Corrective Action Plans

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Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project...
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193 Questioned Costs: $1
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
Finding Number: 2024-001 Finding Title: Late Issuance of 2024 Single Audit Report Package Identification of federal programs: All Assistance Listing Numbers included on the schedule of expenditures of federal awards for the year ended December 31, 2024. Cause: The delay was due to delays in obtainin...
Finding Number: 2024-001 Finding Title: Late Issuance of 2024 Single Audit Report Package Identification of federal programs: All Assistance Listing Numbers included on the schedule of expenditures of federal awards for the year ended December 31, 2024. Cause: The delay was due to delays in obtaining necessary documentation for audit completion. Effect: Late submission of the audit package constitutes noncompliance with federal requirements. Corrective Action Taken: Management will work to meet audit deadlines and assign responsibilities for timely submission. Responsible Party: Marta Carrigan, Executive Director Anticipated Completion Date: September 30, 2026
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Finding 1162353 (2024-002)
Material Weakness 2024
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Report...
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Reports are expected to be filed correctly and timely, with future education being sought as needed.
Finding 1162350 (2024-001)
Material Weakness 2024
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. ...
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. The Director reports several calendaring mechanisms are in place and the reports are being tracked by duplicative methods since that error.
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
November 4, 2025 Carver, Florek & James CPA’s Attn: Keegan Witt Audit Findings Corrective Action Plan Finding number: Section III: Federal Awards Findings and Questioned Costs Contact Person Responsible: Bonnie Buckingham Corrective Action Planned: Financial procedures that Community Food & Agricult...
November 4, 2025 Carver, Florek & James CPA’s Attn: Keegan Witt Audit Findings Corrective Action Plan Finding number: Section III: Federal Awards Findings and Questioned Costs Contact Person Responsible: Bonnie Buckingham Corrective Action Planned: Financial procedures that Community Food & Agriculture routinely follow are as follows: - Operations & Finance Manager will pull reports from QuickBooks accounting software for all federal grants for which a request for funds will be generated. - Executive Director reviews the draw down request, signs off on it, and the Executive Director or the Operations & Finance Manager files a request from the Federal portal, for funds expended for a specific program. All current and future expenditures and drawdown requests will be signed and dated with an electronic stamp certification prior to any drawdown request, as per the Financial Procedures stated above. All staff have been made aware of the strict adherence to this policy. Anticipated Completion Date will be immediate. Sincerely, Bonnie Buckingham Executive Director
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will implement a monitoring system to insure timely review and filing of quarterly reports. Pers...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will implement a monitoring system to insure timely review and filing of quarterly reports. Person Responsible: BCCD Manager Anticipated Completion Date: 11/12/2025
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: Bradford County will file reports on or before required due dates. Person Responsible: Michelle Shedden, chie...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: Bradford County will file reports on or before required due dates. Person Responsible: Michelle Shedden, chief Clerk Anticipated Completion Date: 11/12/2025
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.
Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025
Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025
Views of Responsible Officials and Planned Corrective Actions: Management agrees timeliness is critical. Corrective Action: Maintain an audit compliance calendar with key federal deadlines and internal milestone tracking.
Views of Responsible Officials and Planned Corrective Actions: Management agrees timeliness is critical. Corrective Action: Maintain an audit compliance calendar with key federal deadlines and internal milestone tracking.
Views of Responsible Officials and Planned Corrective Actions: Management agrees and has adopted a SEFA tracking template. Corrective Action: Track federal expenditures monthly by funding source and Assistance Listing Number (ALN), reconcile SEFA totals to the general eldger, and train staff on Unif...
Views of Responsible Officials and Planned Corrective Actions: Management agrees and has adopted a SEFA tracking template. Corrective Action: Track federal expenditures monthly by funding source and Assistance Listing Number (ALN), reconcile SEFA totals to the general eldger, and train staff on Uniform Guidance.
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. Corrective Action: Fair Haven has internal records with tracking assets but will ensure that all qualifying capital asset purchases are properly capitalized and recorded on the balance sheet in accord...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. Corrective Action: Fair Haven has internal records with tracking assets but will ensure that all qualifying capital asset purchases are properly capitalized and recorded on the balance sheet in accordance with GAAP and added to the fixed asset register. Management will review significant purchases at acquisitions to confirm proper treatment going forward.
The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Orga...
The Organization should implement an effective monitoring system to keep track of the compliance calendar, which includes financial reporting deadlines, and automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. Additionally, the Organization should implement a system that will file documents in an organized manner and make them easily accessible to the Organization and auditors. Furthermore, the Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight.
CONDITION: The Regional Office of Education No. 39 did not have sufficient internal controls over the preparation of the SEFA to ensure all federal expenditures during the fiscal year were reported and information in the SEFA was complete and accurately reported. PLAN: The Regional Office of Educati...
CONDITION: The Regional Office of Education No. 39 did not have sufficient internal controls over the preparation of the SEFA to ensure all federal expenditures during the fiscal year were reported and information in the SEFA was complete and accurately reported. PLAN: The Regional Office of Education No. 39 will implement controls over financial statements for both the internal Business Office Manager and the contracted accounting firm to prepare and review the financial statements including the schedule of expenditures of federal awards, to ensure program titles, assistance listing numbers and other pertinent information is accurate for financial statement presentation. ANTICIPATED DATE OF COMPLETION: Implemented August 2025
CONDITION: The Regional Office of Education No. 39 did not submit or timely submit the required reports to the Illinois State Board of Education in compliance with the grant award agreement. PLAN: The Regional Office of Education No. 39 agrees with the audit findings and will provide close oversight...
CONDITION: The Regional Office of Education No. 39 did not submit or timely submit the required reports to the Illinois State Board of Education in compliance with the grant award agreement. PLAN: The Regional Office of Education No. 39 agrees with the audit findings and will provide close oversight for the timely submission of grant expenditures and performance reports. Checklist, due dates, and reminders are shared from the Regional Superintendent to the Business Office Manager and Program Directors. Management will review the grant report submissions in Illinois Web Application Security (IWAS) for accuracy and completion before approving and submitting to Illinois State Board of Education. ANTICIPATED DATE OF COMPLETION: Implemented July 2024
FINDING 2024-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audi...
FINDING 2024-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Material Weakness, Noncompliance Condition: The District did not have proper controls in place to ensure that the RD442-2 and RD 442-3 forms were filled out and submitted. Context: Form RD442-2 and Form RD442-3 were not submitted to the granting agency. The District may submit the financial data in other forms, however, the required reporting information was not submitted at all for the year under audit. The forms are required to be submitted on GAAP accrual basis. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will prepare the required forms which will be reviewed by the Board of Directors prior to submission. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect with the next required submission for 2025.
Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: We recommend ensuring the proper preparation and review of the balance sheets with indication of review with a sign off. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Ac...
Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: We recommend ensuring the proper preparation and review of the balance sheets with indication of review with a sign off. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The year-end actual income statements will be prepared by the Portfolio Accountant based on year-end policies and procedures. The income statement will be reviewed by the Property Director, the Finance Director, initialed and then entered into MINC. Names of the contact persons responsible for corrective action: Julie Schueller, Finance Director and Deanna Hemmesch, Executive Director Planned completion date for corrective action plan: December 31, 2025
Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: We recommend ensuring all income statement items are properly reviewed and reported to the USDA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response t...
Rural Rental Housing Loans - Federal Assistance Listing #10.415 Recommendation: We recommend ensuring all income statement items are properly reviewed and reported to the USDA. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The year-end actual income statements will be prepared by the Portfolio Accountant based on year-end policies and procedures. The income statement will be reviewed by the Property Director, the Finance Director, initialed and then entered into MINC. Names of the contact persons responsible for corrective action: Julie Schueller, Finance Director and Deanna Hemmesch, Executive Director Planned completion date for corrective action plan: December 31, 2025
Finding Reference Number: 2024-3 Description of Finding: The Commission did not submit the single audit reporting package to the Federal Audit Clearinghouse within nine months after the end of the audit period as required. The Commission had staff turnover in the finance position and did not have su...
Finding Reference Number: 2024-3 Description of Finding: The Commission did not submit the single audit reporting package to the Federal Audit Clearinghouse within nine months after the end of the audit period as required. The Commission had staff turnover in the finance position and did not have sufficient controls and redundancies to allow them to close the year to get ready for the audit. Statement of Concurrence or Nonconcurrence: The auditee agrees with these recommendations and has taken the necessary steps to prevent a re-occurrence as of October of 2025. Corrective Action: The CFO and the Executive Director will develop a policy to include a timeline for arranging for the audit, closing out the year and submitting the reporting package in accordance with the Uniform Guidance reporting. The procedures will involve cross-training several employees to prevent any disruption from employee turnover. Name of Contact Person: Candace Harris, Chief Financial Officer Projected Completion Date: November 30, 2025
Description of Finding: The Commission is required to provide a schedule of expenditures of federal awards (SEFA) to the auditor. The Commission did not have sufficient controls to ensure the SEFA accurately reflected each award's federal expenditures. Statement of Concurrence or Nonconcurrence: The...
Description of Finding: The Commission is required to provide a schedule of expenditures of federal awards (SEFA) to the auditor. The Commission did not have sufficient controls to ensure the SEFA accurately reflected each award's federal expenditures. Statement of Concurrence or Nonconcurrence: The auditee agrees with these recommendations and has taken the necessary steps to prevent a re-occurrence as of October of 2025. Corrective Action: The CFO will develop a policy for how revenue is to be accrued into the general ledger with a designation of funding source. The policy shall be memorialized as an MPPDC financial operations document and jointly signed by the CFO and the Executive Director. The policy shall state why the preferred method was selected to ensure continuity of operations in the event of future staff turnover. Name of Contact Person: Candace Harris, Chief Financial Officer Projected Completion Date: November 30, 2025
Finding Reference Number: 2024- I Description of Finding: The Commission is not timely reconciling the bank accounts. The Commission had staff turnover in the finance position and did not have sufficient controls and redundancies to allow all accounting functions to be performed on a timely basis. S...
Finding Reference Number: 2024- I Description of Finding: The Commission is not timely reconciling the bank accounts. The Commission had staff turnover in the finance position and did not have sufficient controls and redundancies to allow all accounting functions to be performed on a timely basis. Statement of Concurrence or Nonconcurrence: The auditee agrees with these recommendations and has taken the necessary steps to prevent a re-occurrence as of October of 2025. Corrective Action: The CFO will develop a policy for how bank reconciliations will occur monthly and to be jointly signed by the CFO and the Executive Director. The policy will contemplate a vacancy in the positions and propose a backup process for bank reconciliations. Name of Contact Person: Projected Completion Date: November 30, 2025
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