Corrective Action Plans

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"Management concurs that formalizing contract management procedures will further strengthen organizational oversight. Since FY2025, Ability1st has made significant investments in improving grant administration and compliance management. These improvements include: • centralized grant files; • enhanc...
"Management concurs that formalizing contract management procedures will further strengthen organizational oversight. Since FY2025, Ability1st has made significant investments in improving grant administration and compliance management. These improvements include: • centralized grant files; • enhanced tracking of reporting deadlines and deliverables; • standardized internal monitoring tools; • expanded written policies and procedures; • improved coordination between program staff, accounting personnel, and executiveleadership; • implementation of CIL Suite to improve documentation, reporting, and participantrecord management; • strengthened Board financial reporting; and • ongoing collaboration with the Organization's accounting firm to ensure compliance with federal, state, and local funding requirements. Management recognizes that compliance is an evolving process and remains committed to continuously improving internal controls as funding requirements expand and organizational capacity grows. Responsible Official: Executive Director Implementation Date: Ongoing. Ability1st is committed to continuous improvement and recognizes that strong financial stewardship is essential to fulfilling our mission. Management believes the corrective actions already implemented significantly strengthen the Organization's internal control environment and position Ability1st for improved compliance, financial reporting, and audit readiness in future years."
"Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program inc...
"Management concurs that stronger documentation surrounding the collection and monitoring of Continuum of Care program income would have strengthened internal controls and the audit trail. The finding relates to a program that has since been discontinued. Throughout the audit period, all program income that was collected was used for allowable program purposes; however, management acknowledges that documentation supporting assessment, collection, monitoring, and reconciliation procedures should have been more comprehensive. Although this activity is no longer part of the Organization's operations, Ability1st has strengthened its overall documentation standards. Should the Organization administer future programs involving program income, written policies and procedures will be implemented prior to program implementation and will include: • documented fee assessment methodology; • collection and deposit procedures; • reconciliation requirements; • supervisory review; • record retention standards; and • periodic internal monitoring. Management believes these procedures will provide an appropriate level of accountability and compliance with federal requirements should program income be collected in the future. Responsible Official: Executive Director Implementation Date: Completed for discontinued program; procedures will be implemented before any future program income activity."
Juel Fairbanks Chemical Dependency Services has implemented a change in how we do our day-to-day process of approvals of payments, authorized signature for payments prior to being issued.
Juel Fairbanks Chemical Dependency Services has implemented a change in how we do our day-to-day process of approvals of payments, authorized signature for payments prior to being issued.
Management acknowledges the recommendation. Throughout the duration of this multi-year project, staff made repeated efforts to obtain quality assurance testing documentation from the applicable contractors and subcontractors. Despite multiple requests and follow-up attempts, we were not successful i...
Management acknowledges the recommendation. Throughout the duration of this multi-year project, staff made repeated efforts to obtain quality assurance testing documentation from the applicable contractors and subcontractors. Despite multiple requests and follow-up attempts, we were not successful in securing the required documentation. We will evaluate and strengthen our procedures going forward to improve contractor compliance and ensure that quality assurance testing records are consistently obtained, reviewed, and retained in accordance with applicable requirements
During FY24 A+ Arts Academy was under a management company arrangement. The management company negotiated and recommended the contract for construction services that prevailing wages were not paid. As of 7/1/25, A+ Arts is self-managed and any future construction contracts will be negotiated by A+ A...
During FY24 A+ Arts Academy was under a management company arrangement. The management company negotiated and recommended the contract for construction services that prevailing wages were not paid. As of 7/1/25, A+ Arts is self-managed and any future construction contracts will be negotiated by A+ Arts administration and presented to the Board for approval. Prior to entering into any contract, a determination will be made if prevailing wages should be paid. Additionally, the fact the construction contract was paid for with Federal dollars is unusual and only happened to do ESSER dollars. it is unlikely that any contracts in the future will be paid for using Federal dollars.
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: This was the first and o...
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: This was the first and only grant Housing Hope has administered that required subrecipient monitoring. The grant has since ended and the organization does not anticipate entering any future agreements that would require subrecipient monitoring. To ensure compliance should such an agreement arise again, Housing Hope adopted a Subrecipient Monitoring Policy. This policy outlines the criteria for identifying subrecipient relationships and establish a standardized process for monitoring subrecipients, if any are engaged in the future. Anticipated completion date: The Subrecipient Monitoring Policy was adopted October 2025 by the Board.
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, ...
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, the Payroll Specialist began saving physically signed timesheets that document allocations to grants. Beginning August 1, 2025, allocations to grants are captured within the payroll system, ADP, along with the supervisor approval. The Payroll Specialist verifies each line on the timesheet is approved, which the system requires for the employee to receive payment. Anticipated completion date: Corrective action of signed allocation timesheets was implemented July 1, 2025. Corrective action of allocations to grants within ADP was implemented August 1, 2025.
U.S. Department of Housing and Urban Development Community Development Block Grant – Assistance Listing No. 14.218 Recommendation: We recommend the City implement policies and procedures to ensure that the Federal Funding Accountability and Transparency Act (FFATA) reporting occurs for all subawards...
U.S. Department of Housing and Urban Development Community Development Block Grant – Assistance Listing No. 14.218 Recommendation: We recommend the City implement policies and procedures to ensure that the Federal Funding Accountability and Transparency Act (FFATA) reporting occurs for all subawards of $30,000 or more for all federal awards and that the reporting be performed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: The Finance Department will ensure that all departments are aware of this compliance requirement and ensure reporting requirements are performed timely in relation to subawards. Name(s) of the contact person(s) responsible for corrective action: Rebecca Campbell, Finance Director Planned completion date for corrective action plan: July 2026
Action Taken: The Organization has re-evaluated its internal controls related to grant budgeting with Federal agencies and cost billing expectations. The updated controls will be implemented in the next fiscal year.
Action Taken: The Organization has re-evaluated its internal controls related to grant budgeting with Federal agencies and cost billing expectations. The updated controls will be implemented in the next fiscal year.
We created a procedure and ensured the appropriate staff members know their responsibilities in filing time and effort documentation
We created a procedure and ensured the appropriate staff members know their responsibilities in filing time and effort documentation
2024-004 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding:...
2024-004 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA111008 and 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: ICWDO acknowledges the recommendation and is actively working on a remedy and on the development of formal policies as recommended, which will assist ICWDO’s fiscal team in ensuring that all reports are appropriately reconciled. ICWDO acknowledges the recommendations from finding 2021-010 related to a formalization of the Administrative/fiscal processes and protocols to ensure that procedures are consistently followed to guarantee that reports agree to the amounts recorded in the general ledger and SEFA. Additionally, the recommendation specifics that protocols to ensure the separation of duties are featured in the policy. ICWDO operates under WIOA guidelines and follows County fiscal/administrative policies. Internal policies that include formal controls and procedures to ensure that monthly reports and general ledgers are consistent, with clear segregation of duties will be formally adopted. Aspects of these policies will include: • Protocol for preparation of monthly reports by the fiscal manager, and approval and signature by ICWDO Director • Protocol for preparation of closeouts that will provide the hierarchy of development, review, and approval for future reference. • Schedule monthly closeout meetings with the fiscal department and administration to ensure that documents are reviewed separately, and issues are addressed promptly. • Protocol for Policy Committee review, comment and direction, and approval for implementation by vote of the full workforce development board. ICWDO anticipates to implement the corrective action by December 31, 2025. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2025
2024-003 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Ty...
2024-003 Program: WIOA Cluster Federal Financial Assistance Listing Number: 17.258, 17.259, 17.277, 17.278 Federal Grantor: U.S. Department of Labor Pass-Through: California Department of Employment Development Award No. and Year: AA011008 and 2019 Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness Management’s or Department’s Response: Imperial County Workforce Development Office (ICWDO) agrees with the finding. Views of Responsible Officials and Corrective Action Plan: The questions from finding 2021-008 relate to a formalization of the fiscal processes and protocols. ICWDO operates under WIOA guidelines and follows Imperial County’s fiscal policies. Internal policy will be formally updated to reflect compliance with WIOA regulations, as well as Imperial County policies. These policies will include formal controls and procedures to evaluate each subrecipient’s risk of noncompliance. Once the formal procedure is drafted, it will go through the ICWDO Policy Committee for comment and direction, and then finally reviewed and approved for implementation by the full Workforce Development Board. Additionally, for any future Memorandums of Understanding (MOUs) between this Imperial County department and any outside agency, there will be an additional step to include review by Imperial County Counsel to reflect that recital around the funding source will specify the following required information: • Federal Award Identification Number • Federal award date of award to recipient by the Federal agency • Name of Federal awarding agency • CFDA Number • Specific identification of whether the award is research and development ICWDO will develop internal policies for formalizing all subrecipient monitoring process. ICWDO operates under WIOA guidelines for monitoring; therefore a formal internal policy for future contracts will be developed and implemented using the usual review and approval procedures followed by the department. ICWDO will develop a formal internal documentation system, with appropriate checks and signatures, for the evaluation and assessment of each subrecipient’s risk of noncompliance. ICWDO will utilize this formal process to properly document the risk assessment of all subrecipients. ICWDO anticipates to implement the corrective action by December 31, 2025. Name of Responsible Person: Priscilla A Lopez, ICWDB Director Implementation Date: December 31, 2025
The foundation is working on completing audits for FY21. The OSA included foundation audits for FY22, FY23, and now FY24. At the conclusion of the FY21 foundation audit, the foundation and Mesalands will meet with the OSA to determine next steps. The foundation and the college will work to reconcile...
The foundation is working on completing audits for FY21. The OSA included foundation audits for FY22, FY23, and now FY24. At the conclusion of the FY21 foundation audit, the foundation and Mesalands will meet with the OSA to determine next steps. The foundation and the college will work to reconcile the balance of this endowment and get the correct amount recorded. Responsible staff: Director of Finance and MCC Foundation Coordinator. Expected date of compliance: June 30, 2026.
On completion of audits the college has made significant progress in reporting for the Federal Department of Education. The timeline of late submissions has grown shorter over the last 2 audits. Responsible staff: President and Director of Finance. Expected date of compliance: FY25 information due i...
On completion of audits the college has made significant progress in reporting for the Federal Department of Education. The timeline of late submissions has grown shorter over the last 2 audits. Responsible staff: President and Director of Finance. Expected date of compliance: FY25 information due in March, 2026 is expected to be on time.
Concur: · 8 instances where the Government was unable to obtain Quarterly Progress Reports. As a result of the audit finding and in accordance with grant requirement, a Governor's Authorized Representative (GAR) Memo is being implemented, requiring Subrecipients to submit Quarterly Progress Reports ...
Concur: · 8 instances where the Government was unable to obtain Quarterly Progress Reports. As a result of the audit finding and in accordance with grant requirement, a Governor's Authorized Representative (GAR) Memo is being implemented, requiring Subrecipients to submit Quarterly Progress Reports within 10 days of quarter end. All reports are reviewed and retained in a centralized location for documentation and audit compliance. · 8 instances where the Government was unable to obtain completion/inspection certificate. Project inspection/certification report(s) are now required for all payment request federal fund drawdowns. The reports must now be uploaded to the Enterprise Resource Planning System (ERP) and retained in centralized location for documentation and record keeping purposes. · 8 subrecipients with no supporting documentation that VITEMA verified that subrecipients expected to be audited as required by 2 CFR part 200, subpart F. The Program will annually notify subrecipients of their audit responsibilities, monitor compliance, obtain required audit reports, and maintain documentation in a centralized location for audit and recordkeeping purposes.
The Program agrees and has established internal controls to ensure that all Federal Funding Accountability and Transparency Act (FFATA) subaward reports exceeding 30,000 are submitted timely and reviewed by the Territorial Public Assistance Officer. Although the SAM.GOV system implemented in FY 2024...
The Program agrees and has established internal controls to ensure that all Federal Funding Accountability and Transparency Act (FFATA) subaward reports exceeding 30,000 are submitted timely and reviewed by the Territorial Public Assistance Officer. Although the SAM.GOV system implemented in FY 2024 does not track individual FFATA filing dates, VITEMA remains committed to submitting all required reports by the last day of the month following each award. A certification process has also been implemented to verify the date reports are filed and reviewed.
To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centraliz...
To address these challenges and strengthen program integrity, DHS implemented the Provider Enrollment Application (PEA) Portal on March 2, 2026. The PEA Portal modernizes provider enrollment and revalidation by electronically collecting, storing, and maintaining required documentation in a centralized system. The portal supports retention of Medicaid Provider Agreements, screening documentation, ownership disclosures, licensure information, and other enrollment records within a single electronic repository. The PEA Portal improves document retention and accessibility, creates an electronic audit trail, and enables staff to retrieve enrollment and screening records more efficiently. It also strengthens oversight by standardizing enrollment workflows, reducing reliance on paper files, and improving documentation consistency. These enhancements better position DHS to demonstrate compliance during future audits and monitoring reviews. DHS recognizes the importance of maintaining complete, accurate, and accessible provider enrollment records. In addition to implementing the PEA Portal, DHS is strengthening policies and procedures related to provider file maintenance, document retention, and quality assurance reviews. Staff training and periodic monitoring will help ensure required enrollment documents and exclusion screening records are consistently maintained and available for inspection. DHS is committed to maintaining compliance with federal Medicaid and CHIP provider enrollment requirements and believes the corrective actions implemented, including deployment of the PEA Portal, will improve documentation controls, strengthen program integrity, and reduce the risk of similar findings in the future.
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To add...
During the audit period, the Department did not complete the required ADP Risk Analysis and System Security Review for systems supporting the Medicaid Program, and certain monitoring controls were not operating at a sufficient level of precision to ensure compliance with federal requirements. To address this finding, the Department recently issued Requests for Qualifications (RFQs) to seven qualified vendors to perform comprehensive security risk assessments of the Medicaid Enterprise Systems (MES), including the VIBES Eligibility and Enrollment System, Provider Enrollment Application (PEA), Pharmacy Benefit Management (PBM) solution, and related supporting systems. Vendor responses are due within three weeks, after which the Department will evaluate submissions and proceed with the procurement process. The selected vendor will conduct the required risk assessments, identify control deficiencies and security vulnerabilities, and provide recommendations to strengthen the Department's security posture and compliance framework. The Department will work collaboratively with its technology partners, system vendors, and oversight entities to implement corrective actions identified through the assessments and enhance monitoring controls to ensure ongoing compliance with applicable federal requirements.
Currently, reports are submitted for review via email. The CMS-64 as well as the CMS-37 is prepared by a consulting firm who submits the copy of the reports for review and approval. Once the Medicaid Director is satisfied, an email is sent approving the report, for further entering into the MBES (CM...
Currently, reports are submitted for review via email. The CMS-64 as well as the CMS-37 is prepared by a consulting firm who submits the copy of the reports for review and approval. Once the Medicaid Director is satisfied, an email is sent approving the report, for further entering into the MBES (CMS system of record) and certification. To ensure access for audit purposes, the Department has implemented a shared folder where copies of approval emails and any time extension requests are stored, since the submission portal does not allow for attachments. Additionally, a Director of Federal Grants has been on-boarded who will assume the role of preparing the reports.
The exceptions identified were limited in nature and did not result in questioned costs. In the instance where the project code on the employee's Notice of Personnel Action (NOPA) had not been updated, program personnel made the necessary adjustments to ensure payroll costs were charged to the appro...
The exceptions identified were limited in nature and did not result in questioned costs. In the instance where the project code on the employee's Notice of Personnel Action (NOPA) had not been updated, program personnel made the necessary adjustments to ensure payroll costs were charged to the appropriate grant. To strengthen internal controls, the Department transitioned from manual timekeeping to a biometric finger-punch time and attendance system utilizing TimeForce in the fall of 2024. This system provides enhanced tracking, reporting, and record retention capabilities and reduces the risk of discrepancies associated with manual timekeeping processes. The Department will continue to strengthen its review and documentation procedures to ensure compliance with federal requirements. The Department of Human Services (DHS) adopted the electronic Timeforce (STATS) system for payroll, replacing manual processes. Time and attendance are approved through management levels, with payroll based on Notice of Personnel Action (NOPA) cost centers. Financial Analysts now assigned to the grant reconciles the payroll. Additionally, in order to ensure that Notices of Personnel Actions are updated on a timely basis, ensuring that salaries are charged to the respective account, DHS has implemented the following process: - Provisional Payroll Codes are requested prior to the close of the Fiscal Year by the Department of Finance through the Office of Management and Budget through the established process. - Once the codes are received, the Division of Human Resources will update the most current Personnel Distribution Sheets to reflect active employees. - The sheets will be submitted to Fiscal for certification by the CFO. - NOPA’s are updated with the provisional codes.
Once payroll is processed by the Department of Finance (DOF), a Flex Earnings Report is generated by the Analyst on each payday. A reconciliation is then performed to ensure that all employees, along with their respective fringe benefits, are accurately captured and drawn. Following this process, DO...
Once payroll is processed by the Department of Finance (DOF), a Flex Earnings Report is generated by the Analyst on each payday. A reconciliation is then performed to ensure that all employees, along with their respective fringe benefits, are accurately captured and drawn. Following this process, DOF posts the payroll to the accounting system. However, staffing has identified that deficiencies can occur in DOF’s postings, sometimes arising in periods subsequent to the actual payday. To address this, the Department of Human Services (DHS) has incorporated an internal control requiring retrospective reconciliation of accounts against the Flex Earnings Report to verify accuracy. Additionally, DHS plans to engage with DOF to better understand the underlying factors and nuances that result in discrepancies between DOF postings and the account coding reflected in the Flex Earnings Report. The Federal Grants Financial Analyst also plays a key role in ensuring that transactions are recorded in the appropriate accounting period and that costs are properly allocated. In this particular instance, no federal funds were drawn.
The Government concurs with the auditor’s findings and recommendations. Management will review current procedures to strengthen monitoring and documentation of provider eligibility for ARP Act stabilization funds. DHS is committed to improving internal controls and ensuring compliance with all progr...
The Government concurs with the auditor’s findings and recommendations. Management will review current procedures to strengthen monitoring and documentation of provider eligibility for ARP Act stabilization funds. DHS is committed to improving internal controls and ensuring compliance with all program requirements. An internal programmatic audit process is actively utilized. Subsidy determinations are cross-checked by different workers according to federally and locally established policies. Additionally, DHS is in the process of developing an internal audit and compliance unit. With the requisite staffing, internal audits will be conducted to ensure alignment with the Federal mandates in addition to ensuring overall compliance.
Internal audits will be conducted quarterly by having OCCRS subsidy staff and Administrators review files for accuracy of eligibility and subsidy determinations. Quality staff will conduct at least 2 unannounced visits per child care facility to monitor attendance. DHS will implement a centralized, ...
Internal audits will be conducted quarterly by having OCCRS subsidy staff and Administrators review files for accuracy of eligibility and subsidy determinations. Quality staff will conduct at least 2 unannounced visits per child care facility to monitor attendance. DHS will implement a centralized, secure tracking matrix. This log will track all fraud referrals, audit start/end dates, findings, total funds identified for recovery, amounts recovered to date, and case closure signatures.
DHS has onboarded additional licensing staff which has built increased capacity to conduct provider visits for the purpose of assessing compliance with health and safety requirements. Efforts to recruit additional staff continue. A visual tracker of provider visits will be utilized to ensure visits ...
DHS has onboarded additional licensing staff which has built increased capacity to conduct provider visits for the purpose of assessing compliance with health and safety requirements. Efforts to recruit additional staff continue. A visual tracker of provider visits will be utilized to ensure visits are conducted across all providers.
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports. Additionally, a Director of Federal Grants has been added to oversee the reporting process. Internal controls have been established, requiring final review...
A Federal Grants Financial Analyst for CCDF program has been hired and is tasked with ensuring the accuracy and submission of financial reports. Additionally, a Director of Federal Grants has been added to oversee the reporting process. Internal controls have been established, requiring final review and approval by the supervisor with final approval by the CFO or designee. Additionally, an Audit and Compliance unit has been established. Once staffed, regular monitoring will occur within the various divisions.
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