Corrective Action Plans

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2023 - 006: Reporting (Compliance; Internal Controls Over Compliance) (Repeat 2014-004, 2015-008, 2016-005, 2017-006, 2018-005 2019-006,2020-006, 2021-005 and 2022-007) Significant Deficiency ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During the testing of the rep...
2023 - 006: Reporting (Compliance; Internal Controls Over Compliance) (Repeat 2014-004, 2015-008, 2016-005, 2017-006, 2018-005 2019-006,2020-006, 2021-005 and 2022-007) Significant Deficiency ALN 21.027 Coronavirus State and Local Fiscal Recovery Funds (ARPA) Condition: During the testing of the reporting compliance requirement for ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds, we noted that the necessary reports were filed timely; however, no general ledger backup was provided to verify the accuracy of the reported numbers. Corrective Action Plan: The Governmental Department will work to establish procedures to ensure that all reports submitted to funding agencies are accurate, complete, and supported by reconciled documentation. These procedures will include reconciling Federal Financial Reports (SF-425) to the general ledger on a quarterly basis, as required by ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds, and verifying the accuracy of the Project and Expenditure Report and the Recovery Plan Performance Report as required for ALN 21.027 – Coronavirus State and Local Fiscal Recovery Funds. Additionally, The Governmental Department will review and incorporate program-specific reporting requirements into a formal policy to maintain compliance with federal guidelines. An internal audit process is being developed and personnel assigned. Forms will be developed to assist with the internal audit process to ensure a timely and consistent process will be followed.
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive ...
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to procurement, CHC will implement the following corrective actions: CHC will develop and implement a written procurement policy that conforms to the Uniform Guidance.; CHC will ensure sta􀀁 receive adequate training on the procurement policy and the required methods of procurement to be made when making procurements with federal awards. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to reporting, CHC will implement the following corrective actions: CHC will implement a workflow process for federal grants that address specific steps and areas of responsibilities to meet grant repo...
Corrective Actions Planned To address the deficiency in internal controls over compliance with respect to reporting, CHC will implement the following corrective actions: CHC will implement a workflow process for federal grants that address specific steps and areas of responsibilities to meet grant reporting requirements; CHC will develop a grant procedure that outlines specific requirements of each grant that include supervisory review and reconciliation of data prior to submission.; Each Grant has a specific schedule for timely submission of reports. CHC plans to build a primary grant schedule that outlines each grant task, responsible member, milestones (if needed) and due date for each grant reporting cycle.; CHC will develop sta􀀁 training requirements that address federal and non-federal reporting responsibilities. Training will focus on the grant project manager, support sta􀀁, and other CHC board members to ensure comprehensive understanding of full disclosure. Responsible Person(s): CHC President, Rob Dibble as Primary; CHC Vice President Betsy Gordon as Backup Corrective Action Plan Dates: Schedule implementation starts: February 1, 2026; Staff training starts: March 1, 2026; Review process in effect starts: April 1, 2026
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did...
FINDING 2023-003 – Reporting: Significant Deficiency over Internal Controls over Compliance Condition/context – In a representative sample of monthly, quarterly, and annual reports due during the year ended December 31, 2023, auditors noted six of the six tested annual financial reports (SF-425) did not agree to the underlying profit and loss detail from the Organization’s General Ledger(s) for the related grants. In addition, the certified authorized official was not an employee of the Organization and there was a lack of documentation for how the certifying official was deemed appropriate. In the sample quarterly reports, the Organization had contradicting responses related to whether reimbursement requests reflect actual spending of designated Supportive Services for Veteran Families (SSVF) funding. Corrective Action Plan: • Internal Controls are being evaluated and addressed with the Board of Directors on clarity of Financial Policy and Procedures • Implement a formal reconciliation process to ensure all grant financial reports agree to the underlying general ledger and profit and loss statements. • Establish a documented policy identifying employees authorized to certify grant reports, ensuring these individuals are employees of the Organization and appropriately trained. • Conduct regular training and internal reviews to confirm consistent understanding of grant-specific reporting requirements, particularly those related to reimbursement-based funding such as SSVF. • Develop a standard operating procedure (SOP) for reviewing and approving financial reports before submission to funders. Prior to sending to funder/portal. Must have reconciliation to numbers prior to next period reporting. • Site Review of reporting will have oversight of Financial Dept and reconciliation communication. Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: We cannot alleviate within 12 months
We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system...
We concur with the finding, and a corrective action plan was created and implemented on January 1, 2024. We have modified our Accounting Policies and Procedures and trained all finance staff on reviewing the necessary backup for disbursements and have been loading this backup into our finance system. The creation and implementation of a google submission for disbursements has added the necessary review and approval of all expenses. Additional Partner Engagement Coordinator review of requests and backup documentation has been implemented for weekly approval of disbursements.
Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 2...
Personnel Responsible for Corrective Action: Tracy Schmitt, Chief Financial Officer Anticipated Completion Date: November 30, 2024 Views of Responsible Officials and Planned Corrective Action: The missed reporting was completed in November 2024 and accepted by the granting organization on February 27, 2025. The Medical Center has implemented a tracking procedure for all grants that includes due dates for required reporting. The Controller maintains a list of compliance requirements for each grant which is reviewed by the Chief Financial Officer. Additionally, the primary contact information for grants is updated upon any changes in personnel to ensure communications are routed to the appropriate individual for follow-up.
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.
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