The County has agreed to strengthen internal controls through regular reconciliations between project managers and the Clerk’s office to ensure timely reporting, submission for reimbursement and inclusion on the financial statements. Responsible Party: Alpena County Treasurer...
Corrective Action Plan: The County has agreed to strengthen internal controls through regular reconciliations between project managers and the Clerk’s office to ensure timely reporting, submission for reimbursement and inclusion on the financial statements. Responsible Party: Alpena County Treasurer and Alpena County Administrator Date of Planned Corrective Action: July 1, 2025 Management Assessment: We concur with the audit assessment regarding this matter.
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