Corrective Action Plans

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Corrective Action Plan - A new CFO is in place and staff have received education. Financial statement preparation is now being completed in a timely and accurate manner. Anticipated Completion Date - We have completed these steps. Responsible Parties - Stephanie Cooper, Chief Executive Officer, 909 ...
Corrective Action Plan - A new CFO is in place and staff have received education. Financial statement preparation is now being completed in a timely and accurate manner. Anticipated Completion Date - We have completed these steps. Responsible Parties - Stephanie Cooper, Chief Executive Officer, 909 Broadway, Hannibal, MO 63401 (573)221-3892
Corrective Action Plan - A new CFO is in place and has caught up the reconciliations and is continuing to complete them in a timely manner. Anticipated Completion Date - We have completed these steps. Responsible Parties - Stephanie Cooper, Chief Executive Officer, 909 Broadway, Hannibal, MO 63401 (...
Corrective Action Plan - A new CFO is in place and has caught up the reconciliations and is continuing to complete them in a timely manner. Anticipated Completion Date - We have completed these steps. Responsible Parties - Stephanie Cooper, Chief Executive Officer, 909 Broadway, Hannibal, MO 63401 (573)221-3892
Finding 2024-001: The Corporation did not make all required reserve for replacements deposits during the year ended December 31, 2024. Comments on the Finding and Each Recommendation: The Corporation should make a deposit of $30,975 to the reserve for replacements fund. Action(s) Taken or Planned on...
Finding 2024-001: The Corporation did not make all required reserve for replacements deposits during the year ended December 31, 2024. Comments on the Finding and Each Recommendation: The Corporation should make a deposit of $30,975 to the reserve for replacements fund. Action(s) Taken or Planned on the Finding: The Corporation concurs with the recommendation and will make the deposit to fully fund the reserve for replacements fund.
View Audit 368702 Questioned Costs: $1
Finding 1156379 (2024-004)
Material Weakness 2024
In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a ...
In 2024, 9/11 Day was unaware of this regulation, but agrees with this finding. 9/11 Day has adopted a written policy that shall ensure that all subgrants made are properly compliant with the Federal Funding Accountability and Transparency Act of 2006 (FFATA). All subgrantees will be entered into a centralized tracking log, and for those receiving pass-through funds exceeding $30,000, the required reporting will be completed directly in SAM.gov, which now includes the Federal Subaward Reporting System (FSRS). Each subgrantee’s eligibility will be verified in SAM.gov, with the date and results of the verification recorded, and all supporting documentation retained on file. This corrective action ensures that all subawards are properly logged, reported, and compliant with FFATA requirements.
View Audit 368692 Questioned Costs: $1
Trempealeau County, being a small county, has limited resources in personnel to accomplish a multi-verification in the reporting process. We will use additional current employees in house to do the verification to make sure the reporting is accurate before submitting. Responsible Person: Mary Martin...
Trempealeau County, being a small county, has limited resources in personnel to accomplish a multi-verification in the reporting process. We will use additional current employees in house to do the verification to make sure the reporting is accurate before submitting. Responsible Person: Mary Martin, County Clerk Anticipated Completion Date: We will attempt to begin the multiple verification process for the 2025 calendar year
The security deposit was refunded to the tenant on the 78th day subsequent to their move-out. Management has taken measures to improve internal controls over compliance related to tenant security deposit refunds.
The security deposit was refunded to the tenant on the 78th day subsequent to their move-out. Management has taken measures to improve internal controls over compliance related to tenant security deposit refunds.
The Human Services Department (HSD) acknowledges this finding regarding the late submission of five FFATA reports and inaccuracies in CAPER reporting. These issues arose during a period of prolonged vacancies and while staff were in the process of being trained on reporting requirements, which reduc...
The Human Services Department (HSD) acknowledges this finding regarding the late submission of five FFATA reports and inaccuracies in CAPER reporting. These issues arose during a period of prolonged vacancies and while staff were in the process of being trained on reporting requirements, which reduced oversight capacity and contributed to delays and errors. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) Manager to provide consistent leadership and supervision. HSD updated department-wide FFATA Reporting Policies and Procedures following the federal transition to SAM.gov. Staff completed federal training, and prior reports were reviewed and corrected. The Department implemented controls to close workflow gaps to ensure obligations and data corrections are captured before submission. Additionally, ongoing training is being provided to reinforce compliance. These actions strengthen internal controls and are intended to ensure FFATA and CAPER reports are accurate, complete, and submitted in a timely manner moving forward.
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of co...
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of contracting with a third-party vendor to complete its annual inspections, including HOME inspections for 2025. The contractor will inspect HUD’s NSPIRE level. With this additional support, OH anticipates it will have the capacity to see that corrections have been completed and documented consistent with the HOME program requirements.
The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) M...
The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) Manager to provide consistent leadership and supervision. The contract specialist receives structured management oversight and ongoing training to strengthen capacity for accurate budget monitoring. In July 2025, the FGMU updated its ESG policies and procedures to incorporate improved controls for earmarking. In addition, the Department has instituted regular training sessions for all staff responsible for federal grant management to reinforce compliance with earmarking and other federal requirements. These corrective actions are designed to strengthen internal controls, provide clearer oversight, and ensure that future expenditures remain within established budget and earmarking limits.
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ...
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ensure all employees' salary schedules are updated when we process the system-wide update. We will have an additional person to review and sign the new salary schedules before the first payroll is processed in the new fiscal year.
Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseases...
Finding 2024-001 – ReportingAssistance Listing No.: 93.391, COVID-19 Activities to Support State, Tribal, Local and Territorial (STLT) Health Department Response to Public Health or Healthcare Crisis Assistance Listing No.: 93.323, COVID-19 Epidemiology and Laboratory Capacity for InfectiousDiseasesManagement will distribute the updated SEFA reporting policy and procedure, outlining the required reporting requirements and timelines. A SEFA preparation checklist will be implemented to ensure that all submissions are accurate and complete. At the end of the year, Finance and Grants Management will collaborate to review all grant activities to ensure proper inclusion in the SEFA.Responsible Official: Annaliza Villamin, System Director of Accounting, Endeavor Health
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Proposed Completion Date: January 1, 2026
1. Maintained and refined the shared federal financial reporting calendar to ensure all relevant deadlines and submission dates are consistently tracked and communicated. 2. Expanded and updated reporting checklists to incorporate additional compliance requirements and ensure completeness and accura...
1. Maintained and refined the shared federal financial reporting calendar to ensure all relevant deadlines and submission dates are consistently tracked and communicated. 2. Expanded and updated reporting checklists to incorporate additional compliance requirements and ensure completeness and accuracy prior to submission. 3. Assigned dedicated staff oversight for federal financial reporting, with cross-training implemented to strengthen continuity and mitigate risk in the event of staff turnover. 4. Conducted periodic evaluations of the reporting process, incorporating feedback and lessons learned from prior submissions, monitoring visits, and audit findings to drive ongoing improvements. 5. Reviewed and updated internal financial policies and procedures to align with current federal reporting requirements and best practices, with updates formally documented and disseminated to staff.
September 29, 2025. Dear Cognizant or Oversight Agency for Audit: Hands of Healing Residential Treatment Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 ...
September 29, 2025. Dear Cognizant or Oversight Agency for Audit: Hands of Healing Residential Treatment Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2024 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2024-000. Corrective Action Plan: Management understands that annual federal financial reports (FFR) are required to be submitted no later than 90 days after the end of each budget period. In order to ensure compliance, Management will delegate responsibilities for completing all FFR reports to the new Chief Financial Officer (CFO). She will be responsible for reading the Notice of Awards and calendaring out all FFR due dates for timely completion. The CFO was hired in part to focus on activities such as these to ensure sustainable compliance in all areas related to federal grant awards. Contact Person Responsible for Corrective Action: Mr. Victor Weetly, Chief Executive Officer. Anticipated Completion Date: The corrective action plan will be completed by September 30, 2025. Respectfully submitted, Mr. Victor Weetly, President.
FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2024-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should reevaluate the established organizational controls regarding federal financial reporting to ensure that such policies and proc...
FINDING - FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services 2024-001 Head Start – Assistance Listing #93.600 Recommendation: The Organization should reevaluate the established organizational controls regarding federal financial reporting to ensure that such policies and procedures are being followed. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action taken in response to finding: The finding was recognized by management as an out of the ordinary deficiency of internal controls experienced during a period of financial staff turnover. Action Plan: A written procedure will be developed to ensure that documentation of oversight is performed prior to the certification of federal financial reporting. Training will be provided to staff with oversight responsibilities. Name(s) of the contact people responsible for correction action: Donalda Dodson, Chief Executive Officer Plan completion date for corrective action plan: November 30, 2025
To: Boyer & Ritter From: Stephanie Phillips, Senior Financial Manager RE: Corrective Action Plan for 2024-001 Date: September 23, 2025 Finding 2024-001: Compliance Finding Finding Title: Reporting Anticipated Completion Date: Already Implemented Name of Agency Responsible for carrying out the correc...
To: Boyer & Ritter From: Stephanie Phillips, Senior Financial Manager RE: Corrective Action Plan for 2024-001 Date: September 23, 2025 Finding 2024-001: Compliance Finding Finding Title: Reporting Anticipated Completion Date: Already Implemented Name of Agency Responsible for carrying out the corrective action plan: Finance Person in the agency (name & title): Stephanie Phillips, Senior Financial Manager County Management acknowledges the importance of timely and accurate submission of Cash on Hand Quarterly Reports in accordance with PA Department of Housing and Urban Development requirements. Accordingly, the Finance department will work collaboratively with the Housing and Redevelopment Authority to strengthen oversight, encourage timely reporting and promote compliance. The county has taken the following steps to address this compliance finding – established a reporting calendar that outlines submission deadlines and responsible parties clearly identified, a verification process through which the Finance department confirms timely electronic filing via IDIS, enhanced internal compliance monitoring checklist used by Finance, and formalizing a review process to ensure that any issues identified during monitoring are promptly communicated to the Housing and Redevelopment Authority along with a timeline for submitting corrective action plans.
Federal Program: Community Development Block Grant – Disaster Recovery (CDBG-DR) (ALN 14.228) Condition: Untimely submission of monthly progress reports. Planned Corrective Action: Management acknowledges the finding related to the timeliness of monthly report submissions. Although reports were prep...
Federal Program: Community Development Block Grant – Disaster Recovery (CDBG-DR) (ALN 14.228) Condition: Untimely submission of monthly progress reports. Planned Corrective Action: Management acknowledges the finding related to the timeliness of monthly report submissions. Although reports were prepared internally by the required due date, submission to the PRDOH reporting system was delayed pending review and approval of the prior month’s report by PRDOH . To strengthen compliance with reporting requirements, the Organization will implement the following corrective actions: • Internal documentation: Maintain dated copies of all monthly reports prepared by the 5th day following the reporting period to demonstrate timely preparation. • Communication with PRDOH: Retain written communications with PRDOH when reports cannot be submitted due to pending approvals, documenting the cause of delay. • Formal request: Submit a written request to PRDOH seeking clarification of reporting requirements and advocating for a process that permits timely submission regardless of system approval delays. • Monitoring: assign responsibility to the Finance and Compliance Officer to track reporting deadlines and ensure documentation of both preparation and submission efforts. Responsible Official: Thomas P. King Anticipated Completion Date: Ongoing – procedures to be implemented beginning with reports due for October 2025.
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the find...
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Below is the process for submitting required grant reporting. 3. The Director will input the required information 4. Prior to submission of the report, the Director will have the Deputy Director verify the information that has been entered against the supporting documentation. 5. The Deputy Director will let the Director know if it is ok to submit the report. 6. The Director will submit and print a completed submission document that the Deputy Director will verify again. 7. The Deputy Director and Director will both sign and date the completed report. 8. This will be filed for audit purposes. Anticipated Completion Date: This is already taking place. The 2025 filing in April followed this process.
Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: During our testing of the Schedule of Expenditures of Federal Awards (SEFA) and the SESA, we noted that the expenditures were not reported in accordance with GAAP. An adjustment of $268,000 was recorded to pro...
Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: During our testing of the Schedule of Expenditures of Federal Awards (SEFA) and the SESA, we noted that the expenditures were not reported in accordance with GAAP. An adjustment of $268,000 was recorded to properly state the expenditures. Recommendation: Implement policies and procedures to ensure that all expenditures have been properly recorded in accordance with GAAP in the SEFA and SESA. Corrective action plan: Management agrees with the finding. Beginning in fiscal year 2025, a detailed reconciliation process will be implemented to ensure that all expenditures are properly accrued and reported at the grant level in the SEFA and SESA, aligned with the appropriate reporting period, and the general ledger. Responsible officer: Gouri Kulkarni, Vice President of Finance. Estimated completion date: December 31, 2025.
Finding 2024-007 SEFA Reporting Issue: We lacked consistent grant-level financial reporting, which made preparation of the required Schedule of Expenditures of Federal Awards {SEFA) difficult and time-consuming. • What's been done: We have improved our accounting systems and can now produce regular ...
Finding 2024-007 SEFA Reporting Issue: We lacked consistent grant-level financial reporting, which made preparation of the required Schedule of Expenditures of Federal Awards {SEFA) difficult and time-consuming. • What's been done: We have improved our accounting systems and can now produce regular internal financial reports by grant. All grant managers are given a monthly transaction listing for their grants to ensure transactions are posted to the correct grant. They are also given monthly financial statements for each grant to reconcile with their records. • Next steps: Financial reporting will be done on a timely basis, ideally no more than 5 days after the month closing so grant managers can reconcile their records. • Timeline: By early October, we hope to implement the monthly closing no more than 5 days after the month end. • Responsible party: Finance manager with oversight by President
Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting ...
Recommendation: We recommend that the Board of Directors be aware of the internal control deficiencies over financial reporting. And, if possible, implement procedures to ensure that the Organization has the expertise necessary to prevent, detect and correct misstatements and be capable of drafting the financial statements, related footnote disclosures and SEFA in accordance with the modified cash basis of accounting.
Views of responsible officials and planned corrective actions: The Association believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledg...
Views of responsible officials and planned corrective actions: The Association believes it has personnel who possess suitable skill, knowledge, or experience to oversee services the auditor provides in assisting with financial statement presentation which requires a lower level of technical knowledge than the competence required to prepare the financial statements, related footnote disclosures, and SEFA in accordance with the modified cash basis of accounting.
Finding ref number: 2024-001 Finding caption: The City did not have adequate internal controls and did not comply with federal wage-rate requirements. Name, address, and telephone of City’s contact person: Josh DeLay 271 9th St NE East Wenatchee, WA 98802 (509) 886-4507 Corrective action the auditee...
Finding ref number: 2024-001 Finding caption: The City did not have adequate internal controls and did not comply with federal wage-rate requirements. Name, address, and telephone of City’s contact person: Josh DeLay 271 9th St NE East Wenatchee, WA 98802 (509) 886-4507 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). All the projects audited this period are still in progress and have not been closed out or accepted by the City. As a result, the final project files were not available, leading to the audit evaluating “working” files. Auditing these files with the expectation that they would be in a finalized state is both misrepresenting the City’s standard of care for accepted projects and created an added financial burden to provide support from working files. The City would like it noted the audit did not find any payments to have been processed that did not include payment of prevailing wage. Additionally, as stated above, these projects are all still in progress and will not be fully closed out until all certified payrolls are received. In a theoretical case where there was an instance of a contractor not paying prevailing wage on one of these projects, the City would address it prior to closeout, which would ensure it is not liable for paying additional wages. The City hires consultants to administer these projects in accordance with all relevant statutes and best practices. The City also provided the SAO with emails showing the City’s consultants requesting overdue certified payrolls as a part of the pay estimate preparation process. To mitigate any risk that may exist in the City’s current process the City will develop a cover sheet to accompany pay estimates on federally funded projects that will require the consultant to certify that certified payrolls from all contractors are up to date, tracks how far overdue any non-submitted certified payrolls are, and ensure the City verifies certified payrolls in a timely manner. The City will also look further into the applicable statutes to determine whether it needs to establish a policy outlining when to withhold payment from a contractor due to outstanding certified payrolls. The City does not believe that an audit finding is necessary on this issue. These certified payrolls will be collected prior to the projects being accepted, ensuring that any noncompliance from contractors are not the financial responsibility of the City. As outlined above, the City acknowledges that there are areas that it could improve its process and will implement policies and systems to continue delivering the best possible projects for taxpayers. Anticipated date to complete the corrective action: Immediately, where necessary
Corrective Action Plan June 30, 2024 67 Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.667 Social Service Block Grant Program 21.027 Coronavirus State and Local Fiscal Recovery Funds Program Federal Agency U.S. Department of Health and Huma...
Corrective Action Plan June 30, 2024 67 Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.667 Social Service Block Grant Program 21.027 Coronavirus State and Local Fiscal Recovery Funds Program Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Condition UFC did not submit its audited financial statements and SEFA to the Federal Audit Clearinghouse website within nine (9) months of June 30, 2024. UFC also didn’t submit its audited financial statements, SEFA, CFR, CYEFR and other required information to the GATA portal within nine (9) months after June 30, 2024. Views of Responsible Officials and Planned Corrective Actions Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within the accounting and finance department are able to complete their tasks in a more timely manner. Persons Responsible: Marlin Bryant, CFO Date of Implementation: September 2025
Finding 2024-002 Finding: The Organization has not timely submitted the Single Audit Reporting Packages for the year ended December 31, 2023. Planned Corrective Action: The Organization will submit the Single Audit Reporting Packages for the year ended December 31, 2024 in accordance with 2 CFR 200....
Finding 2024-002 Finding: The Organization has not timely submitted the Single Audit Reporting Packages for the year ended December 31, 2023. Planned Corrective Action: The Organization will submit the Single Audit Reporting Packages for the year ended December 31, 2024 in accordance with 2 CFR 200.512(a)(1). Responsible Contact Person: Barbara Ewing, Chief Executive Officer
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