Corrective Action Plans

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Agency will develop a written process for submitting FSRS as required to include tracking schedule by subcontract to ensure timely submissions within one month following the signing of a new award. In Addition, the agency has appointed a cost specialist to carry out this responsibility with the Head...
Agency will develop a written process for submitting FSRS as required to include tracking schedule by subcontract to ensure timely submissions within one month following the signing of a new award. In Addition, the agency has appointed a cost specialist to carry out this responsibility with the Head Start Director serving as back up. The report is submitted to the CFO and filed in the agency’s fiscal electronic filing system in preparation for the annual audit. The FSRS for FY2026 is complete and timely submitted in alignment with subcontract renewals.
Management will develop, formally approve, and implement written procurement procedures that comply with the Uniform Guidance procurement standards in 2 CFR §§ 200.317 through 200.327 and will be approved by the Board of Directors.
Management will develop, formally approve, and implement written procurement procedures that comply with the Uniform Guidance procurement standards in 2 CFR §§ 200.317 through 200.327 and will be approved by the Board of Directors.
Finding 2025-001 Subrecipient Monitoring AL 93.778 and Medical Assistance Program and DHS Medical Assistance Transportation Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program’s vendor. These monitor...
Finding 2025-001 Subrecipient Monitoring AL 93.778 and Medical Assistance Program and DHS Medical Assistance Transportation Program Criteria: Internal control procedures require the County to perform subrecipient monitoring procedures over the funding disbursed to the Program’s vendor. These monitoring procedures include documenting the procedures performed and the results of those procedures along with documenting the risk assessment associated with the selected procedures. Condition: During the audit, it was noted that the County was not performing subrecipient monitoring over the Program’s vendor. Cause: The County does not have adequate controls in place or the expertise to ensure proper subrecipient monitoring procedures. Effect: The Program’s vendor may be using grant funding inappropriately. Questioned Costs: The amount of questioned costs, if any, is undeterminable. Recommendation: The County should implement internal control procedures that ensure the vendor is being properly monitored and document those procedures and results of procedures. Management Response: Management is working to implement and document proper subrecipient monitoring internal controls. Anticipate Completion Date: Immediate
The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.945 Recommendation: We recommend the Organization create proper policies and procedures to ensure indirect cost is properly calculated and tracked. Explanation of disagreement with audi...
The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.945 Recommendation: We recommend the Organization create proper policies and procedures to ensure indirect cost is properly calculated and tracked. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement policies and procedures to ensure indirect cost is properly calculated and tracked. Name(s) of the contact person(s) responsible for corrective action: Sharon Brown, CEO Planned completion date for corrective action plan: December 31, 2026
The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Exp...
The Department of Health and Human Services/Centers for Disease Control and Prevention – Assistance Listing No. 93.495 Recommendation: We recommend that the Organization implements policies and procedures to perform subrecipient monitoring and that monitoring is formally documented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement policies and procedures to implement subrecipient monitoring as required in future grants and contracts. Name(s) of the contact person(s) responsible for corrective action: Sharon Brown, CEO Planned completion date for corrective action plan: December 31, 2026
We concur with the findings and acknowledge the deficiency and instance of noncompliance related to subrecipient monitoring. We are committed to strengthening internal controls to ensure full compliance with applicable federal requirements. During 2025, we implemented a corrective action plan that i...
We concur with the findings and acknowledge the deficiency and instance of noncompliance related to subrecipient monitoring. We are committed to strengthening internal controls to ensure full compliance with applicable federal requirements. During 2025, we implemented a corrective action plan that included the development and adoption of a comprehensive subrecipient monitoring policy and the establishment of standardized, documented procedures for the review of financial and performance reports. These actions are designed to create a consistent, risk-based, and fully documented monitoring framework that enhances accountability, reduces compliance risk, and ensures proper stewardship of federal funds. We remain committed to continuously improving our processes and maintaining compliance with all applicable regulations moving forward.
Finding 2025-002 (ALN: 93.889) The Organization did not retain procurement records documenting the criteria required by Section 200.318(j). Management Response: Management agrees with the finding and will strengthen internal controls over procurement documentation. The Program team will receive refr...
Finding 2025-002 (ALN: 93.889) The Organization did not retain procurement records documenting the criteria required by Section 200.318(j). Management Response: Management agrees with the finding and will strengthen internal controls over procurement documentation. The Program team will receive refresher training to ensure required records for federally funded purchases are complete, properly maintained, and retained in accordance with Federal requirements. Management will conduct periodic monitoring to verify compliance and address any deficiencies timely. Contact Person (s) Responsible for Corrective Action: David McDermott, Grants Director, Steve Baron, Program Manager, and Venice Northe, Manager, Enterprise Accounting Operations. Anticipated Completion Date: December 31, 2026.
Finding 2025-001 (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2). This is a repeat finding (2024-005) Management Response: Management agrees with the finding and will ensu...
Finding 2025-001 (ALN 93.889) The Organization did not have sufficiently designed internal controls to ensure that property records are retained in accordance with Section 200.313(d)(1) and (2). This is a repeat finding (2024-005) Management Response: Management agrees with the finding and will ensure that the enhanced procedures and monitoring controls already in place are consistently followed to ensure that equipment acquired with Federal grant funds is accurately recorded, properly tracked, and supported by property records that are maintained and retained in accordance with 2 CFR § 200.313(d)(1) and (2). The Program team is responsible for ensuring that physical inventories are conducted at least every two years, reconciled to the applicable property records, and that any discrepancies identified are investigated and resolved in a timely manner. These corrective actions will strengthen internal controls over federally funded equipment and support continued compliance with applicable Federal requirements. Contact Person(s) Responsible for Corrective Action: Steve Baron, Program Manager Anticipated Completion Date: December 31, 2026
Finding Number: 2025-001 Condition: The Organization did not maintain the 61-participant minimum enrollment (10 Infant/Maternal, 12 Preschool, 25 School-Age, 14 Special Needs) required under Section 4.4 of its Child Care Delegation of Funds Contract with ACUDEN during the year ended December 31, 202...
Finding Number: 2025-001 Condition: The Organization did not maintain the 61-participant minimum enrollment (10 Infant/Maternal, 12 Preschool, 25 School-Age, 14 Special Needs) required under Section 4.4 of its Child Care Delegation of Funds Contract with ACUDEN during the year ended December 31, 2025. Management response: Management concurs with this finding. The Organization acknowledges that the required minimum of 61 eligible participants was not maintained during the year ended December 31, 2025 and is committed to implementing the corrective action described below. Corrective action plan: In response to the condition in reference management will establish the following corrective action: • Strengthen recruitment and community outreach efforts to fill and maintain all 61 authorized enrollment slots by category. • Establish and actively manage a waitlist so that vacated slots are backfilled within 30 days. • Assign the Program Director to monitor enrollment against the 61-participant minimum on a weekly basis. Responsible Person Program director, accountant officer Expected completion date December 31 and thereon on a continues basis
Condition: Timecards did not consistently agree with hours reported in payroll records. Discrepancies were noted between employee timecards and ADP payroll reports, and one instance was identified in which a timecard lacked required approval. Planned Corrective Action: Management will strengthen pay...
Condition: Timecards did not consistently agree with hours reported in payroll records. Discrepancies were noted between employee timecards and ADP payroll reports, and one instance was identified in which a timecard lacked required approval. Planned Corrective Action: Management will strengthen payroll controls by implementing a dual-review process. Supervisors will be required to approve all employee timecards prior to payroll processing, and accounting personnel will verify approved timecards against payroll system reports before payroll is finalized. In addition, management will conduct periodic spot checks and quarterly reviews on or around April 1st, July 1st, October 1st, January 1st to ensure payroll records are accurate, properly supported, and in compliance with established procedures. Anticipated Completion Date: December 31, 2026. Contact Person: Pam Schuellerman, Executive Director.
Condition: Management was unable to locate approved payment request forms demonstrating evidence of review and approval prior to submission for reimbursement in 15 of the 60 transactions selected for testing. Planned Corrective Action: Management will implement and enforce a standardized reimburseme...
Condition: Management was unable to locate approved payment request forms demonstrating evidence of review and approval prior to submission for reimbursement in 15 of the 60 transactions selected for testing. Planned Corrective Action: Management will implement and enforce a standardized reimbursement packet checklist requiring documented approval before reimbursement requests are submitted. All reimbursement packets and supporting documentation will be maintained electronically in a centralized filing system. Training will be provided to accounting staff regarding documentation and record retention requirements. Quarterly reviews will be conducted to ensure compliance with established procedures on or around April 1st, July 1st, October 1st, January 1st annually. Anticipated Completion Date: December 31, 2026. Contact Person: Pam Schuellerman, Executive Director
Finding 1239115 (2025-001)
Material Weakness 2025
CAPI USA has developed and implemented formal written subrecipient monitoring procedures, which have been incorporated into the Organization's Financial Handbook. These procedures require verification and documentation that subrecipients are not suspended, debarred, or otherwise excluded from partic...
CAPI USA has developed and implemented formal written subrecipient monitoring procedures, which have been incorporated into the Organization's Financial Handbook. These procedures require verification and documentation that subrecipients are not suspended, debarred, or otherwise excluded from participation in federal programs through review of SAM.gov or other appropriate sources. In addition, the Organization has revised its subaward agreement and related templates to ensure all information required under 2 CFR 200.332(b) is included. The updated subaward agreement has been provided to the current subrecipient for review and execution. To support ongoing compliance with Uniform Guidance requirements, CAPI USA will periodically review its subrecipient monitoring procedures and subaward agreement templates and update them as necessary to reflect regulatory changes and organizational practices. The Financial Handbook and template revisions have been completed as of the date of this corrective action plan. Full implementation of the corrective action will be finalized upon execution of the revised subaward agreement by the subrecipient. The Organization strives to remain compliant with Uniform Guidance in all respects to present both accurate and transparent records. If Minnesota Department of Human Services or U.S. Department of Health and Human Services have questions regarding this plan, please call Mary Niedermeyer, Chief Executive Officer, at 651-392-4069.
MEDA concurs with the recommendation. To ensure full compliance with internal control and federal award requirements, MEDA is implementing an updated review workflow for all financial and performance reports prior to submission. Under this process, designated reviewers will complete and sign a stand...
MEDA concurs with the recommendation. To ensure full compliance with internal control and federal award requirements, MEDA is implementing an updated review workflow for all financial and performance reports prior to submission. Under this process, designated reviewers will complete and sign a standardized digital approval checklist or retain documented email/system approvals accompanying each report and its supporting documentation. These record files will be systematically maintained in MEDA’s central repository in alignment with our record retention policy. Implementation is targeted for completion by December 31, 2026 under the direction of the Chief Financial Officer.
Management will implement written procedures for federal grant administration applicable to all federal awards. Reimbursement requests will be limited to costs incurred and supported by documentation at the time of the request. The reimbursement request, expenditure listing, supporting documentation...
Management will implement written procedures for federal grant administration applicable to all federal awards. Reimbursement requests will be limited to costs incurred and supported by documentation at the time of the request. The reimbursement request, expenditure listing, supporting documentation, and documented allowability review will be maintained together in a referenced file and will include preparer and reviewer sign-off. For advance payments, management will document the program's immediate cash requirements supporting the amount and timing of each advance and monitor the period between receipt and disbursement of federal funds. The reimbursement log reconciliation and Schedule of Expenditures of Federal Awards will be subject to documented review by an individual who was not involved in their preparation. Management will also coordinate with the USDA Forest Service regarding the $64,969 in questioned costs and follow the awarding agency's direction.
Subrecipient Monitoring (Significant Deficiency) Views of the Responsible Official: We agree with condition noted in the Schedule of Findings and Questioned Costs. Although GNHP had oversight of the Horizon Heights and St. Michael's Monastery projects, it did not maintain sufficient documentation to...
Subrecipient Monitoring (Significant Deficiency) Views of the Responsible Official: We agree with condition noted in the Schedule of Findings and Questioned Costs. Although GNHP had oversight of the Horizon Heights and St. Michael's Monastery projects, it did not maintain sufficient documentation to demonstrate that it consistently monitored the subrecipients' use of SLFRF funds, performance, and compliance with subaward requirements. GNHP will establish formal procedures for assessing subrecipient risk, conducting and documenting monitoring activities, and following up on identified issues through resolution.
Reporting (Significant Deficiency) Views of the Responsible Official: We agree with condition noted in the Schedule of Findings and Questioned Costs. We recognize that our procedures did not consistently ensure the preparation, review, and submission of the quarterly financial and performance report...
Reporting (Significant Deficiency) Views of the Responsible Official: We agree with condition noted in the Schedule of Findings and Questioned Costs. We recognize that our procedures did not consistently ensure the preparation, review, and submission of the quarterly financial and performance reports required by the SLFRF subaward agreements. GNHP will formalize its reporting procedures to track deadlines, reconcile financial reports to the general ledger and supporting records, document management review, and retain evidence of submission.
Finding 1239071 (2025-005)
Material Weakness 2025
Finding number: 2026-005 - Noncompliance with Required Project Deliverable Timeline Condition: Blue Krewe did not complete the required rooftop solar installation within the established Year 1 performance period. Management represented that it has remained in communication with the City regarding th...
Finding number: 2026-005 - Noncompliance with Required Project Deliverable Timeline Condition: Blue Krewe did not complete the required rooftop solar installation within the established Year 1 performance period. Management represented that it has remained in communication with the City regarding the status of the project and that no concerns have been raised by the City; however, written documentation from the City approving the delay was not available. Views of responsible official: Management acknowledges that the rooftop solar installation was not completed within the original Year 1 performance period. Management has been communicating with the City regarding the project and will continue to coordinate with the City regarding completion of the required deliverable and obtain and retain written documentation of any approved changes to the project timeline. Expected Completion date: November 30, 2026
Finding 1239070 (2025-004)
Material Weakness 2025
Finding number: 2026-004 - Absence of Written Standards of Conduct Condition: The Organization had not adopted written standards of conduct addressing conflicts of interest and employee conduct requirements applicable to federal awards. Views of responsible official: Management agrees with the findi...
Finding number: 2026-004 - Absence of Written Standards of Conduct Condition: The Organization had not adopted written standards of conduct addressing conflicts of interest and employee conduct requirements applicable to federal awards. Views of responsible official: Management agrees with the finding. The Organization will develop and adopt written standards of conduct addressing conflicts of interest and other ethical requirements applicable to federal awards and will communicate those standards to employees and Board members. Expected Completion date: November 30, 2026
Finding 1239069 (2025-002)
Material Weakness 2025
Finding 2025-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Award Number/Year: Not applicable / 2021 Federal Agency: U.S. Department of Treasury Repeat of Finding 2024-002 Condition The County was not able to provide evidence that the suspen...
Finding 2025-002 Program ALN: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Award Number/Year: Not applicable / 2021 Federal Agency: U.S. Department of Treasury Repeat of Finding 2024-002 Condition The County was not able to provide evidence that the suspension and debarment verification was completed for the three contractors selected for testing. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: Training has been provided to the County’s Purchasing division regarding the requirement to review and record evidence that verification is completed on vendors prior to contracting. Name(s) of Contact Person(s) Responsible for Corrective Action: Kristin Vander Kooi, Rock County Finance Director Anticipated Completion Date: December 31, 2025
Corrective Action Plan Formal written procedures now require suspension, and debarment checks before any covered transaction. Acceptable verification methods and documentation requirements are clearly defined. A mandatory Verification Form will be incorporated into the procurement workflow, preventi...
Corrective Action Plan Formal written procedures now require suspension, and debarment checks before any covered transaction. Acceptable verification methods and documentation requirements are clearly defined. A mandatory Verification Form will be incorporated into the procurement workflow, preventing final approval until verification is documented. A centralized repository will be established to store all verification records in accordance with retention requirements. Procurement and finance staff will receive mandatory training, with annual refresher sessions. Quarterly reviews will confirm compliance and identify any gaps for correction. Action Date 9/10/26 Final Implementation Date 12/31/27 Name And Phone No. Of Person Responsible For Implementation: Kenneth Knappe 631-854-9939
Corrective Action Plan • Implementing mandatory risk-based monitoring, including annual risk assessments for all subrecipients, with follow up actions documented. • Adopted standardized monitoring tools, including desk review checklists, on-site review templates, financial reconciliation forms, and ...
Corrective Action Plan • Implementing mandatory risk-based monitoring, including annual risk assessments for all subrecipients, with follow up actions documented. • Adopted standardized monitoring tools, including desk review checklists, on-site review templates, financial reconciliation forms, and CAP follow-up templates. • Conduct staff training for program and fiscal personnel involved in oversight of SSBG-funded subrecipients to ensure consistent understanding and application of monitoring requirements. • Establish an internal compliance review, performed by fiscal management, to confirm monitoring activities are timely, complete, and appropriately supported. Action Date September 4, 2026 Final Implementation Date December 31, 2026 Name And Phone No. Of Person Responsible For Implementation Jennifer Cicero-631-854-9331
Corrective Action Plan Regarding the child abuse and neglect registry check: Corrective Action Plan: It was found that four case files did not include a printed copy of the child abuse and neglect registry check, a checklist showing it was run was included in the cases. The child abuse and neglect r...
Corrective Action Plan Regarding the child abuse and neglect registry check: Corrective Action Plan: It was found that four case files did not include a printed copy of the child abuse and neglect registry check, a checklist showing it was run was included in the cases. The child abuse and neglect registry check were conducted when the homes were first certified as Foster Homes and were included in the Foster Home case record. Foster Home case records are purged after eight years of the home being a closed Foster Home. Currently the printed child abuse and neglect registry check is included in the Adoption Subsidy case file. Action Date 2022 Final Implementation Date 12/31/2039 Name And Phone No. Of Person Responsible For Implementation Lori Rhein (631) 854-9330
Corrective Action Plan It was found that eight cases did not contain evidence in the case record that would indicate the participant’s categorical eligibility. A memo will be distributed to all staff as a reminder on the need to adequately document the case record to support the eligibility determin...
Corrective Action Plan It was found that eight cases did not contain evidence in the case record that would indicate the participant’s categorical eligibility. A memo will be distributed to all staff as a reminder on the need to adequately document the case record to support the eligibility determination to ensure compliance with state and federal regulations and the need to scan all documents to IEDR in a timely manner. A separate memo will be distributed to all supervisory staff as a reminder on their need to ensure the case is properly documented and stored in IEDR when reviewing the case record for eligibility determination. The agency will monitor training classes offered by OTDA throughout the year to assign staff to attend to reinforce and strengthen their knowledge on properly documenting and determining eligibility for program. Action Date 9/14/2026 Final Implementation Date 9/30/2027 Name And Phone No. Of Person Responsible For Implementation Bryan Bogad – 631-854-9880
Corrective Action Plan It was found that four cases did not contain evidence in the case record that would indicate the participant’s categorical eligibility. A memo will be distributed to all staff as a reminder on the need to adequately document the case record to support the eligibility determina...
Corrective Action Plan It was found that four cases did not contain evidence in the case record that would indicate the participant’s categorical eligibility. A memo will be distributed to all staff as a reminder on the need to adequately document the case record to support the eligibility determination to ensure compliance with state and federal regulations and the need to scan all documents to IEDR in a timely manner. A separate memo will be distributed to all supervisory staff as a reminder on their need to ensure the case is properly documented and stored in IEDR when reviewing the case record for eligibility determination. The agency will monitor training classes offered by OTDA throughout the year to assign staff to attend to reinforce and strengthen their knowledge on properly documenting and determining eligibility for program. Action Date 9/14/2026 Final Implementation Date 9/30/2027 Name And Phone No. Of Person Responsible For Implementation Bryan Bogad – 631-854-9880
Finding 1239014 (2025-002)
Material Weakness 2025
The Commissioner’s office will implement additional policies to ensure verification is performed to ensure a vendor is not suspended, debarred, or otherwise excluded from a project and to ensure documentation is maintained.
The Commissioner’s office will implement additional policies to ensure verification is performed to ensure a vendor is not suspended, debarred, or otherwise excluded from a project and to ensure documentation is maintained.
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