Corrective Action Plans

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This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time fra...
This finding occurred as a result of staff shortages, new employees and increased caseloads. The Domestic Relations Department filled vacant positions through 2023. The Domestic Relations Department provided semi-annual training to the Intake Unit staff in Case Initiation, record retention, time frame for conversion of applications/ petitions to case files and file documentation beginning in November 2023.
SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.
SAOP will establish a rocedure to track reporting due dates and implement a process for verifying the accuracy and completeness of required reports before submission.
SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.
SAOP will enhance the internal controls over the payroll allocation process by conducting regular reviews and reconiliations to ensure the accuracy of payroll allocations.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall establish a procedure to securely store payment support, ensuring all transactions are supported by proper documentation.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
2023-007 Internal Controls over Systems for Award Management (SAM Debarment) (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to suspe...
2023-007 Internal Controls over Systems for Award Management (SAM Debarment) (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to suspension and debarment are consistently implemented. Corrective Action: 1. SAM Debarment Registration: Under new leadership, we became compliant with SAM Debarment Registration in March 2025. 2. Compliance Tracking: We have implemented systems to ensure that registration will be completed annually and on time, supported by a robust compliance tracking system. 3. Vendor Vetting: 1. All new vendors will be vetted through the SAM (System for Award Management) Department prior to the initiation of services. 2. Continuous service providers will undergo an annual vetting process to ensure ongoing compliance and quality. Responsible Parties: Sandra Robicheaux – ED Madelyn Wages – Director of Operation Date to be Corrected: March 2025
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that ...
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to special tests and provisions – reasonable rental rates are consistently implemented including maintaining documentation of the verification of rental reasonableness in the program participant's file. Corrective Action: In response to the findings from the 2023 audit regarding the annual requirement for rent reasonableness, we developed the following action plan to ensure compliance with HUD regulations: 1. Annual Schedule: We established that annual rent reasonableness assessments for Temenos TCDC would be conducted each January, as required by HUD. This included comprehensive assessments for all scatter site properties. 2. Staff Reminders: A systematic reminder protocol was implemented for all staff involved in the rent reasonableness process. This included: 1. Calendar alerts 2. Email notifications 3. Regular team meetings to discuss timelines and responsibilities 3. Monitoring and Compliance: The Executive Director (ED) and Director of Operations closely monitored the compliance process to ensure assessments were completed accurately and on time. By implementing this action plan, Temenos TCDC aimed to address the 2023 audit findings effectively and ensure compliance with HUD's annual rent reasonableness requirements, including assessments for all TCDC site properties. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Implemented in January of 2025
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are c...
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the award...
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: The Tribe was unable to provide copies of the required quarterly progress/performance reports, and as a result, we could not verify whether the reports were submitted to the awarding agency as required. Corrective Action: The Tribe has hired a full-time bookkeeper along with a new fiscal consultant to assist the bookkeeper in journal entries, bank statements, etc. on a monthly basis. All required reporting will be done within 30 days of the end of reporting date. Anticipated date of completion: April 1, 2026.
Hale County Health Care Authority respectfully submits the following corrective action plan for the year ended September 30, 2023. The finding from the September 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in t...
Hale County Health Care Authority respectfully submits the following corrective action plan for the year ended September 30, 2023. The finding from the September 30, 2023 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Significant Deficiency (2023-001) - Reporting (Late Filing) Recommendation: We recommend that the Authority complete its audit and submit the required by the deadline. Planned Corrective Action: We are continuining to institute processes and procedure to complete timely reconcilations to allow for future filings to be made prior to deadline. Contact Person: Shay Cherry
Action Item Title 2023-006 – Federal Award Findings Status (Open: In-process) Condition Single Audit Reporting Package Submission The Corporation did not comply with the Single Audit Reporting Package submission date requirement for the years ended June 30, 2023, and 2022. Identified root cause Due ...
Action Item Title 2023-006 – Federal Award Findings Status (Open: In-process) Condition Single Audit Reporting Package Submission The Corporation did not comply with the Single Audit Reporting Package submission date requirement for the years ended June 30, 2023, and 2022. Identified root cause Due to the Commonwealth of Puerto Rico's (the Commonwealth) filing for Title III under PROMESA, most of its instrumentalities were required to reduce staff as part of the Fiscal Plan to lower expenditures. This staff reduction resulted in a lack of personnel, which impacted key internal controls. Grantee resolution plan The Corporation will submit the outstanding Single Audit Reporting Packages Completion date 2022 2023 Submitted and accepted by the Federal Audit Clearinghouse on August 20, 2024. May 2025 Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
Action Item Title 2023-004 – Federal Award Findings Status (Open: In-process) Condition Inactive SAM Registration Impacting Eligibility The Corporation’s SAM registration expired on September 6, 2023. Identified root cause The Corporation has been unable to update the SAM’s registration due to probl...
Action Item Title 2023-004 – Federal Award Findings Status (Open: In-process) Condition Inactive SAM Registration Impacting Eligibility The Corporation’s SAM registration expired on September 6, 2023. Identified root cause The Corporation has been unable to update the SAM’s registration due to problems with the platform to correct their physical address. Grantee resolution plan After multiple attempts, the entity’s information was successfully validated on December 21, 2024. Completion date Corrected on December 21, 2024. Name and Title of contact: Linnette Dávila Alemán- Financial and Budget Assistant Manager Phone: 787-724-4747 ext. 2105 Email: ldavila@cba.pr.gov Jetppeht Pérez de Corcho Morgado – General Manager Phone: 787-724-4747 ext. 2102 Email: jperez@cba.pr.gov
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; ...
2023-004 TIMING OF AUDIT COMPLETION - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks HOME Investment Partnership Program ALN 14.239; passed through the County of Berks. Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Coronavirus State and Local Fiscal Recovery ALN 21.027; passed through the Commonwealth of Pennsylvania Department of Community and Economic Development. Condition The Authority did not submit the Single Audit reporting package and Data Collection Form to the Federal Audit Clearinghouse within the required timeframe of nine months after the end of the audit period. The 2022 reporting package was submitted on May 7, 2025, which was after the one month due date of September 30, 2023. In addition, the 2023 reporting package was not submitted by the September 30, 2024 due date. Recommendation We recommend that the Authority continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse. Management Response The Authority will continue to execute their plan to bring the accounting records up to date and submit outstanding audited financial statements to the Federal Audit Clearinghouse.
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on f...
2023-003 ALLOWABLE ACTIVITIES AND ALLOWABLE COSTS - SIGNIFICANT DEFICIENCY Federal Program Emergency Rental Assistance ALN 21.023; passed through the County of Berks. Condition/Cause For 23 out of 60 cases tested, the amount paid for rent or utilities did not agree to a lease agreement or bills on file for the following reasons: (I) clerical errors, (2) duplicate payments due to multiple staff working on the same file, or (3) failure to request or maintain support before payment was made. Known questioned costs associated with the 23 exceptions noted in our testing were $9,867. Based on the projection of the sampling results to the remaining population, we project additional likely questioned costs of approximately $173,400. The Authority did not have controls in place to detect the noncompliance prior to issuing payments. We recommend the Authority revisit and strengthen internal controls over tracking individual payments for transactions entered as batches, particularly when related to federal awards. We encourage the Authority to continue working to identify the individual transactions making up the remainder of the federal expenditures under this program. We also recommend the Authority revisit and strengthen internal controls over allowable activities and allowable costs related to grant programs. Management Response The Authority launched the Emergency Rental Assistance Program (ERAP) with little administrative guidance from the U.S. Treasury. The Authority contracted with the Berks Coalition to End Homelessness (BCEH) to undertake various aspects of the Emergency Rental Assistance Program and in the late fall of 2021, the Authority began reviewing all case documentation provided by BCEH. This review eliminated the vast majority of the errors noted. The Authority also updated case documentation checklists as well as provided training for staff involved with ERAP. Current Status of Corrective Action Plan The Authority has resolved this finding. An additional review was added at the close of each case.
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.
Finding 1166097 (2023-006)
Material Weakness 2023
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025
Finding 1166069 (2023-002)
Material Weakness 2023
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site whi...
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site which could of lead to this finding, I strongly feel that we are improving on this finding as we progress in stressing internal controls. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T. Spencer, City Comptroller December 31, 2025
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionall...
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionally, reasonably and in a timely manner to secure our 2022 audit within the required timeline. Despite our diligence, the previous auditing company and their representatives were grossly non-responsive and ultimately, we had to dispute our payment that was made in full for not receiving the 2022 audit services in a timely manner. This impacted our 2023 audit not being completed as indicated in the finding. Corrective Action: The Organization chose a new audit company that is responsive, professional and highly experienced in non-profit audits. The Organization continues to have a process in place to ensure that required audits are completed in accordance with established guidelines. In advance, we seek at least three bids from reputable audit companies; our finance team provides documentation in a timely manner; we utilize a designated person to ensure the audit process is not delayed including conducting routine follow-ups or check-ins and ensuring any issues are resolved quickly; and we pay our bills on time. Our corrective action plan is in place to ensure timely audits in the future as applicable.Name of Contact Person Sophia Nash – HR-Business Manager; 229-854-3660; hr.fwocga@gmail.com Projected Completion Date: December 31, 2025
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as iden...
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as identified. In addition, any project associated with outside funding has gone through or will go through a reconciliation process to evaluate its current standing, including all related receivables and payables, and will continue to do so monthly. The City is working to ensure all invoices are paid within a timely manner of the related award advances and according to application of Federal and State regulations.
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. A calendar of all federal reporting...
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. A calendar of all federal reporting requirements will be developed and maintained. This calendar will be reviewed monthly to ensure all federal compliance timelines are met. A federal program grant activity report will be shared monthly with the district leadership team. This report will keep financial monitoring to the forefront of the leadership team. All federal program reporting will be reviewed with the Business Office prior to submission. Business Office will complete federal program management and reporting training by December 31st by working with the federal program specialists at the State Department of Education and reading and retaining for future reference any grant specific guidance.
U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit...
U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.
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