Corrective Action Plans

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FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: David M. Kennard Contact Phone Number and Email Address: 812-677-3959 clerk@princetoncity.com Views of Responsible Officials: We...
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: David M. Kennard Contact Phone Number and Email Address: 812-677-3959 clerk@princetoncity.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will follow the City’s procurement policy. Management will verify that vendors are not excluded or disqualified by checking the System for Awards Management website, collecting a certification from the vendor, or adding a clause or condition to the contract signed by the vendor. Documentation of the verification will be retained in the City’s records. Anticipated Completion Date: The corrective action plan will go into effect immediately.
Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Correcti...
Corrective Action Plan – Federal Funds Review and Processing Audit Finding Reference: Response to Finding 2024-002: Improvement Control Over Period of Performance for Federal Awards Name of Contact Person and Completion Date: Krystal De Gray, COO of Nashua School District 09-22-2025 Planned Corrective Action: The Nashua School District acknowledges the finding related to the control over the period of performance for federal awards (Finding 2024-002). In response, the district will develop and implement a formal internal procedure to ensure that all purchases funded by federal awards are both placed and received within the established period of performance. This procedure will include appropriate review, documentation, and oversight to maintain compliance with federal grant regulations. To further strengthen internal controls, the Nashua School District will implement a procedure limiting purchases to occur no later than 15 days prior to the grant’s end date. Additionally, all necessary services must be received and completed prior to the expiration of the grant period. Mario Andrade Krystal De Gray Superintendent Chief Operating Officer
View Audit 370436 Questioned Costs: $1
Management will implement a process to ensure all required reports are submitted as required in a timely manner.
Management will implement a process to ensure all required reports are submitted as required in a timely manner.
All subrecipient risk assessments will be assigned a level of risk and review process will be documented with any audit findings investigated. All expenditures submitted for reimbursement will be reviewed for compliance and approved.
All subrecipient risk assessments will be assigned a level of risk and review process will be documented with any audit findings investigated. All expenditures submitted for reimbursement will be reviewed for compliance and approved.
SHN will ensure that all Federal Awards are carefully reviewed to confirm that the Federal Assistance Listing Number is accurately stated, the pass-through entity identifying numbers are correct, and are included in the correct Cluster.
SHN will ensure that all Federal Awards are carefully reviewed to confirm that the Federal Assistance Listing Number is accurately stated, the pass-through entity identifying numbers are correct, and are included in the correct Cluster.
The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.
The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.
The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.
The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.
2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.
2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.
View Audit 370339 Questioned Costs: $1
2024-002 The City did not submit the required Program Reports for all four quarters of 2024. Stephen Fricker, Director of Finance December 31, 2025 The City will implement additional control procedures to ensure all reports are filed in a timely manner.
2024-002 The City did not submit the required Program Reports for all four quarters of 2024. Stephen Fricker, Director of Finance December 31, 2025 The City will implement additional control procedures to ensure all reports are filed in a timely manner.
Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creati...
Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that inc...
To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign-off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.
Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monit...
Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monitoring plan for all identified subrecipients, ensuring that required monitoring activities (including review of reports and Single Audits, where applicable) are performed and documented throughout the period of performance.  Ensure the SEFA accurately reflects subrecipient relationships and amounts passed through.  This monitoring plan has already been implemented.
The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers ...
The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers using the new due-to due-from procedures. In addition, our staff is currently researching a variety of software programs in order to strengthen our in-house grant management procedures to maintain full compliance. The Town will also consider hiring additional personnel and/or soliciting the services of a professional grant manager to further assist with future grant opportunities, particularly those involving grant funds.
Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Feder...
Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Federal Financial Report was not submitted timely and required performance reporting was not completed during the year. Questioned Costs - N/A Context - The Federal Financial Report for the reporting period end September 29, 2024 was due December 28, 2024, however, this was not submitted until February 25, 2025. Additionally, two (2) performance reports were due during the year, however, neither were completed. The first was for the period September 30, 2023 - March 31, 2024 and was due April 30, 2024, and the second was for the period April 1, 2024 - September 30, 2024 and was due October 30, 2024. Effect - The Company did not comply with federal reporting requirements. Cause - Management turnover caused uncertainty in assigned responsibilities, including this reporting requirement. Identification as a Repeat Finding - N/A Recommendation - The Company should review reporting requirements in grant award documents for all federal awards to ensure compliance. Client Planned Action: Benson Hospital agrees to the finding. The issue was identified in February of 2025 and the required reporting was completed and submitted. Going forward we have established a protocol by which reports for such Congressional Funding shall be submitted timely. Client Responsible Party: Mark Nellis, CFO; (520) 586-1873 Completion Date: February 22, 2025
Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assess...
Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.
View Audit 370226 Questioned Costs: $1
Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.
Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.
Finding 1159572 (2024-002)
Material Weakness 2024
Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.
Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.
Management will amend each subaward agreement to include all required identifying award information, including the allocation of state and federal funds to the award.
Management will amend each subaward agreement to include all required identifying award information, including the allocation of state and federal funds to the award.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.
September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an...
September 30, 2025 Management’s Response to 2024 Audited Financial Statements Findings and Corrective Action Plan: Coastal Community Action Program agrees with the findings reported and has made corrective actions to rectify the findings. The omission of this award from the SEFA was the result of an unusual reallocation of funding by the Washington State Department of Commerce. The award was originally awarded and recorded as state funds. In September 2024, the Washington State Department of Commerce reallocated a portion of its funding and amended the grant terms to designate the award as being funded under the Coronavirus State and Local Fiscal Recovery Funds (21.027). Because the reallocation and revised terms were communicated late in the fiscal year, management did not identify the change in time to ensure that the award was correctly reported as federal on the SEFA. The adjustment was therefore an oversight and not an intentional misclassification. 2024-001 Preparation of the Schedule of Expenditures of Federal Awards CCAP Executive Leadership understands the function and necessity of preparing a complete and accurate SEFA. 1. Policy and Procedures Development: By November 15, 2025, management will develop and adopt written policies and procedures requiring formal review of all grant amendments, reallocations, and correspondence from pass-through entities to determine whether funding sources have changed and whether SEFA reporting is affected. 2. Internal Control Implementation: Management will implement a dual-review process in which both the Finance Director and Grants Manager verify the funding source and assistance listing number for all awards and amendments before SEFA preparation. 3. Training: Staff responsible for grants management and financial reporting will complete training on Uniform Guidance financial management and SEFA preparation requirements by November 15, 2025, with refresher training annually thereafter. 4. Ongoing Monitoring: Management will conduct a pre-audit SEFA review each year, reconciling all awards and amendments to source documentation, including grant agreements, amendments, and communications from pass-through entities. Responsible Party: Lucy Machowek, CFO Planned Completion Date: November 15, 2025
Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the Decemb...
Health Resources and Services Administration Brooklyn Plaza Medical Center, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID-19 Health Center Program Cluster (Assistance Listing Number 93.224/93.527) FAIN # H8000410, H8N53897, and H8L50850 for 2024 Finding 2024-001 – Special Tests and Provisions MATERIAL WEAKNESS Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts be monitored and reviewed by a supervisor on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Corrective action for this finding was put in place in September 2024 We agree with the auditors finding. We acknowledge that, within the current audit sample of 57 patient files, 2 were found to contain instances of noncompliance with the Sliding Fee Scale (SFS) requirements. We recognize the importance of full compliance and remain firmly to continuous improvement in this area. It is important to note that this represents a significant improvement from the prior year’s audit. The identification of only 2 errors out of 57 patients’ files selected highlights the effectiveness of the corrective actions plan we implemented in response to the previous finding. Corrective Actions and Improvements Implemented: 1. Staff Training- Following the prior audit, front desk staff received additional training emphasized accurate application of SFS policies, required documentation, and proper income verification protocols. 2. Internal Auditing- Beginning in September 2024, The CEO designated the Compliance Officer to conduct daily audits of SFS related documentation. These real time audits help identify and correct issues promptly, with findings continuously incorporated into staff training programs. While we are encourage with the progress made, we remain focused on achieving full compliance and will continue to refine our processes and training to meet that goal. If the Health Resources and Services Administration has questions regarding this plan, please call Daniel Desire, Chief Financial Officer at 718-596-9800, ext 226. Sincerely yours, Daniel Desire, CFO
Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, Nati...
Finding 2024-008 I. Procurement and Suspension and Debarment Information on the federal program: Grantor: Grantor: Department of Agriculture, Department of Defense, Department of Labor, National Aeronautics and Space Administration, Promotion of the Arts Grants to Organizations and Individuals, National Science Foundation, Department of Veteran Affairs, Environment Protection Agency, Department of Energy, Department of Health and Human Services, U.S. Agency for International Development Program Name: Research and Development Cluster Assistance Listing No.: Various Views of responsible officials and planned corrective actions: Management agrees with the finding described above. Due to a system failure, vendor payment files from January through September 2024 were not transmitted to Mount Sinai’s sanction screening vendor. Mount Sinai has taken corrective actions to address this issue. All current vendors in our vendor master file, as well as all new vendors added through our new vendor credentialing process, are now processed through our sanction screening vendor on a monthly basis. In addition, a new manual control has been implemented to review, confirm, and reconcile to ensure that the vendor master file has been transmitted successfully, and all vendors are screened for sanctions, and a report thereof is provided each month. Our process will also document and maintain evidence that unverified vendors or those that were indicated as excluded were investigated and evaluated by the Health System. We will also periodically perform independent sanction screening checks on a sample of our vendors to validate the accuracy of the results of our third-party sanction screening vendor. Name of responsible official: Franco Sagliocca Corporate Director, Supply Chain Franco.sagliocca@mountsinai.org Projected completion date: Our vendor credentialing process was establishing with our ERP implementation on October 7, 2024. Our enhanced procedures to reconcile our file transmissions to our independent third-party and perform screening checks on samples of vendors verified by our independent third-party is expected to be implemented by December 31, 2025.
View Audit 370128 Questioned Costs: $1
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