Corrective Action Plans

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Inadequate Supporting Documentation - ELC - DPHHS - The Montana Department of Public Health and Human Services established a procedure and a shared location for project documentation in 2023. The department will verify compliance through periodic reviews to ensure it is used. In addition, management...
Inadequate Supporting Documentation - ELC - DPHHS - The Montana Department of Public Health and Human Services established a procedure and a shared location for project documentation in 2023. The department will verify compliance through periodic reviews to ensure it is used. In addition, management will periodically remind staff of the procedures for storing all files in the designated shared location. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/21/2026
Noncompliant Incentive Compensation Controls - SFA - MSU - The Montana State University - Bozeman concurs with the finding. Since approximately 2023, language has been included on the lump-sum bonus form that prohibits any bonus for classified staff related to the recruitment or admission of student...
Noncompliant Incentive Compensation Controls - SFA - MSU - The Montana State University - Bozeman concurs with the finding. Since approximately 2023, language has been included on the lump-sum bonus form that prohibits any bonus for classified staff related to the recruitment or admission of students. Any bonus request submitted to the Office of the Commissioner of Higher Education for contract employees is reviewed and approved by the University's Compensation Advisory Council, which also reviewed these federal regulations. In December 2024, the Montana University System Staff Compensation Plan was updated to explicitly exclude such payments. Responsible Party - Jeannette Grey Gilbert, Chief Human Resources Officer, Montana State University - Bozeman Target Implementation Date - 12/31/2024
Noncompliant GLBA Oversight - SFA - MSU - The Montana State University - Bozeman concurs. The University has hired a Chief Information Security Officer, who is designated as the Qualified Individual as part of the University’s Information Security Plan. Responsible Party - John Williams, Chief Infor...
Noncompliant GLBA Oversight - SFA - MSU - The Montana State University - Bozeman concurs. The University has hired a Chief Information Security Officer, who is designated as the Qualified Individual as part of the University’s Information Security Plan. Responsible Party - John Williams, Chief Information Security Officer, Montana State University - Bozeman Target Implementation Date - 2/28/2025
Inaccurate COA Calculations - SFA - UM - The University of Montana – Missoula conducted additional review and provided supplemental documentation and clarification for the remaining sampled student records; however, one exception could not be fully resolved. The University is committed to strengthen...
Inaccurate COA Calculations - SFA - UM - The University of Montana – Missoula conducted additional review and provided supplemental documentation and clarification for the remaining sampled student records; however, one exception could not be fully resolved. The University is committed to strengthening its documentation, retention, and review processes to ensure that support for cost-of-attendance calculations and adjustments is consistently maintained, documented, and adequately substantiated going forward. Responsible Party - Morgan Hahn, Interim Financial Aid Director, University of Montana - Missoula Target Implementation Date - 12/31/2026
Noncompliant Title IV Disbursement Controls - SFA - UM - The University of Montana - Missoula has strengthened fraud prevention and detection efforts through enhanced identity verification procedures, targeted review of higher-risk populations, ongoing monitoring of suspicious activity, and increase...
Noncompliant Title IV Disbursement Controls - SFA - UM - The University of Montana - Missoula has strengthened fraud prevention and detection efforts through enhanced identity verification procedures, targeted review of higher-risk populations, ongoing monitoring of suspicious activity, and increased collaboration across university departments. The university will continue to evaluate emerging fraud trends, federal guidance, and institutional controls to reduce the risk of future improper disbursements. Responsible Party - Morgan Hahn, Interim Financial Aid Director, University of Montana - Missoula Target Implementation Date - 6/30/2027
Noncompliant Incentive Compensation Controls - SFA - UM - The University of Montana - Missoula will strengthen enforcement of existing procedures by implementing a formal incentive compensation policy that prohibits incentive compensation based on enrollment or financial aid outcomes and helps ensur...
Noncompliant Incentive Compensation Controls - SFA - UM - The University of Montana - Missoula will strengthen enforcement of existing procedures by implementing a formal incentive compensation policy that prohibits incentive compensation based on enrollment or financial aid outcomes and helps ensure compliance with federal regulations. Responsible Party - Jay Stephens, Vice President for People and Culture, University of Montana - Missoula Target Implementation Date - 3/8/2026
Noncompliant Direct Loan Reconciliation Controls - SFA - MSUB - The Montana State University - Billings concurs with the finding and has taken corrective action to strengthen segregation of duties within the cash management reconciliation process. While the reconciliation process has historically in...
Noncompliant Direct Loan Reconciliation Controls - SFA - MSUB - The Montana State University - Billings concurs with the finding and has taken corrective action to strengthen segregation of duties within the cash management reconciliation process. While the reconciliation process has historically involved both Financial Aid and Financial Services personnel, the reconciliation and review were performed inconsistently within the Financial Aid office. Effective immediately, Financial Aid and Financial Services have implemented a monthly reconciliation meeting to jointly review and validate the cash management reconciliation. During this meeting, Financial Services provides reconciliation information from the University’s financial records, and Financial Aid independently extracts and reviews corresponding information from the Banner system and the Common Origination and Disbursement system. Any discrepancies identified are discussed and resolved collaboratively. The monthly meeting and review process will be documented and retained as evidence of review and approval. This enhanced process establishes a formal review control involving personnel from separate offices and strengthens segregation of duties over the cash management reconciliation process. Responsible Party - Justin Beach, Director of Financial Aid & Scholarships, Montana State University - Billings Rebecca Bunn, Controller, Montana State University - Billings Target Implementation Date - 8/31/2026
Inadequate Grant Reconciliations - SPED - OPI - The Montana Office of Public Instruction will update procedures and desk manuals to ensure monthly reconciliations for federal programs between the agency’s grant system, the state’s accounting system, and a manually updated tracking spreadsheet contai...
Inadequate Grant Reconciliations - SPED - OPI - The Montana Office of Public Instruction will update procedures and desk manuals to ensure monthly reconciliations for federal programs between the agency’s grant system, the state’s accounting system, and a manually updated tracking spreadsheet contain adequate documentation and verify federal compliance. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 9/30/2026
Inadequate HDS System Access Controls - HVC - Commerce - The Montana Department of Commerce has developed a user access review procedure to be performed semiannually. The first review was completed in June 2026. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerc...
Inadequate HDS System Access Controls - HVC - Commerce - The Montana Department of Commerce has developed a user access review procedure to be performed semiannually. The first review was completed in June 2026. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 12/16/2026
Inadequate HAP Reconciliation Controls - HVC - Commerce - The Montana Department of Commerce has provided additional staff training to ensure housing assistance payments are issued timely, even though the error rate was less than one percent. Responsible Party - Ingrid Mallo, Chief Financial Officer...
Inadequate HAP Reconciliation Controls - HVC - Commerce - The Montana Department of Commerce has provided additional staff training to ensure housing assistance payments are issued timely, even though the error rate was less than one percent. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/19/2026
Inadequate Field Agent Payment Controls - HVC - Commerce - The Montana Department of Commerce has updated its processes to ensure that contract limits are reviewed prior to payments being issued and that contract amendments are pursued when needed. Responsible Party - Ingrid Mallo, Chief Financial O...
Inadequate Field Agent Payment Controls - HVC - Commerce - The Montana Department of Commerce has updated its processes to ensure that contract limits are reviewed prior to payments being issued and that contract amendments are pursued when needed. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/24/2026
Inadequate HQS Inspection Controls - HVC - Commerce - The Montana Department of Commerce has updated its inspection procedures to clearly outline requirements, including annual reexaminations. While the department may have lacked documentation of certain monthly reports, both the fiscal year 2024 an...
Inadequate HQS Inspection Controls - HVC - Commerce - The Montana Department of Commerce has updated its inspection procedures to clearly outline requirements, including annual reexaminations. While the department may have lacked documentation of certain monthly reports, both the fiscal year 2024 and fiscal year 2025 Section 8 Management Assessment Program Indicator 12 inspection reviews received all available points. The department is also transitioning to the National Standards for the Physical Inspection of Real Estate (NSPIRE) model for inspections. Staff completed training on June 16, 2026, and have begun using the federal inspection checklist to ensure compliance with current standards. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 9/18/2025
Inadequate FASS Reporting Controls - HVC - Commerce - The Montana Department of Commerce has developed procedures for the Financial Assessment Subsystem (FASS) reports to ensure they are complete and accurate and that the reviews of these reports are sufficiently documented. Responsible Party - Ingr...
Inadequate FASS Reporting Controls - HVC - Commerce - The Montana Department of Commerce has developed procedures for the Financial Assessment Subsystem (FASS) reports to ensure they are complete and accurate and that the reviews of these reports are sufficiently documented. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/20/2026
Inadequate Monthly Subrecipient Case File Reviews - CCDF - DPHHS - The Montana Department of Public Health and Human Services will further strengthen compliance by enhancing its internal control framework. The Department will refine supervisory review protocols, formalize documentation requirements,...
Inadequate Monthly Subrecipient Case File Reviews - CCDF - DPHHS - The Montana Department of Public Health and Human Services will further strengthen compliance by enhancing its internal control framework. The Department will refine supervisory review protocols, formalize documentation requirements, and improve monitoring procedures to ensure full alignment with State Plan objectives. The department will also review its State Plan and submit an amendment if necessary. These improvements will ensure continued compliance with State Plan requirements. The Department anticipates full implementation of these strengthened processes in early 2027. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 3/26/2027
CORRECTIVE ACTION PLAN2025-001 [2023-001]—TRACKING AND VALUATION OF MORTGAGE RECEIVABLES AND AMOUNTS DUE TO GRANTORType of Finding: (A) Material Weakness in Internal Control Over Financial ReportingStatement of ConditionWhile the Housing Trust has begun a complete review of its loan portfolio, the p...
CORRECTIVE ACTION PLAN2025-001 [2023-001]—TRACKING AND VALUATION OF MORTGAGE RECEIVABLES AND AMOUNTS DUE TO GRANTORType of Finding: (A) Material Weakness in Internal Control Over Financial ReportingStatement of ConditionWhile the Housing Trust has begun a complete review of its loan portfolio, the project has not yet been completed. Therefore, we were unable to obtain sufficient audit evidence to support the Housing Trust’s tracking and valuation of its mortgage receivables and amounts that are due to grantor.Per our audit procedures, we noted that management was unable to provide the following:A reasonable methodology for estimating its allowance for loan losses.Funding provided by grantors for the loan programs that should also be classified as amounts that are due to grantor.Not all current year loans were recorded in the general ledger (approximative $512,066) and approx. $481,201 were recorded twice.A net prior year adjustment of $36,460 for mortgages receivable and $35,000 for land leases held was necessary.Reclassification between loans accounts and grant revenue were necessaryContextThe Housing Trust has a portfolio of over six-hundred individual mortgage receivables that include both non-amortizing and amortizing loans, which management has valued at approximately $25,291,075. These loans have been funded by several sources, including federal, state, and local funding. Some of the grantors have established in their agreements that these funds do not belong to the Housing Trust, but actually belong to the grantor. CriteriaThe Housing Trust should ensure it has a board-approved policy for its loan portfolio to ensure that these assets are properly tracked, classified, and maintained with specialized loan management software that can perform the following:Loan Classification and TrackingEach loan is properly identified with its funding source (federal, state, local, etc.) and type of restriction Each loan agreement has the funding source specifiedThe current status of each loan is tracked (current, delinquent, defaulted)Loan funding that has been established as due to the grantor is properly tracked.Compliance and ReportingEnsure the loans comply with the specific guidelines of their respective funding source. Audit trails are available for all transactions and valuations.The receivables and related interest accruals supported by the loan management software should be reconciled to the Housing Trust’s accounting software.Financial TrackingThe valuation of the portfolio should be updated periodically (at least quarterly) for any changes in loan status or market conditions.All new loans should be recorded in the general ledger A loan loss policy was established that includes a loan loss methodology incorporating risk classes based on the borrower’s ability to repay. However, the calculations seem to follow a different methodology established afterwards. The policy should be updated with calculation methodology and with the backup research of historical data. A loan review committee should be responsible for reviewing and approving the classifications of loans and the associated allowance for loan losses which should be supported by high-quality data collection on each borrower’s payment history and any relevant economic indicators. The calculations and methodology should follow the approved policy, or the policy should be improved to include all factors mentioned above.EffectThe auditors were not able to verify the accuracy of the loan records and financial statements related to mortgage loans, the related accrued loan interest, the allowance for loan losses and loan funding that should also be recorded as due to grantor. CauseWhile the Housing Trust has begun a complete review of its loan portfolio, the project has not yet been completed. Therefore, the loan portfolio tracking and valuation have not yet been designed or implemented to support its policies and procedures or provide the loan review committee with a workable system for reviewing, approving and monitoring the organization’s mortgage receivable portfolio. The methodology seems to be changing, and the calculations do not seem to be accurate,RecommendationWe recommend the Housing Trust update policies and procedures for its loan portfolio as identified in the “Context” section of this finding to include methodology, risk assessment, historical loan data research, calculations method with reasoning.View of Responsible OfficialThe Housing Trust acknowledges the finding. Due to turnover in prior years, historical loan records and tracking systems were incomplete or inaccurate. Since then, SFCHT has taken the following steps:A second title company has been contracted to obtain final loan data for the 2026 loan portfolio. A title company will also be engaged annually at year-end to identify and resolve any differences arising during the year.Establish one master loan inventory using Portfol data. This inventory will serve as the master loan control schedule for monthly financial reconciliations. All differences will have a documented resolution, including reconciliation of receivables and related interest between the two systems. Reconciliations will be completed by the 15th business day of the following month.Create a new loan-recording process for every loan closing.Create a Due to Grantor Matrix based on findings from the annual loan review performed by the title company. Supporting documentation, such as grant agreements, correspondence, or other applicable documentation, will be maintained.Review the ASC 326 loan loss methodology to ensure it reflects the actual calculation methodology and is supported by appropriate research. This review will be performed quarterly.Establish a formal loan review committee and process to review loan calculations and the allowance for loan losses. The committee will meet quarterly and review reports from Portfol. Meeting minutes will document updates, decisions, and changes.Corrective Action Plan TimelineFinalize and implement the loan loss methodology: by December 2026Begin monthly Portfol-to-QBO reconciliations: by September 2026Fully hand over all loans to Amerinat by end of 2026; Land Leases will remain “in-house”Continue staff training and Executive-level reviewDesignated Employee Responsible for Corrective Action-Director of Operations-Accounting Specialist2025-002 [2023-002]—FINANCIAL CLOSE AND RESTATEMENTS TO BEGINNING NET ASSETSType of Finding: (A) Material Weakness in Internal Control Over Financial ReportingStatement of ConditionDuring the audit of the financial statements, we noted that material adjustments and restatements were necessary to correct errors in the current and previously reported financial statements. A summary of the areas and the net effect of the changes are as follows: Type Amount, net Accounts Receivable $ (13,490) Grants and Contracts Receivable 830,747 Accrued Interest 5,798 Amortizing Loan Receivable 419,551 Non-Amortizing Loans Receivable (433,722) Land Held in Trust (61,323) Other Assets (145,000) Prepaid Expenses (61,940) Notes Receivable (195,000) Developments Projects (184,559) Real Estate Inventory to Sell (333,079) Fixed Assets (785,081) ROU Accumulated Amortization (7,511) Accounts Payable (807) Due to Grantor 10,000 Grant Advances (97,963) Accrued Expenses (6,249) Other Current Liabilities 52,841 Lease Liabilities 7,845 Notes Payable (9,710) Net Assets 1,154,733 Total $ 146,081 CriteriaAccounting Standards Codification (ASC) 265 “Presentation of Financial Statements—Communicating Internal Control Related Matters Identified in an Audit” requires that deficiencies in internal control over financial reporting be communicated to those charged with governance when the design or operation of a control does not allow management or employees to prevent or detect misstatements on a timely basis.The correction of material misstatements indicates the existence of a material weakness in internal control over the maintenance of the organization’s financial statements.EffectThe material adjustments and restatements resulted in significant changes to the current year balances and beginning balances of the organization’s unrestricted and restricted net assets. These adjustments could potentially undermine the stakeholders' confidence in the financial information presented by the organization and may lead to difficulties in securing future funding or maintaining current donor relationships.CauseThe material misstatements were caused by a weakness in the development and implementation of internal controls and financial reporting processes, as well as significant turnover in the organization’s management.RecommendationWe recommend the Housing Trust strengthens its internal controls and financial reporting processes to prevent future occurrences of such errors. This could involve adding additional staff, training current accounting staff and implementing more robust review procedures to ensure that all financial reporting is in strict accordance with GAAP. View of Responsible OfficialThe Housing Trust acknowledges the finding. In prior years, however, internal controls were insufficient. There was no formal month-end close or review process, and prior audits relied on outdated balances without verification. Under new leadershipA formal monthly close calendar has been established, with the monthly close to be completed within 10-15 business days.Create a supporting schedule for every balance sheet account. These schedules will be used as part of the monthly reconciliation process and will be certified.A grant receivable roll-forward will be prepared for each grant, compared to QuickBooks, and reconciled monthly.Each development project will have its own subledger, which will be reconciled monthly.A detailed fixed asset register will be maintained and reconciled quarterly.6. To help prevent future restatements, establish a formal journal-entry control process that requires appropriate supporting documentation and approvals.7. Establish a policy requiring documentation and approval for any changes made to beginning balances.8. The CEO and Finance Committee will perform monthly analytical reviews using the balance sheet, profit and loss statement, and actual-to-budget comparisons.9. Establish a reconciliation exception and audit adjustment log to track outstanding issues requiring resolution, including a timeline for resolving each item.Corrective Action Plan Timeline The timeline to complete this is prior to December 31, 2026.Designated Employee Responsible for Corrective Action-Director of Operations-Accounting Specialist2025-003 [2024-003] - GRANT TRACKING AND SEFA RECONCILIATIONFederal Agency: U.S. Department of Housing and Urban Development (HUD)Federal Program: Housing Opportunities for Persons With AIDS (HOPWA)Assistance Listing Number: 14.241Award Number and Period: [NMH240051], [November 1, 2024 – October 31, 2027]Type of Compliance Requirements: Internal Controls Type of Finding: (B) Significant Deficiency in Internal Control Over Financial ReportingKnown Questions Cost: NoneStatement of ConditionDuring our audit, we identified initial differences between expenditures reported on the Schedule of Expenditures of Federal Awards (SEFA) and the general ledger. Management subsequently provided additional supporting schedules and completed a reconciliation of the SEFA to the general ledger. However, the reconciliation required manual effort because one federal award included program income amounts that had not been properly reconciled or corrected, another federal award had expenses that did not belong to the award, and recycled funds were tracked separately partially only from new grant funds in the accounting records. Some of expenses did not have appropriate backup documentation, however, the billing to the grant was correct. Expenses from program income for salaries did not match the timesheets. CriteriaPer 2 CFR 200.302 and 200.510(b), recipients of federal awards must maintain accurate, current, and complete records that adequately identify the source and application of funds. Grant expenditures must be traceable to the financial records and properly classified. Program income, including recycled funds, must be used and tracked in accordance with federal requirements and grantee policies. Specifically, all grants should be tracked separately in the general ledger, and the revenue and expenses should match the reimbursement grants. The SEFA reconciliation should be done thoroughly and discrepancies reconciled or resolved, if that is the case. The policies for recycling the funds should be updated with the financial tracking in the general ledger and update with all grantor recommendations. The HOPWA program policy was updated in July 2025.The recycled funds received/spent should be separately tracked and used per policies and grantor recommendations.EffectThe lack of properly tracking expenditures and recycled funds increases the risk of misstating the SEFA, billing non-allowable or duplicate costs to the grantor, and not meeting timeliness or use restrictions related to program income. This may lead to questioned costs or future audit findings.Recycled funds not properly tracked separately may result in noncompliance with the application of loan funding. CauseThe issues stemmed from frequent staff turnover and the complexity of accounting for loans and recycled funds across departments. RecommendationWe recommend the Housing Trust:Revise and implement grant management policy and procedures that ensure each grant has a dedicated general ledger account.Require all reimbursement requests to be supported by general ledger detail.Ensure program income and recycled funds are separately tracked in accordance with federal guidelines (separate classes).Establish regular reconciliations between Finance and Program records to maintain consistency.View of Responsible OfficialThe Housing Trust acknowledges the finding. Corrective Action Plan: 1. A master grant register has been created that includes all active grants and federal awards.2. Each grant will have a unique class/project established in QuickBooks to capture payroll and other grant-related expenses. Reports will be generated monthly.3. Each grant will be reconciled monthly.4. Grant reimbursement requests will be supported by appropriate documentation.5. Payroll review procedures have been established to confirm that payroll costs are properly allocated to grants.6. Program income will be tracked separately for all applicable income and expenditures.7. Monthly SEFA reconciliations will be completed for all grants, including grants that do not meet the definition for inclusion in the SEFA.8. A grant reconciliation exception log will be established to track outstanding issues, responsible parties, and timelines for resolution. Corrective Action Plan Timeline- Finalize and adopt new Grant Management Policies: by September 2026- Implement monthly SEFA reconciliations: by September 2026- Complete staff training on program income and federal grant tracking: by September 2026Designated Employee Responsible for Corrective Action-Director of Operations-Accounting SpecialistCurrent Year Findings 2025-004 - Program Income Federal Agency: U.S. Department of Housing and Urban Development (HUD)Federal Program: Housing Opportunities for Persons With AIDS (HOPWA)Assistance Listing Number: 14.241Federal Award: [NMH240051], [November 1, 2024 – October 31, 2027]Compliance Requirement: Program Income Known Questions Cost: None Type of Finding: (F, G) Significant Deficiency in Internal Control Over Compliance of Federal Awards and Instance of Noncompliance related to Federal Awards Statement of Condition During 2025, the Housing Trust received certain repayments of loans originally funded by HOPWA awards. Of this amount, certain amount may have remained unspent or had not been recorded/reconciled in accordance with HUD requirements as of December 31, 2025. Management did not maintain a documented control to identify HOPWA repayment receipts, determine the applicable award requirements, reconcile receipts and expenditures among IDIS, QuickBooks, and the program-income subsidiary record, and document approval of their disposition. Criteria Under 2 CFR 200.307(c), program income earned after a Federal award’s period of performance is subject to Federal requirements only when required by Federal agency regulations or the terms and conditions of the award, and the Federal agency may establish appropriate disposition requirements through closeout. HUD may require HOPWA-funded loan repayments received after the original award period to be recorded as program income.CauseThe Housing Trust had not designed and assigned ownership of a formal program-income and grant-closeout control addressing repayments generated from HOPWA-funded loans after the originating award’s period of performance. Effect Program income may have been subject to incorrect or untimely reporting/use, increasing the risk of noncompliance and misstatement of federal expenditures. Known questioned costs were unknown. RecommendationHousing Trust should implement a documented monthly program-income reconciliation and grant-closeout control that identifies the originating award, applicable HUD disposition requirement, IDIS receipt, QBO classification, eligible use, remaining balance, reviewer approval, and resolution of differences. Evidence of HUD determinations for post-period receipts should be retained with the reconciliation.Views of Responsible Officials: SFCHT acknowledges the finding and notes that the New Mexico HOPWA program is the only documented HUD grant that funds mortgages.Management has established a formal process to identify and track repayments associated with HOPWA-funded loans. Management will maintain a subsidiary program income register that identifies the originating federal award, receipts, applicable HUD disposition requirements, accounting classification, eligible expenditures, and remaining balance. Program income activity will be reconciled monthly among loan-servicing records, QBO, IDIS, and supporting program records. Written HUD determinations regarding post-period repayments will be retained when applicable.Corrective Action Plan TimelineAn onsite meeting with HUD HOPWA representatives is scheduled for September 10, 2026, at the Santa Fe offices. During this meeting, policies and procedures, including the program income policy, will be reviewed and formalized, and a HUD determination log will be established.The HOPWA Program Income Register will be implemented, and repayment schedules for HOPWA loans will be documented in the master loan inventory. Implementation date: July 2026.HOPWA program income will be expended before additional HOPWA IDIS reimbursement requests are approved.A historical review of HOPWA loans and funding sources will be completed. Target date: August 2026.QBO, Portfol, Amerinat, and IDIS will be reconciled monthly. Beginning: July 2026 and ongoing.Post-period repayments and related HUD determinations will be reviewed. Target date: September 2026.Designated Employee Responsible for Corrective Action Director of Operations, with assistance from the Accounting Specialist and HOPWA HUD program staff, as applicable.Signature Title
Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supe...
Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supervisory reviews to ensure all required reports are submitted accurately and timely. Management Response: Management concurs with the recommendation. The Management Analyst will ensure accurate and timely grant reporting. Anticipated Completion Date: September 30, 2026 Responsible Party: GIna Sherman, Management Analyst
Suspesion and Debarment Recommendation: The City should perform SAM checks for all vendors or contracors prior to entering into covered transactions and retain docuentation of these processes. Management Response: Management concurs with the finding. As part of the federal grant award process, City ...
Suspesion and Debarment Recommendation: The City should perform SAM checks for all vendors or contracors prior to entering into covered transactions and retain docuentation of these processes. Management Response: Management concurs with the finding. As part of the federal grant award process, City Management will ensure SAM checks are performed prior to contracting with vendors. Anticipated Completion Date: Septembe 30, 2026 Responsibnle Party: Gina Sherman, Management Analyst
Finding 2025-002 Corrective Action: Management concurs with the finding. The Organization will implement a formal review and approval process over monthly CACFP requests for reimbursement. Prior to submission, the Grant Manager, who is independent of the preparation process, will review the monthly ...
Finding 2025-002 Corrective Action: Management concurs with the finding. The Organization will implement a formal review and approval process over monthly CACFP requests for reimbursement. Prior to submission, the Grant Manager, who is independent of the preparation process, will review the monthly request for reimbursement and supporting documentation, including payroll and nonpayroll costs allocated to the CACFP to verify that costs are appropriately allocated to the program and are allowable under the applicable federal requirements. Evidence of the review and approval will be documented and retained with the monthly reimbursement documentation. Anticipated Completion Date: September 2026 Personnel Responsible for Corrective Action: Alison Elder, CFO
Significant Deficiency Finding No. 2025-004: Reporting Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2024-004) and current year renumbered recommendation (2025-004), acknowledging that the unexpected resignation of the former independent...
Significant Deficiency Finding No. 2025-004: Reporting Views of Responsible Officials and Planned Corrective Action The Organization concurred with the prior year (2024-004) and current year renumbered recommendation (2025-004), acknowledging that the unexpected resignation of the former independent auditor (January 2023), and the domino effect of a delay in securing a new independent auditor (April 2023) and completion of single audits continued to challenge the Organization through the fiscal year ended June 30, 2025. The Organization notes the following: A. Status and Progress of Single Audits 1. Single Audit as of fiscal year ended (FYE) June 30, 2022, filed in the Federal Audit Clearinghouse (FAC) on February 20, 2025. 2. Single Audit as of FYE June 30, 2023, filed in the FAC on March 9, 2026. 3. Single Audit as of FYE June 30, 2024, filed in the FAC on June 20, 2026. 4. Single Audit as of FYE June 30, 2025, projected for filing in the FAC no later than September 30, 2026. Note: Once the FYE June 30, 2025, single audit is filed, the Organization will no longer be delinquent in filing its single audit in the FAC. 5. Single Audit as of FYE June 30, 2026, engagement letter signed with scheduled field work to commence after the June 30, 2025, FAC filing (e.g., November 2026); with a projected on-time FAC filing no later than March 31, 2027, in compliance with 2 CFR §200.514 – Standards and scope of audit; and 2 CFR §200.512 – Report submission via Form SF-SAC: Data Collection Form, nine months after year end of the audit period. B. Policy, Process and Communications re: Single Audits, the Organization implemented the following policy, process and communications practices: 1. Financial Policies: Internal Control Environment Policy, Implementation of Significant Accounting Policies. 2. Process: Review and Approve Audit Report, including Financial Statements. 3. Communication of the status of the single audit(s) via Memo to the Board occurred in February, March, May, June and August 2026; and as a continuing practice will be completed for each Board meeting.Finding No. 2025-004: Reporting Contact Person(s) Responsible for Corrective Action: Sheri Daniels, Ed.D., Chief Executive Officer, Marisa Wilson, Director of Administrative Operations and Sylvia Hussey, Ed.D., Chief of Staff.
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility - E Recommendation: We recommend that the Commission review its process for collecting third party income support to ensure that accurate data is used as part of the rent and HAP calculation. Explanation of disagreement with audit find...
Housing Voucher Cluster – FALN No. 14.871 & 14.879 – Eligibility - E Recommendation: We recommend that the Commission review its process for collecting third party income support to ensure that accurate data is used as part of the rent and HAP calculation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: HCHC staff attended a NAHRO training that provided an in-depth review of programmatic changes. In the training the HUD hierarchy of collecting documents was reviewed while also referencing the Commission’s Administrative Plan. The voucher team meets at least monthly to discuss HCVP issues, tools, and solutions that both meet the needs of the participants and comply with HUD regulations. Name(s) of the contact person(s) responsible for corrective action: Crystal Gorham, Director of Rental Assistance Planned completion date for corrective action plan: September 2026.
Corrective Action Plan: Finding 2025 – 004 corrective action is addressed in the corrective action plan for Finding 2025 – 003 as the questioned costs in 2025 – 004 relate to that finding. Management has transitioned reporting and compliance responsibilities to the Grant Manager and implemented over...
Corrective Action Plan: Finding 2025 – 004 corrective action is addressed in the corrective action plan for Finding 2025 – 003 as the questioned costs in 2025 – 004 relate to that finding. Management has transitioned reporting and compliance responsibilities to the Grant Manager and implemented oversight procedures performed by the Chief Operating Officer to ensure required reporting is completed accurately and submitted timely. Responsible Party: Michael Galea, Grant Manager Karen Johnson, Chief Operating Officer Melinda Asbury, Chief Executive Officer
Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review, it was determined that the configuration of the Sliding Fee Discount Program within our Practice Management System had been set up ...
Recommendation The Center should establish a system of internal controls to ensure that all patients receive the correct sliding fee discount. Action Taken Upon review, it was determined that the configuration of the Sliding Fee Discount Program within our Practice Management System had been set up incorrectly. Specifically, the "Slide After Insurance Method" setting was configured as CHGAMT rather than BALANCE. The Sliding Fee Maintenance settings were corrected in the system on May 27, 2026, to ensure the Sliding Fee Discount Program is applied appropriately following insurance adjudication. In addition, ConnextCare conducted a comprehensive audit of all 2026 dates of service for patients actively enrolled in the Sliding Fee Discount Program. No additional occurrences of this issue were identified. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Tracy Wimmer, CFO at (315) 264-0991. Sincerely yours, Tracy Wimmer Sr. VP/Chief Financial Officer
Internal Control over Compliance- Subrecipient Monitoring Recommendation: We recommend all expenses incurred by subrecipients are reviewed and approved prior to reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Response by management to t...
Internal Control over Compliance- Subrecipient Monitoring Recommendation: We recommend all expenses incurred by subrecipients are reviewed and approved prior to reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Response by management to the finding: We acknowledge that prior to the completion of our January 1, 2024 – December 31, 2024 audit CASA relied on summary level expense reports from subrecipients under the PCCD grant and did not consistently verify underlying invoices. More detail regarding process in place at the time of FY2024 audit can be found in the corrective action plan for that year. Due to the timing of the FY2024 audits completion having been finalized in December 2025 procedural changes to address the concerns were not consistently implemented until the end of FY2025. As a result, the actions put in place in the prior year corrective action plan were not reflected in our FY2025 procedure. Actions taken prior to and since the issuance of the FY2024 audit include engagement of a new contracted accounting firm with a wider breadth of experience and expertise; an internal restructuring of staff to provide increased opportunity for oversight and review of contracted financial services, a new review protocol of invoices requiring verification of supporting documentation, and documentation of management approval of invoices. Also of note, the PCCD grant in question required a lengthy budget modification process, which required additional oversight and review of allowable costs. The term of this funding ends 9/30/2026 and will not be extended or renewed. Name of the contact person responsible for corrective action: Leigh Anne McKelvey, Executive Director Planned completion date for corrective action plan: 9/30/26 If the U.S. Department of the Treasury has questions regarding this plan, please call Leigh Anne McKelvey, Executive Director, at 610-565-2208.
The Cooperative will make deposits to the general operating reserve to meet the HUD regulatory agreement. In September 2025, the Cooperative entered into a management agreement with Paramark Real Estate Services to manage the Cooperative. The management agent will implemement a process to ensure dep...
The Cooperative will make deposits to the general operating reserve to meet the HUD regulatory agreement. In September 2025, the Cooperative entered into a management agreement with Paramark Real Estate Services to manage the Cooperative. The management agent will implemement a process to ensure deposits are made as required by the regulatory agreement.
The Cooperative will obtain appropriate approvals for withdrawls exceeding 20% of the general operating reserve to meet the HUD regulatory agreement. In September 2025, the Cooperative entered into a management agreement with Paramark Real Estate Services to manage the Cooperative. The management ag...
The Cooperative will obtain appropriate approvals for withdrawls exceeding 20% of the general operating reserve to meet the HUD regulatory agreement. In September 2025, the Cooperative entered into a management agreement with Paramark Real Estate Services to manage the Cooperative. The management agent will implement a process to ensure approvals are obtained as required by the regulatory agreement.
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