Corrective Action Plans

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Finding 576245 (2024-004)
Significant Deficiency 2024
Auditor's Recommendation: Strengthen policies and procedures to ensure proper documentation retention for review and approval of all Programmatic Reports prior to grantor submission. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the ...
Auditor's Recommendation: Strengthen policies and procedures to ensure proper documentation retention for review and approval of all Programmatic Reports prior to grantor submission. Management Response: While ODI does not disagree with the audit finding, the Agency does clarify the context of the finding. ODI has a process for monitoring activities under Federal awards: Program Managers and Directors are responsible for monitoring activities under Federal awards, with the support of the Agency’s Compliance Specialist. The Agency tracks comparisons of program accomplishments to program objectives and reports these data to grantors as required and, where necessary, communicates significant development to the Federal agency and/or pass-through entity. Corrective Action: Establish comprehensive guidelines to retain documentation of quality control and review for programmatic reports through electronic approvals via email and/or approved tracked changes or review notes within software platforms demonstrating review and approval. Responsible Personnel: Jessie Mabry, CEO; Jeremy Huynh, Compliance Specialist Implementation Date: Immediate implementation to assess tracking methods for Federal programmatic reports, and to develop written guidelines for documenting programmatic report quality control.
Apprenti agrees with the finding and acknowledges the importance of maintaining a full audit trail for all disbursement approvals. Apprenti adhered to its internal controls over compliance with allowable costs in accordance with 2 CFR Part 200 for all nonpayroll expenditures and had no findings in p...
Apprenti agrees with the finding and acknowledges the importance of maintaining a full audit trail for all disbursement approvals. Apprenti adhered to its internal controls over compliance with allowable costs in accordance with 2 CFR Part 200 for all nonpayroll expenditures and had no findings in prior Single Audits. However, due to a financial system migration, the audit trail documenting approval workflows for certain transactions was lost and could not be recovered or reconstructed. To prevent similar issues in the future and reinforce compliance, Apprenti has implemented the following corrective action: System Audit Trail Safeguards: Post‐migration, Apprenti implemented robust data retention protocols across both primary and backup financial systems to ensure that all approval workflows are securely preserved and transferable in the event of future system changes or migrations.
The Project acknowledges the finding regarding the interproject payable. Management has developed the following corrective action plan: Repayment of Payable - The outstanding payable balance ot the related HUD project will be repaid in full by September 30, 2025. Documentation of repayment will be ...
The Project acknowledges the finding regarding the interproject payable. Management has developed the following corrective action plan: Repayment of Payable - The outstanding payable balance ot the related HUD project will be repaid in full by September 30, 2025. Documentation of repayment will be maintained and made available for audit verification. Elimination of Interproject Borrowing - Effective immediately, the Project has ceased the practice of borrowing funds from other HUD-assisted projects. Future interproject transactions will not be initiated unless expressly authorized by HUD. Polidy Development and Implementation - The Project will adopt a written policy governing cash management and interproject transactions by September 30, 2025. The policy will prohibit interproject loans without HUD approval and establish procedures for timely monitoring of accounts payable. Training and Oversight - Project staff responsible for financial reporting will receive training on HUD requirements and Uniform Guidance within 120 days. In addition, management will review monthly financial reports to ensure no interproject balances exist.
View Audit 366023 Questioned Costs: $1
Finding 576102 (2024-002)
Significant Deficiency 2024
2024-002 FINDING Contact Person – Scott Peters, Auditor/Treasurer Corrective Action Plan – Will review procedures over timecard approval. Completion Date – September 30, 2025
2024-002 FINDING Contact Person – Scott Peters, Auditor/Treasurer Corrective Action Plan – Will review procedures over timecard approval. Completion Date – September 30, 2025
Finding 576082 (2024-004)
Significant Deficiency 2024
DOCUMENTATION OF SUSPENSION AND DEBARMENT Recommendation: It is recommended the County retain documentation related to the applicable federal requirements to ensure compliance with said federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit find...
DOCUMENTATION OF SUSPENSION AND DEBARMENT Recommendation: It is recommended the County retain documentation related to the applicable federal requirements to ensure compliance with said federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will retain documentation related to applicable federal requirements. Name of the contact person responsible for corrective action plan: Denise Snyder, Auditor-Treasurer Planned completion date for corrective action plan: December 31, 2025
Significant deficiency in internal controls over financial reporting of leases in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action ...
Significant deficiency in internal controls over financial reporting of leases in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: Review lease terms at inception of lease(s) and ensure accounted for correctly in the leasing software and general ledger; review all leases again at year end to ensure any changes to said leases were recorded properly. Anticipated Completion Date: End of 2025 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors
Significant deficiency in internal controls over financial reporting of net assets with and without donor restrictions in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following co...
Significant deficiency in internal controls over financial reporting of net assets with and without donor restrictions in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management Response: We acknowledge the finding and provide the following corrective action plan. Corrective Action Plan: PDA instituted a monthly review of foundation grant spending to ensure spending is in line with assumptions. By the completion of each fiscal year, PDA will have proper information gathered to release funds from restricted net assets accordingly. Anticipated Completion Date: Implemented in 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Barbara Donohue, Director of Finance Lisa Daugaard, Tara Moss, and Fe LopezGaetke Co-Executive Directors
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible C...
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director
2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents ...
2024-002 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over the demographic data and income verification information entered into the patient billing system in order to ensure that financial documents are retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on document retention policies in relation to the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review of current patient sliding fee applications to ensure all required documents are maintained and retained for the appropriate length of time as per PCHC Board of Director approved policies. Weekly audits verifying supporting documents for the sliding fee applications are conducted under the supervision of management, and improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025
2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification ...
2024-001 Health Center Program Cluster– Assistance Listing Nos. 93.224 and 93.527 Recommendation: PCHC should implement a second level independent review over demographic data and income verification information entered into the patient billing system in order to ensure the financial classification is correct. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Front desk receptionist and Enrollment staff were retrained on the sliding fee discount scale and the federal poverty level policy and procedure. Commencing in August 2025, PCHC implemented a weekly internal review process of prior period patient sliding fee applications and approved slide adjustment calculations. Weekly audits of patient applications are conducted under the supervision of management to ensure the financial classification is correct. Improvements will be reported quarterly at the Board of Directors Finance Committee meetings. Name(s) of the contact person(s) responsible for corrective action: Alfonso Aguilera, Chief Financial Officer Planned completion date for corrective action plan: 12/31/2025.
Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action YWCA of Northeast Kansas agrees with the finding. An addendum to the Grant Oversight Policy will require quarterly reviews of grant expenditures. The...
Contact person responsible for correction action – Linda Aziz, Chief Financial Officer Anticipated completion date – August 29, 2025 Corrective action YWCA of Northeast Kansas agrees with the finding. An addendum to the Grant Oversight Policy will require quarterly reviews of grant expenditures. The CFO will ensure expenditures are properly coded and reported in the correct period, in collaboration with accounting partners. Discrepancies will be promptly addressed.
View Audit 365889 Questioned Costs: $1
Finding 2024-001: Non-compliance with Special Tests and Provisions: Disbursements Condition For 3 of 25 students selected for testing, the disbursement dates did not agree between the student’s institutional account and the data reported to COD. Each student had disbursements that were later partial...
Finding 2024-001: Non-compliance with Special Tests and Provisions: Disbursements Condition For 3 of 25 students selected for testing, the disbursement dates did not agree between the student’s institutional account and the data reported to COD. Each student had disbursements that were later partially or fully refunded. The sample was not a statistically valid sample. Recommendation It is recommended that policies, procedures and effective controls are put in place to verify that the disbursement dates for federal funds are matching between the student account detail and the COD system. Corrective Action The Foundation will ensure that policies, procedures and effective controls are in place to verify the matching of the disbursement dates for federal funds between the student account detail and the COD system. Anticipated completion date of implementing the corrective action plan will be immediate.
View Audit 365871 Questioned Costs: $1
The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" t...
The Corporation contacted the local Continuum of Care and regional HUD office in an effort to verify the required number of units occupied by individuals meeting the definition of "homeless". The local Continuum of Care had no record of the original grant agreement or required number of "homeless" to be served. The Corporation contacted three staff in the regional HUD office, including the staff that had been our representative for annually renewed operation and support service grants for the two projects. Regional HUD staff were not able to provide a copy of the original grant agreements which would indicate the number of persons to be served by each project. HUD staff stated that they do not keep copies of grant agreements longer than seven years. Corporation management will continue to work with HUD personnel to determine the continuing compliance requirements of the Continuum of Care funding received for initial construction or rehabilitation. Corporation management will continue to serve individuals meeting the definition of homelessness at its two projects and document evidence in the file.
Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures mo...
Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has assigned an employee charged with ensuring monitored visits occur in compliance with 4337 of the Texas Department of Agriculture - Child and Adult Care Food Program - Child Care Centers Handbook. This employee ensures monitored visists occur and meals monitored do not include snacks. Monitored visits are based on the meal times with the greatest number of meals served at the centers. These were discovered before the audit and procedures were implemented to rectify these two instances before year-end. Twinkle Wonders Rice: This facility was formely called Kaleidoscope. Because of the change in management, the facility did not have a full program year to be monitored. This is where confusion emerged regarding amount of monitors and monitoring events needed versus what actually occured. Top Leaders: This facility was monitored three times during the year. Two of these monitors were PM snacks. There were monitored August 2024 and a follow-up was scheduled for September 2024. The facility must be given enough time to correct its recommendations. Because the issue was so close to the end fo the program year, there was not enough time to proceed with the follow-up and another monitoring of an additional meal. The facility's next monitoring event was a meal, but it was visited in the following program year.
Planned Corrective Action: Assistant Director to review and initial all Executive Director's timesheets. Planned Implementation Date of Corrective Action: July 2024 Person Responsible for Corrective Action: Annette Pettengill
Planned Corrective Action: Assistant Director to review and initial all Executive Director's timesheets. Planned Implementation Date of Corrective Action: July 2024 Person Responsible for Corrective Action: Annette Pettengill
Finding 575781 (2024-001)
Significant Deficiency 2024
The City Clerk-Treasurer will attempt to monitor transactions and structure the duties of the office personnel to ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints.
The City Clerk-Treasurer will attempt to monitor transactions and structure the duties of the office personnel to ensure as much segregation of duties as possible within the City's staffing limitations and funding constraints.
OAK STREET SENIOR APARTMENTS, INC. HUD PROJECT NO. 048-EE018 CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Oak Street Senior Apartments, Inc. respectfully submits the following corrective action plan for the year end December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave. Suite 1...
OAK STREET SENIOR APARTMENTS, INC. HUD PROJECT NO. 048-EE018 CORRECTIVE ACTION PLAN YEAR ENDED DECEMBER 31, 2024 Oak Street Senior Apartments, Inc. respectfully submits the following corrective action plan for the year end December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Ave. Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Corporation Contact Person: Elliott Broderick, Management Agent Representative The finding from the December 31, 2024 schedule of findings and questioned costs are discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding – Federal Award Findings and Questioned Costs Finding 2024-001: Considered a significant deficiency in internal control over financial reporting Recommendation: The Corporation should ensure that there are proper internal controls in place over financial reporting to ensure accurate and timely submission of financial transactions, including monthly replacement reserve deposits. Action to be Taken: The Management agent concurs with the facts of this finding and as properly funded the replacement reserve account in 2025.
View Audit 365715 Questioned Costs: $1
Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2024-05 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft a new CRM to track benefit limitation and mandatory documentation. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.
Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identif...
Finding 2024-04 Insufficient Documentation Supporting Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. As a result, three of the sixty transactions tested did not include sufficient documentation to support eligibility determinations, representing instances of noncompliance with the eligibility requirements under the federal program. Corrective Actions Taken or Planned: The Organization will transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. We will include mandatory eligibility fields and document upload requirements before service can be recorded. We will develop a standardized eligibility checklist to be completed for all new and returning participants. Staff will be trained on Pantry Soft usage, eligibility requirements and document retention stands.
View Audit 365678 Questioned Costs: $1
Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. ...
Corrective Action: Finding Reference Number: Finding No. 2024-001: Time and Effort reporting Corrective Action: In FY25, Pro Bono Resource Center of Maryland (PBRC) had specific time sheets as dictated by the federal grants for employees reducing the reliance on excel spreadsheets and allocations. Name of Contact Person: Amy M Smitherman, amy.smitherman@gmail.com, 646-240-3185 Projected Completion Date: 9/15/2025
View Audit 365647 Questioned Costs: $1
Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standa...
Federal Award Findings and Questioned Costs Finding 2024-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Section 8 Housing Choice Vouchers Program Assistance Listing Number: 14.871 Noncompliance – N. Special Tests and Provisions - Housing Quality Standards Non Compliance Material to the Financial Statements: No Significant Deficiency in Internal Control over Compliance for Special Tests and Provisions Criteria: Housing Quality Standards Inspections. The PHA must inspect the unit leased to a family at least biennially to determine if the unit meets the Housing Quality Standards (HQS) and the PHA must conduct quality control re-inspections. The PHA must prepare a unit inspection report (24 CFR sections 982.158(d) and 982.405(b)). For units that fail inspection the PHA must correct all life threatening HQS deficiencies within 24 hours and all other deficiencies within 30 days. Condition: Based upon inspection of the Authority’s files and on discussion with management, there was a failed inspection that did not pass reinspection within 30 days without penalty. Context: There were approximately six hundred ninety four (694) failed inspections during the audit period. Of a sample size of twenty-five (25) failed inspections, one (1) unit did not pass reinspection within 30 days. HAP was not abated nor was the tenant transferred. Known Questioned Costs: $5,322 Our sample size is statistically valid. Cause: There is a significant deficiency in internal controls over the compliance for the special tests and provisions type of compliance related to HQS inspections. Effect: The Section 8 Housing Choice Vouchers Program is in non-compliance with the special tests and provisions type of compliance related to HQS inspections. Recommendation: We recommend the Authority design and implement a corrective action plan that will assure compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor and will make the necessary changes to its inspection process to ensure enforcement of Housing Quality Standards (or any subsequent replacement). Sanford Riggs, Director of Operations, is responsible for implementing this corrective action by December 31, 2025
View Audit 365643 Questioned Costs: $1
Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key exec...
Finding 2024.003 – Cash Management Recommendation The Center should develop written procedures to review all drawdowns that occur to ensure accuracy. Not a repeat finding. Action Taken Since September 2023, the Center has implemented weekly grants management reviews with the grants team and key executives. Action items are tracked through meeting agendas, minutes, and NMH’s project management platform, Monday.com. Meetings include invoice approvals for grant-funded expenditures, and review of allocations, payroll dates, and stipends for drawing down calculations. The meetings going forward will document the amounts for federal grants drawdowns and will be logged within Monday.com and through an external verification spreadsheet. Starting May 2025, an updated verification spreadsheet along with an itemized attestation was implemented.
Bank Depository Agreements Recommendation: Obtain depository agreements for all bank accounts as required by HUD. Response/Action Taken: we are working directly with our banking institutions to ensure that all accounts holding HUD funds have the required depository agreements. As of August 2025, ...
Bank Depository Agreements Recommendation: Obtain depository agreements for all bank accounts as required by HUD. Response/Action Taken: we are working directly with our banking institutions to ensure that all accounts holding HUD funds have the required depository agreements. As of August 2025, two of the three existing accounts have updated agreements, and the final agreement is currently under legal review and anticipated for completion by the end of Q3 2024. Context from Prior Audit Findings (FY23) The 2023 audit included findings related to documentaion gaps in areas such as Reasonable Rent, Utility Allowance Schedules, Waiting List procedures, and Housing Quality Standards enforcement. HALC took corrective actions in 2024 to address each of these deficiencies. The recurring nature of some 2024 findings indicates an ongoing effort to build stronger internal controls, rather than unresolved issues form the prior year. If the U.S. Department of Housing and Urban Development has questions regardin this plan, please contact Karen Rockwell at 541-265-5326.
Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required ...
Tenant Filing Documentation Processes Recommendation: Implement processes to ensure that all required documentation is properly maintained for every tenant. Response/Action Taken: HALC has standardized the documentation process through updated SOPs and training modules. All staff are now required to follow a uniform documentation checklist during intake and recertification. Additionally, file reviews are conducted quarterly by supervisors to ensure compliance and identify any gaps in documentation.
HUD-50058 Listing Review Process Recommendation: Implement a higher-level review of the HUD-50058 forms submitted to the PIC system. Response/Action Taken: To enhance quality control and data integrity, HALC has introduced a supervisory review of HUD-50058 forms before submission to PIC. A new sec...
HUD-50058 Listing Review Process Recommendation: Implement a higher-level review of the HUD-50058 forms submitted to the PIC system. Response/Action Taken: To enhance quality control and data integrity, HALC has introduced a supervisory review of HUD-50058 forms before submission to PIC. A new second-level review process was developed in Q2 2025, and designated staff now review the forms for accuracy and completeness weekly. We are also coodinationg periodic refresher trainings for housing specialists to stay aligned with HUD requirements.
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