Corrective Action Plans

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We have met with the responsible party and explained the need to be more careful. We also have a new person responsible for that input.
We have met with the responsible party and explained the need to be more careful. We also have a new person responsible for that input.
Federal program: FAL 21.027, Coronavirus State and Local Fiscal Recovery Funds Significant deficiency Criteria: Management is responsible for designing, implementing, and maintaining effective internal controls to ensure accurate financial reporting and safeguard assets. Downstreet’s internal contro...
Federal program: FAL 21.027, Coronavirus State and Local Fiscal Recovery Funds Significant deficiency Criteria: Management is responsible for designing, implementing, and maintaining effective internal controls to ensure accurate financial reporting and safeguard assets. Downstreet’s internal control procedures require the Vermont Housing Improvement Program (VHIP) expenditure tracking spreadsheets to be updated and reviewed prior to disbursements of VHIP grant funds to grant awardees. Condition: During testing of the VHIP grant fund disbursement process, the auditor found that the control designed to ensure all payments were supported by adequate documentation was not operating effectively. Corrective action plan: Downstreet has revised the VHIP approval process to ensure invoices and tracking sheets are verified before disbursement, with documentation uploaded to client files. Staff roles within the Homeownership Center have been realigned to improve accuracy, and a new staff member now supports the program, with responsibilities that include auditing files at disbursement to confirm completeness. All corrective actions have been implemented as of September 2025. Responsible official: Schuyler Anderson, CFO/COO
FIDNING #2024-001: Financial Statement and Schedule of Expenditure of Federal Awards (SEFA) Preparation Responsible Individuals: Jessicca McKeown, Finance Officer Corrective Action Plan: The City Finance Officer reviews the financial statements and SEFA in detail each year. It is more cost effective...
FIDNING #2024-001: Financial Statement and Schedule of Expenditure of Federal Awards (SEFA) Preparation Responsible Individuals: Jessicca McKeown, Finance Officer Corrective Action Plan: The City Finance Officer reviews the financial statements and SEFA in detail each year. It is more cost effective and efficient for a public accounting firm to prepare the financial statements during the audit process. The City will continue to have the auditor prepare the annual financial statements. Anticipated Completion Date: Ongoing
REPORTING (PRIOR YEAR 2023-007) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community H...
REPORTING (PRIOR YEAR 2023-007) Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Program (Medicaid Cluster) Assistance Listing Number: 93.778 Pass-Through Agency: Minnesota Department of Human Services and the Aitkin-Itasca-Koochiching Community Health Board Federal Award Identification Number and Pass-Through Number: 2405MN5ADM, 2405MN5MAP Compliance Requirement Affected: Reporting Award Period: Year Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that the County ensure each report is reviewed by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure each report is reviewed by someone other than the preparer. Name of the contact person responsible for corrective action: Eric Villeneuve, Health and Human Services Director Planned completion date for corrective action plan: December 31, 2025
2024-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensa...
2024-01: Segregation of Duties Name of contact person: J.R. Davis, Chief Executive Officer Corrective Action: Duties and functions will be reviewed to determine where segregation needs to occur. The duties will be separated as much as possible and alternative controls will be implemented to compensate for lack of segregation. However, the risk of not segregated certain duties are not worth the additional costs. Nonfinancial employees will be trained and provide some assistance. Proposed completion date: The Board will implement the above procedure immediately.
Catholic Charities had implemented procedures to ensure that monthly expenditure reports were filed by the required deadline of the 15th day of the following month. In the following fiscal year, all grant reports were submitted on time, with the exception of the first few months of the beginning of ...
Catholic Charities had implemented procedures to ensure that monthly expenditure reports were filed by the required deadline of the 15th day of the following month. In the following fiscal year, all grant reports were submitted on time, with the exception of the first few months of the beginning of the grant year when the required reporting templates were not yet available from the administering agency. These programs have since been closed; therefore, no ongoing corrective action or monitoring is required.
Finding Reference Number: 2024-001 and 2024-004 Finding Title: Preparation of Financial Statements and Year-End Adjustments Responsible Person: David Bernhauser, Finance Director Corrective Action Plan: The Township acknowledges the auditor’s finding that it does not prepare its own financial statem...
Finding Reference Number: 2024-001 and 2024-004 Finding Title: Preparation of Financial Statements and Year-End Adjustments Responsible Person: David Bernhauser, Finance Director Corrective Action Plan: The Township acknowledges the auditor’s finding that it does not prepare its own financial statements and year-end adjustments in accordance with accounting principles generally accepted in the United States of America (GAAP). Management recognizes the importance of financial reporting as a core internal control responsibility and will implement the following corrective actions: 1. Hire a Human Resources Specialist – this process will remove benefit administration, payroll processing, and human resource issues from the finance director, which will free up the finance director to perform high level financial responsibilities during the year. 2. Hire a Staff Accountant – this will further improve the segregation of duties within the accounting department by having a second qualified accountant to handle these duties. 3. The finance director will perform monthly spot checks on the accounts to facilitate easier and more efficient preparation of the necessary year-end adjustments. Anticipated Completion Date: The Finance Director will make these staffing requests to the Board of Commissioners as part of the budget process for 2026. The goal would be to have these positions filled by September 2026.
FINDING No. 2024-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should comply with state law and HUD regulations for refunding security deposits timely. Action Taken: Staff training has been provided and included in monthly reporting procedures. If the Ov...
FINDING No. 2024-002: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should comply with state law and HUD regulations for refunding security deposits timely. Action Taken: Staff training has been provided and included in monthly reporting procedures. If the Oversight Agency for Audit has questions regarding the plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips, CFO
Oversight Agency for Audit, MM III, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: J...
Oversight Agency for Audit, MM III, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067. Audit period: January 1, 2024 through December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2024-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures to ensure tenant applications contain all the appropriate documentation, inclusive of date and time received. In addition, the waiting list should contain explanations for passing over tenants. Action Taken: Staff training has been provided with additional HUD training inclusive of EIV reporting and tenant file maintenance and included in monthly reporting procedures.
Completeness of the Schedule of Expenditures of Federal Awards - Federal Agency: Department of Health and Human Services. Award Name: Health Resources and Services Administration: Community Project Funding/Congressionally Directed Spending – Construction. Program Ye ar: January 1, 2024 – December 31...
Completeness of the Schedule of Expenditures of Federal Awards - Federal Agency: Department of Health and Human Services. Award Name: Health Resources and Services Administration: Community Project Funding/Congressionally Directed Spending – Construction. Program Ye ar: January 1, 2024 – December 31, 2024. Assistance Listing Number: 93.493. Criteria: Management is responsible for preparing a complete and accurate Schedule of Expenditures of Federal Awards. Condition: During compliance testing, it was determined that the Schedule of Expenditures of Federal Awards provided to us to begin our audit was not complete and accurate. Context: Management was unable to fully reconcile the Schedule of Expenditures of Federal Awards to the general ledger. Cause: The information contained in the Schedule of Expenditures of Federal Awards was not accurate. Effect: As a result of the condition, management was unable to fully reconcile the Schedule of Expenditures of Federal Awards to the general ledger. Recommendation: In the future, management should ensure it implements appropriate processes and controls to ensure the Schedule of Expenditures of Federal Awards contains complete and accurate data. Views of Responsible Officials: Management acknowledges the finding and will implement appropriate processes and controls to ensure the Schedule of Expenditures of Federal Awards contains complete and accurate data. Corrective Actions Taken or Planned: The System will implement appropriate processes and controls to ensure the Schedule of Expenditures of Federal Awards contains complete and accurate data. Responsible Parties: Stephen W. Forney, Senior Vice-President/Chief Financial Officer. Anticipated Completion Date: December 31, 2025.
Allowable Costs – Nonpayroll Disbursements Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Sh...
Allowable Costs – Nonpayroll Disbursements Block Grants for Prevention and Treatment of Substance Abuse – Assistance Listing No. 93.959 COVID-19 - Substance Abuse and Mental Health Services Projects of Regional and National Significance – Assistance Listing No. 93.243 Recommendation: We recommend Shatterproof ensure internal controls are in place and operating effectively so that when changes in vendors involved in the financial reporting process occur there is an evaluation of the electronic evidence of the performance of internal controls and other data to ensure needed documentation is retained or continues to be accessible in line with their record retention policies and requirements of the grant agreements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2024, Shatterproof implemented Bill Spend & Expense (Divvy), a cloud-based platform designed to automate receipt tracking, provide a clear audit trail for expense coding, and support a streamlined approval workflow. Name of the contact person responsible for corrective action: Young Kim Planned completion date for corrective action plan: 4/1/2024
View Audit 367790 Questioned Costs: $1
Wyoming Health Council entered all missede 2024 first-tier subawards into SAM.gov using the correct obligation dates as of September 19, 2025. As FSRS was officially retired on March 8, 2025, all reporting was completed in SAM.gov, the current federal reporting platform. Procedures and Controls Impl...
Wyoming Health Council entered all missede 2024 first-tier subawards into SAM.gov using the correct obligation dates as of September 19, 2025. As FSRS was officially retired on March 8, 2025, all reporting was completed in SAM.gov, the current federal reporting platform. Procedures and Controls Implemented: • Developed and implemented a Monthly FFATA/SAM.gov Reporting Checklist and secondary review process. • Designated the Executive Director as the responsible official for verifying timely entry of subawards. • Integrated a reconciliation step into the monthly close process to ensure all new and modified subawards greater than $30,000 are reported by the end of the month following the obligation date. • Prepared and will approve a formal policy and procedure for FFATA/SAM.gov reporting by September 26, 2025, which will be added to the compliance manual and communicated to all responsible staff.
The corrective action for this finding was completed following the 2023 audit. The finding did not reoccur since that time but rather the reissue of the finding for reporting periods that occurred prior to the implementation of the 2023 corrective action plan. The position of Grants Coordinator was ...
The corrective action for this finding was completed following the 2023 audit. The finding did not reoccur since that time but rather the reissue of the finding for reporting periods that occurred prior to the implementation of the 2023 corrective action plan. The position of Grants Coordinator was created and filled to handle grants management functions which ensures proper quarter end dates and expenditures appropriate for the period are reported. Under this process, the Grant Coordinator collaborates with the Construction Financial Administrator to complete forms which are then reviewed with the Director of Grants and CFO prior to submission.
In September 2025, Management has implemented the following corrective action item to eliminate the 2024-001 finding: 1. Management has redesigned our schedule of federal awards template to align with the format presented in the Single Audit report, thus eliminating reliance on summation formulas. 2...
In September 2025, Management has implemented the following corrective action item to eliminate the 2024-001 finding: 1. Management has redesigned our schedule of federal awards template to align with the format presented in the Single Audit report, thus eliminating reliance on summation formulas. 2. Management has implemented an additional review of the draft Single Audit report to be performed by the Controller. This is followed by the final review from the CFO before the report submission. Staff have reviewed the applicable Uniform Guidance (2 CFR 200.510b) to ensure full comprehension of reporting requirements. All corrective action items have been implemented and followed for the preparation of the schedule of federal expenditures. Contact Person Responsible for Corrective Action: Blaine Hoovis, Chief Financial Officer Email: BHoovis@ifaw.org Phone: 1 508 744 2134
Corrective action steps were taken at 12/31/24 to ensure proper modified accrual accounting standards were followed. Expenditures were accrued properly, and we plan to follow Controller Office accrual guidelines moving forward as the Controller sets and administers the accounting rules for the County....
Corrective action steps were taken at 12/31/24 to ensure proper modified accrual accounting standards were followed. Expenditures were accrued properly, and we plan to follow Controller Office accrual guidelines moving forward as the Controller sets and administers the accounting rules for the County. It is important to note that under SLFRF Reporting and Compliance guidance, expenditures may be reported on a cash or accrual basis, as long as the methodology is disclosed and consistently applied . We report on a cash basis and due to this reason, we did not monitor that all SLFRF related expenditures were accrued at year end 2023.
B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file...
B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file out of compliance sub recipient forms per the timetable noted in Section D below. C. Timetable of dates for performance of planned corrective action steps including completion date: Slated to begin new process August 1, 2025 for new contracts and/or contract renewals. Once process has been finalized, ACHD Fiscal will also review past agreements that are still in effect. D. Description of monitoring to be performed to ensure corrective action steps are taken: ACHD Financial Manager and Grants Manager will ensure lists and monitoring activities are maintained.
We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by ...
We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by individual grants. All match from all HUD programs is added together and submitted on one final report at the end of each funding year. The requirement is 25% on all budget lines except for Leasing. However, if one program’s match is short of the 25% requirement, the overall CoC is responsible for the filll match, so additional DHS admin costs are used to represent the additional match needed. For our FY23-24 annual report to HUD, we submitted 32.94% in match for the overall fimding. This amount did not include any additional HMIS (data system) costs, Allegheny Link (our coordinated entry system) costs or additional DHS admin costs. With these additional eligible activities, our matching amount could have been over 50%. Therefore, even if some identified items were considered ineligible our match would not be in jeopardy since we have a lot of eligible costs that DHS covers that would be considered match.
The balance error was a result of human error. Specifically, the Program Income and Grant balances were combined erroneously. The staff person responsible for submitting the Cash on Hand report has since received additional training from HUD Pittsburgh Field Office’s Senior Financial Analyst, Cather...
The balance error was a result of human error. Specifically, the Program Income and Grant balances were combined erroneously. The staff person responsible for submitting the Cash on Hand report has since received additional training from HUD Pittsburgh Field Office’s Senior Financial Analyst, Catherine Byrne. ACED's Fiscal staff will follow the steps on the Cash on Hand checklist template, following all steps to complete the report. The Assistant Director of Finance or the Assistant Director of Operations will review and approve the report for accuracy and completion. This procedure is outlined in the attached policy and procedures manual. (p. 32)
ACED has filed all past reports. Two staff have been assigned the responsibility of filing the reports in a timely manner. Specifically, they are responsible for checking the Department’s IMS Project Management database monthly, generating a list of all newly funded projects of $30,000 or more, then...
ACED has filed all past reports. Two staff have been assigned the responsibility of filing the reports in a timely manner. Specifically, they are responsible for checking the Department’s IMS Project Management database monthly, generating a list of all newly funded projects of $30,000 or more, then reporting the information into the FSRS reporting system at SAM.gov. Additionally, the responsible staff person receives a notification from the Department’s Contract Coordinator when the contract is executed, to later be shared with HUD. This procedure is outlined in the procedures manual. (p. 37)
ACHD Fiscal will review open “amount remaining” on contracts at year end. Send listing to all program managers within the Health Department for review. If applicable for year-end service dates, ACHD Fiscal to accrue.
ACHD Fiscal will review open “amount remaining” on contracts at year end. Send listing to all program managers within the Health Department for review. If applicable for year-end service dates, ACHD Fiscal to accrue.
B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file...
B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file out of compliance sub recipient forms per the timetable noted in Section D below.C. Timetable of dates for performance of planned corrective action steps including completion date: Slated to begin new process August 1, 2025 for new contracts and/or contract renewals. Once process has been finalized, ACHD Fiscal will also review past agreements that are still in effect. D. Description of monitoring to be performed to ensure corrective action steps are taken: ACHD Financial Manager and Grants Manager will ensure lists and monitoring activities are maintained.
ACHD Fiscal will review open “amount remaining” on contracts at year end. Send listing to all program managers within the Health Department for review. If applicable for year-end service dates, ACHD Fiscal to accrue.
ACHD Fiscal will review open “amount remaining” on contracts at year end. Send listing to all program managers within the Health Department for review. If applicable for year-end service dates, ACHD Fiscal to accrue.
Finding 1155432 (2024-001)
Material Weakness 2024
Semi
CA
Finding Reference Number: 2024-01 Description of Finding: As required by 2 CFR Part 170, Appendix A,, SEMI did not report information on each subaward or amendment of $30,000 or more in federal funds in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) before t...
Finding Reference Number: 2024-01 Description of Finding: As required by 2 CFR Part 170, Appendix A,, SEMI did not report information on each subaward or amendment of $30,000 or more in federal funds in the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) before the last day of the month following the month in which the subaward obligation was made or modified. Corrective Action: 1. Update the formal subaward reporting policy with detailed responsibilities, timelines, and review steps.  SEMI’s SAM.gov account administrator will enter the subawards required to be entered in the federal subaward reporting system before the last day of the month following the month in which the subaward obligation was made or modified. This will occur on or soon after the day the subaward is fully executed. 2. Conduct quarterly internal compliance reviews to monitor reporting timeliness and accuracy. Responsible Official: Kevin Bauer (Chief Financial & Business Operations Officer) Melissa Grupen-Shemansky (VP, Technology Communities) Completion Date: Task was completed as of August 22, 2025 Management Response: SEMI concurs with the finding and has implemented the above corrective actions to ensure full compliance with 2 CFR Part 170, Appendix A requirements. Sincerely, Kevin Bauer
2024-004 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findi...
2024-004 Conservation Research and Development Program – Assistance Listing #81.086 Recommendation: The Organization should establish written policies and procedures regarding first-tier subawards including tracking and proper internal control procedures. Explanation of disagreement with audit findings: There is no disagreement with the audit findings. Action Plan: Effective September 30, 2024, we established written policies and procedures regarding tracking and reporting first-tier subawards under the Federal Funding Accountability and Transparency Act. Moving forward, we will strengthen these procedures by incorporating an additional review step to ensure compliance with federal special reporting requirements. This added oversight will help maintain accuracy, consistency, and accountability in the reporting process. Name(s) of the contact people responsible for correction action: Gina Avalos-Limardo, Director of Finance & Operations and Cho Heide, Contracts & Compliance Manager Plan completion date for corrective action plan: September 30, 2025
Finding 2024-001: For the year ending December 31, 2023, the Corporation did not submit the Data Collection Form to the Federal Audit Clearinghouse in the time period required by Uniform Guidance. Comments on the Finding and Each Recommendation: The Corporation should submit the Data Collection Form...
Finding 2024-001: For the year ending December 31, 2023, the Corporation did not submit the Data Collection Form to the Federal Audit Clearinghouse in the time period required by Uniform Guidance. Comments on the Finding and Each Recommendation: The Corporation should submit the Data Collection Form to the Federal Audit Clearinghouse within the required time period. Management agrees with the finding and recommendation. Action(s) taken or planned on the finding: The Data Collection Form for the year ended December 31, 2023, was submitted on December 18, 2024.
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