Corrective Action Plans

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Management will implement an internal procedure to ensure proper filing within 30 days of quarter end to be in reporting compliance.
Management will implement an internal procedure to ensure proper filing within 30 days of quarter end to be in reporting compliance.
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prior...
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prior...
To address the noted deficiencies in the late submissions to HUD and the FAC, management has changed management of the organization in March 2025, established new and experienced supervisors in April 2025, reviewed Standard Operating Procedures and implemented anew, reviewed all properties and prioritized needed corrections in May and June 2025, transitioned from MRI software to Yardi software as of June 2025, sent Occupancy Specialists to a 2 ½ day Quadel training to review all the basic requirements of HUD in July 2025, and we continue to provide internal training and process orientation to Occupancy Specialists. In addition, we will continue to ensure all Standard Operating Procedures are followed. This oversight will be provided by all supervisors, re-establish the regular reviews of new tenant files outlined in the SOP “OCC-05 Occupancy File Reviews,” and continue internal training for staff as needed.
Finding: Reporting—financial and performance reports Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in ...
Finding: Reporting—financial and performance reports Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial processes including grant reconciliation. This updated contractual agreement & relationship occurred on March 1, 2024. ▪ Taken: An ongoing process has been put in place to ensure multiple checks and balances are conducted prior to grant submission to identify reporting requirements and responsible parties. This will be facilitated by our Development team with assistance of our outsourced accounting firm, this process was implemented July 1, 2025. ▪ Taken: Stronger supervision of required reporting and deadlines. This will be facilitated by our Chief Development Officer, Nick Roman with our Sikich partners. This control process was implemented July 1, 2025 ▪ Planned: Alignment with our Board approved Financial Policy documentation that includes information on appropriate finance and accounting processes. The review and assessment of our current processes to the Finance Policy will be conducted by our external accounting firm, with a completion of that process occurring by September 30th, 2025.
Finding: Data collection form filing Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial pr...
Finding: Data collection form filing Corrective Actions Taken or Planned: ▪ Taken: This finding was a result of staff turnover and Center on Halsted has put in place an established relationship with an external accounting firm (Sikich), that will help create stability and support in all financial processes including grant reconciliation. This updated contractual agreement & relationship occurred on March 1, 2024. Planned: Center on Halsted leadership, with the assistance of our external accounting firm, will ensure proper documentation, internal controls, and processes that will support a timelier audit. This includes an organization-initiated internal audit for the Center on Halsted processes that will stress test our ability to produce accurate supporting documentation and allows us to build more effective and efficient processes prior to our annual audit. This will be led by Sikich with a targeted completion date of October 31st, 2025.
Finding Number: 2024-001 Program Name/Assistance Listing Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Mark Ollerton, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District acknowledges and unde...
Finding Number: 2024-001 Program Name/Assistance Listing Title: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Contact Person: Mark Ollerton, Business Manager Anticipated Completion Date: June 30, 2025 Planned Corrective Action: The District acknowledges and understands that the expenditures should have been reported as federal. The LEA will correct this oversight and ensure compliance going forward by implementing the following actions: 1. Grant Identification and Training – Provide annual training for all staff involved in grant management to ensure awareness of federal versus state funding sources and their respective reporting requirements. 2. Internal Controls and Oversight – Require that all new grants be reviewed and approved by the Business Manager prior to set-up in the District’s financial system, to confirm proper federal identification and ALN coding. 3. Quarterly SEFA Reviews – Implement quarterly reconciliations of grant expenditures against SEFA records to ensure completeness and accuracy throughout the fiscal year. 4. Management Review – Conduct higher-level review of SEFA preparation by the Superintendent and Business Manager before submission to auditors.
Supporting Documentation of Payroll Costs Recommendation: Policies and procedures over the processing of payroll transactions should include proper review and approval of timesheets to ensure hours match the hours per payroll register and correct hours are charged to the grant. There is no disagreem...
Supporting Documentation of Payroll Costs Recommendation: Policies and procedures over the processing of payroll transactions should include proper review and approval of timesheets to ensure hours match the hours per payroll register and correct hours are charged to the grant. There is no disagreement with the audit finding. Action planned/taken in response to finding: High quality accounting personnel will ensure hours match the hours per payroll register and correct hours are charged to the grant. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately
Supporting Documentation of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure proper supporting documentation is maintained and available for each expenditure. There is no disagreement with the audit finding. Act...
Supporting Documentation of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure proper supporting documentation is maintained and available for each expenditure. There is no disagreement with the audit finding. Action planned/taken in response to finding: Outside accounting firm will be ensure proper supporting documentation is maintained and available for each expenditure. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately
Proper Cut-Off of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure completion in accordance with the accrual basis to ensure expenditures are being recorded and reported in the proper period. There is no disagre...
Proper Cut-Off of Expenditures Recommendation: Policies and procedures over monthly vouchers should include preparation and review of the voucher to ensure completion in accordance with the accrual basis to ensure expenditures are being recorded and reported in the proper period. There is no disagreement with the audit finding. Action planned/taken in response to findings: Outside Accounting Firm will oversee the monthly voucher process to ensure completion in accordance with the accrual basis to ensure expenditures are recorded and reported in the proper period. Name(s) of the contact person(s) responsible for corrective action: Mary Ann Mahon Huels, President and CEO Planned completion date for corrective action plan: Immediately
Views of Responsible Officials: Management understands and agrees. Unfortunately, this issue was identified late into FY24 when the FY23 audit was being completed so the issue persisted into FY24. From the corrective action plans taken from the FY23 audit and desk review, this issue has been address...
Views of Responsible Officials: Management understands and agrees. Unfortunately, this issue was identified late into FY24 when the FY23 audit was being completed so the issue persisted into FY24. From the corrective action plans taken from the FY23 audit and desk review, this issue has been addressed and resolved in early FY25. MBN currently has an SOP regarding fixed assets that is already implemented. To address these concerns, MBN updated the SOP to include a clear process for equipment disposals, specifically for assets with a fair market value over $10,000, in accordance with Uniform Guidance. This update will ensure that all disposals are properly documented, and appropriate notifications are made to USAGM. We would like to confirm that the equipment disposal forms have already been updated to ensure that all necessary responses are reviewed and accurately completed as part of the notification process for disposals. Furthermore, we have strengthened our tracking, reporting and disposal processes to ensure the final disposition of equipment, including salvage value, is appropriately recorded.
Views of Responsible Officials: Management agrees and if funding had not stopped, audit fieldwork was originally slated to begin April 1st which would have allowed for timely completion. We fully intend to complete our FY25 audit well before the nine-month deadline.
Views of Responsible Officials: Management agrees and if funding had not stopped, audit fieldwork was originally slated to begin April 1st which would have allowed for timely completion. We fully intend to complete our FY25 audit well before the nine-month deadline.
Views of Responsible Officials: Management agrees and was fully aware of the situation it found itself in when funding was cut. The Organization was not able to keep enough staff employed during this time to review and correct these errors before the audit fieldwork began. Now that these historical ...
Views of Responsible Officials: Management agrees and was fully aware of the situation it found itself in when funding was cut. The Organization was not able to keep enough staff employed during this time to review and correct these errors before the audit fieldwork began. Now that these historical balances have been corrected, the team undergoes a rigorous month-end close process where these issues will be caught and addressed immediately going forward.
Audit Finding 2024-001 Reference: Over-allocation of payroll expenditures to grant-funded programs (2 instances out of 40 sampled) ________________________________________ 1. Issue Summary During the audit of allowable payroll costs, two instances of over-allocation to grant-funded programs were ide...
Audit Finding 2024-001 Reference: Over-allocation of payroll expenditures to grant-funded programs (2 instances out of 40 sampled) ________________________________________ 1. Issue Summary During the audit of allowable payroll costs, two instances of over-allocation to grant-funded programs were identified. These occurred early in the fiscal year due to imprecise monthly allocation methods and insufficient review prior to posting. ________________________________________ 2. Root Cause Analysis • Use of a monthly allocation methodology lacking precision. • Insufficient review and approval of payroll allocations before posting. • Lack of real-time substantiation of salary distributions with actual time worked. ________________________________________ 3. Corrective Actions • Already implemented in the second half of the fiscal year, continue using the granular allocation method based on actual pay periods; including ongoing monitoring. • Implement a mandatory review of payroll allocations by project staff with support from SP&F accountants • Require timesheets or effort certifications and manager’s approval for personnel charged to federal awards. • Update internal payroll allocation policies to reflect new methodology and controls. • Conduct training sessions for finance and staff assigned to grants on revised payroll allocation procedures and compliance requirements. ________________________________________ 4. Responsible Parties Sponsored Projects Finance Team: Transaction reviews Finance Director: Oversight and implementation of corrective actions ________________________________________ 5. Timeline Action Item Target Completion Date Allocation Actual Pay Already implemented Review of Allocations Already implemented Timesheet/Policy Development Already implemented Staff Training Completed initial training, additional will be ongoing
Finding 2024-002 Submission of Reporting Package Criteria: 2 CFR 200.512(a)(1) states that the audit, the data collection form, and the reporting package must be submitted within 30 calendar days after the auditee receives the auditor's report or nine months after the end of the audit period (whiche...
Finding 2024-002 Submission of Reporting Package Criteria: 2 CFR 200.512(a)(1) states that the audit, the data collection form, and the reporting package must be submitted within 30 calendar days after the auditee receives the auditor's report or nine months after the end of the audit period (whichever is earlier). Condition: The Organizations did not timely submit the Single Audit Reporting Packages for the year ended December 31, 2023. Cause: Due to delays in the audit process, the December 31, 2023 audit was not completed until after the submission deadline. Effect: The Organizations could miss out on grant opportunities. Recommendation: We recommend ensuring the accounting records are prepared and reconciled in a timely manner to ensure the audit and submission of the data collection form be completed in a timely manner. Corrective actions taken or planned: Management will develop and execute a comprehensive corrective action plan, including the implementation of controls and procedures around the period-end closing process. This will ensure that all necessary adjustments and reconciliations are completed and reviewed prior to the year-end audit fieldwork. Additionally, management will provide traning for finance and accounting staff to emphasize the importance of accuracy and timely financial reporting. Name of contract person responsible for corrective action plan: Brian Gillette, Chief Financial Officer Anticipated completion date: December 31, 2025
Name of auditee: Community Services Programs, Inc. and Affiliates TIN: 51-0139050 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: July 31, 2024 CAP prepared by: Margaret O’Leary Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2024-...
Name of auditee: Community Services Programs, Inc. and Affiliates TIN: 51-0139050 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: July 31, 2024 CAP prepared by: Margaret O’Leary Current Finding on the Schedule of Findings and Questioned Costs and Recommendations (2) Finding 2024-002 (a) Comments on the finding and recommendations: Management agrees with the finding. Management also agrees with the recommendation. (b) Action taken: Management has taken steps to ensure timely filing for the year ended July 31, 2025.
We agree with the auditors' recommendations, and the following action will be taken to improve the timeliness of the financial reporting process. Management will consult with the audit firm and outside CPA firm to develop an agreed upon schedule for the FY 2025 financial reporting process and relate...
We agree with the auditors' recommendations, and the following action will be taken to improve the timeliness of the financial reporting process. Management will consult with the audit firm and outside CPA firm to develop an agreed upon schedule for the FY 2025 financial reporting process and related audit to meet the Financial Audit Clearinghouse reporting requirement. We will also identify additional training for departmental staff to improve skills and address identified deficiencies. Finally, Management will review capacity constraints and development solutions to improve capacity.
Condition: The Agency’s controls in place for financial reporting submissions did not identify that the SF-425 Federal Financial Report (“FFR”) submitted for the annual reporting period ending August 31, 2023, indicated that the report was prepared on the accrual basis of accounting when the report ...
Condition: The Agency’s controls in place for financial reporting submissions did not identify that the SF-425 Federal Financial Report (“FFR”) submitted for the annual reporting period ending August 31, 2023, indicated that the report was prepared on the accrual basis of accounting when the report was actually prepared on the cash basis of accounting. The report filed did not reflect the accrued expenditures for the program. Planned Corrective Action: Thresholds current policy is as follows. For purposes of financial reporting on federal awards, financial reports will be prepared by the grant accountant (or other appropriate party) and reviewed by the Senior Director of Grants Accounting (or their designee). Unfortunately, this policy did not identify this mistake, because these payments came from a construction escrow account and did not go through the normal accounts payable process. We will add additional requirements for any accounting entry resulting from construction escrow payments. Namely, we will scrutinize and verify the accrual period(s) for such escrow expenditures before posting the accounting entry. Contact person responsible for corrective action: Al Shoreibah, Chief Financial Officer Anticipated Completion Date: 03/01/2025
Name of auditee: Neurovascular Diagnostics, Inc. TIN: 81-2945332 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: Vince Tutino vincentt@buffalo.edu Finding 2024-001 Neurovascular Diagnostics (the Company) attempted to receive ap...
Name of auditee: Neurovascular Diagnostics, Inc. TIN: 81-2945332 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: January 1, 2024 - December 31, 2024 CAP prepared by: Vince Tutino vincentt@buffalo.edu Finding 2024-001 Neurovascular Diagnostics (the Company) attempted to receive approval from the federal awarding agency to elect the program-specific audit option to satisfy reporting requirements. After several attempts without response, the Company opted to have a full financial statement audit conducted. The Company engaged a certified public accounting firm to conduct the audit for the year ended December 31, 2024 and completed its audit and reporting requirements as of October 2025. Further, the Company intends to engage the same firm in future years to ensure timely submission of the data collection form to the Federal Audit Clearinghouse.
The delay in closing the prior fiscal year was due to the transition in management company and the difficulty in obtaining prior year information, account statements and other key documentation in a timely manner. The current fiscal year has been completed through June 2025. The year-end closing pla...
The delay in closing the prior fiscal year was due to the transition in management company and the difficulty in obtaining prior year information, account statements and other key documentation in a timely manner. The current fiscal year has been completed through June 2025. The year-end closing plan in place with our current audit team and anticipate that all required submissions will be timely.
The District will implement a process to track the submission time of the data collection form and audit package.
The District will implement a process to track the submission time of the data collection form and audit package.
Head Start Semi Annual and Annual Federal Financial Reports will be filed by the VP of Administration.
Head Start Semi Annual and Annual Federal Financial Reports will be filed by the VP of Administration.
The Finance Department has created additional month-end and year end review of the adjustments. In addition, The Director of Finance will meet with the Audit Team prior to year-end work for consultation regarding year-end adjustments.
The Finance Department has created additional month-end and year end review of the adjustments. In addition, The Director of Finance will meet with the Audit Team prior to year-end work for consultation regarding year-end adjustments.
Management acknowledges that there have been challenges with the preparation of the September 30, 2024 financial statements due mainly to the implementation of a new accounting system in January 2024. Three months’ data was recorded in the legacy software system with nine months in the new system. A...
Management acknowledges that there have been challenges with the preparation of the September 30, 2024 financial statements due mainly to the implementation of a new accounting system in January 2024. Three months’ data was recorded in the legacy software system with nine months in the new system. Additionally, implementation of data from the old system to the new system did not mirror each other due to prior management decisions that were made, and so a software consultant was hired to convert all the newly converted data into the old, legacy format. This created duplicate journal entries that took time to identify and correct. These issues have since been resolved. Closing of future fiscal years should not encounter these same challenges. There were additional challenges with the recording of grants. In fiscal year 2024, management of grants had been mainly decentralized. There was a grants department who was responsible for some grants; a grants position in the County Auditor’s office who was responsible for other grants; and the management of even other grants being outsourced to an outside consultant. The Commissioners Court recognized the issues that this caused, and for fiscal year 2026, the grants department has been disbanded. The function of that department will be centralized with the outside consultant – with management oversight by a county employee. The financial recording will be centralized in the County Auditor’s office by an accountant who will be adequately trained in the accounting for grants. The position is currently being advertised, with a hire date of no later than November 30, 2025 being anticipated.
The policies and procedures around the Single audit will be reviewed, assigning responsibility, and implementing tracking systems. The CEO, COO, CFO, and Grants Manager will be responsible for overseeing the data collection and submission process internally, keeping track of the audit deadlines to e...
The policies and procedures around the Single audit will be reviewed, assigning responsibility, and implementing tracking systems. The CEO, COO, CFO, and Grants Manager will be responsible for overseeing the data collection and submission process internally, keeping track of the audit deadlines to ensure that all processes are moving forward in a timely fashion. All relevant parties will be trained on the reporting requirements and due dates.
Management Response/Corrective Action Plan: Additional reports will be run to verify totals before filings of quarterly reports, paying particular attention to end of year and the needed reversal of the prior year payroll accrual. Errors found in reports will be corrected in subsequent records as al...
Management Response/Corrective Action Plan: Additional reports will be run to verify totals before filings of quarterly reports, paying particular attention to end of year and the needed reversal of the prior year payroll accrual. Errors found in reports will be corrected in subsequent records as allowable under Department of Treasury grant reporting guidelines.
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