Corrective Action Plans

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Upon OSAI's recommendation. we are putting into place protocols in an official policy and procedures manual specific 1o all Federal Crants. With their guidance, future Federal Grants will be better documenled and monitored in accordance with this policy.
Upon OSAI's recommendation. we are putting into place protocols in an official policy and procedures manual specific 1o all Federal Crants. With their guidance, future Federal Grants will be better documenled and monitored in accordance with this policy.
Corrective Action Planned: Management will strengthen procedures over the Sliding Fee Discount Program to ensure each patient’s discount is accurately determined based on documented annual income and family size and correctly applied to patient charges. Procedures will include documented supervisory...
Corrective Action Planned: Management will strengthen procedures over the Sliding Fee Discount Program to ensure each patient’s discount is accurately determined based on documented annual income and family size and correctly applied to patient charges. Procedures will include documented supervisory review of income determinations and verification that the approved sliding-fee discount is accurately reflected in the patient billing process. Management will also provide appropriate staff training and incorporate periodic monitoring to identify and correct discrepancies timely. Management’s Response: Management agrees with the finding. The exceptions identified resulted from approved sliding fee discounts being incorrectly applied to patient accounts. Management has enhanced review and monitoring procedures to ensure discount determinations are accurately reflected in the billing process and that supporting review is appropriately documented. These improvements are intended to strengthen compliance and prevent similar errors in the future.
Management concurs with the finding and recommendation. The Organization recognizes the importance of maintaining complete and accurate documentation supporting expenditures reported under federal awards and ensuring that amounts reported to the grantor reconcile to the underlying accounting records...
Management concurs with the finding and recommendation. The Organization recognizes the importance of maintaining complete and accurate documentation supporting expenditures reported under federal awards and ensuring that amounts reported to the grantor reconcile to the underlying accounting records. Management has strengthened its procedures for preparing and reviewing ARPA and other grant-related financial reports. The Partnership corrected the reporting discrepancy through its March 2024 Q1 report to the City of College Park, with all subsequent reports reflecting the correction. The final report to the City, submitted on May 16, 2025, as part of the grant closeout, provided a complete accounting of the grant funds expended and their intended purposes, together with bank statements and supporting documentation. The City did not identify any additional concerns with the corrected or subsequent reports following the December 2023 Q4 report. The Partnership has also implemented broader improvements including a redesigned chart of accounts, grant specific project records within QuickBooks, a centralized grant tracker, reorganized electronic files centered on individual grant awards, and a regular review meeting between the Partnership and TCG. These improvements provide clearer grant level accounting, reporting, deadline tracking, and supporting documentation. In addition, since the period under audit, the Partnership has already implemented adjustments to grant reporting. Management maintains a reconciliation between cumulative expenditures reported to the grantor and cumulative expenditures recorded in the general ledger. Management is finalizing written grant administration and reporting policies and procedures as part of the financial policies and procedures updates – outlining requiring grant specific reconciliations to the general ledger and supporting documentation, documented explanations for adjustments and corrections, management review and approval before submission,complete grant reporting files, and period review of reporting and closeout requirements by grantor. Management anticipates competing and formally implementing these policies and procedures by November 30, 2026. Once established, the Finance Committee will receive periodic updates on grant reporting controls and the status of related corrective actions. The Partnership will retain the reports and supporting documentation associated with the $3,86 identified by the auditors and will provide additional information if requested by the City or the federal awarding agency. If a management decision requires additional action, the Partnership will respond withing the timeframe identified in that decision.
The Town will develop and formally adopt written policies and procedures addressing Uniform Guidance requirements, including allowable costs, cash management, travel, procurement, suspension and debarment, equipment and inventory, and subrecipient monitoring. Policies will include defined responsibi...
The Town will develop and formally adopt written policies and procedures addressing Uniform Guidance requirements, including allowable costs, cash management, travel, procurement, suspension and debarment, equipment and inventory, and subrecipient monitoring. Policies will include defined responsibilities and internal controls and will be revieved periodically.
The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also...
The Village acknowledges the recommendation and will continue to strengthen its procedures for identifying and tracking grant activity. Management plans to implement additional review procedures over grant funding sources and related expenditures for purposes of SEFA reporting. The Village will also consider providing the SEFA and supporting expenditure information to its external engineering consultants for review to help ensure all grant activity administered on behalf of the Village is properly identified and reported.
We will establish written procedures reconciling patient billing reports to the general ledger for receivables, pharmacy, dental and medical revenues, contractual adjustments, and cash collections, as applicable. Complete cross training using written procedures, demonstrations, and supervised perfor...
We will establish written procedures reconciling patient billing reports to the general ledger for receivables, pharmacy, dental and medical revenues, contractual adjustments, and cash collections, as applicable. Complete cross training using written procedures, demonstrations, and supervised performance. After implementation, complete reconciliations monthly, target close within 45 days after month end, and provide financial results and unresolved exceptions to management and the governing board or its designated committee. Escalate staffing gaps and overdue reconciliations promptly. Reconcile federal award reporting to the accounting records and track audit deliverables and applicable reporting deadlines.
Audit Finding Number 2024-006 Audit Finding Title Subrecipient Monitoring Planned Corrective Action Effective September 2026, procedures were put in place for each subgrantee to complete an attestation and submit their internal or audited financials before we contract with them. Any findings or issu...
Audit Finding Number 2024-006 Audit Finding Title Subrecipient Monitoring Planned Corrective Action Effective September 2026, procedures were put in place for each subgrantee to complete an attestation and submit their internal or audited financials before we contract with them. Any findings or issues are documented along with the resulting resolution. BWHI has always maintained close contact with our subgrantees and monitored their performances with frequent meetings. This process will now be formally documented. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting Zsanai Epps, Interim EVP Programs and Advocacy
Audit Finding Number 2024-005 Audit Finding Title Procurement and Suspension and Debarment Planned Corrective Action Effective September 2026, procedures were put in place for each subgrantee or anyone being paid over $25,000 using federal funds to complete an attestation and submit their internal o...
Audit Finding Number 2024-005 Audit Finding Title Procurement and Suspension and Debarment Planned Corrective Action Effective September 2026, procedures were put in place for each subgrantee or anyone being paid over $25,000 using federal funds to complete an attestation and submit their internal or audited financials before we contract with them. This will ensure that they have the financial ability to carry out the agreed upon work. We also perform our own verification of their suspension and debarment status. Their Year 4 contracts include a certification that they have not been suspended or debarred and that they are required to inform us if that status changes. We are also in the process of implementing a procurement policy related to federal funding. This policy will be fully implemented by December 2026. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting Michelle Swittenberg, EVP of Enterprise Operations
Audit Finding Number 2024-004 Audit Finding Title Reporting Planned Corrective Action Effective October 2026, the 2023, 2024, 2025 FFATA reporting requirements have been completed. Going forward, once the NOA is confirmed and the subgrantees have submitted workplans and signed agreements, the FFATA ...
Audit Finding Number 2024-004 Audit Finding Title Reporting Planned Corrective Action Effective October 2026, the 2023, 2024, 2025 FFATA reporting requirements have been completed. Going forward, once the NOA is confirmed and the subgrantees have submitted workplans and signed agreements, the FFATA will be completed in the Federal Subaward Reporting System. This item is still pending for 2026 because those agreements have not been signed. Name(s) and title(s) of contact person(s) responsible for corrective action Kim Cockerham, Sr. Director of Finance and Accounting
The Finance Director and Finance Manager will jointly oversee and follow the established processes to ensure all subrecipient requirements are met. Due to current staffing shortages within the county, these responsibilities are being managed by existing leadership until full staffing levels are rest...
The Finance Director and Finance Manager will jointly oversee and follow the established processes to ensure all subrecipient requirements are met. Due to current staffing shortages within the county, these responsibilities are being managed by existing leadership until full staffing levels are restored. The County is correcting a capital asset data gap caused by an ongoing software conversion and will resolve it for future financial reporting. To ensure accuracy moving forward, Capital is partnering with the Auditor’s Office to establish a collaborative review. Additionally, an internal audit of fully depreciated assets still in use will launch as soon as the department reaches full staffing capacity. Furthermore, the County is leveraging newly added position within the Auditor's Office to expand its operational capacity and eliminate the compressed reporting timelines of prior years. This new staff capacity will directly assist in completing and reviewing the financial statements. This coordinated approach will successfully restore timely, accurate, and transparent financial reporting for public and oversight agencies.
Management concurs with the finding. The Organization did not maintain adequate procedures to identify, monitor, and document compliance with reporting requirements established in the Subaward Agreement. To correct this deficiency, management has established formal grant compliance procedures to ens...
Management concurs with the finding. The Organization did not maintain adequate procedures to identify, monitor, and document compliance with reporting requirements established in the Subaward Agreement. To correct this deficiency, management has established formal grant compliance procedures to ensure that all reporting requirements are identified and monitored throughout the life of each Federal award. Management will maintain a centralized grant compliance file containing copies of all reports submitted to the pass-through entity, supporting documentation, and correspondence related to reporting requirements. In addition, management will assign responsibility for the preparation and review of required reports and will perform periodic reviews to verify that all reports are submitted timely and properly documented. If reporting requirements are waived or determined to be inapplicable, management will obtain and retain written evidence from the pass-through entity supporting such determination. Management believes these procedures will strengthen internal controls over compliance and ensure adherence to future reporting requirements.
10. Centralized monitoring matrix. Maintain a center-by-center schedule showing review due dates, approved meal service times, visits performed and whether the required meal observation has been completed for the applicable review period. 11. Mandatory completion review. Require the Senior Monitor t...
10. Centralized monitoring matrix. Maintain a center-by-center schedule showing review due dates, approved meal service times, visits performed and whether the required meal observation has been completed for the applicable review period. 11. Mandatory completion review. Require the Senior Monitor to verify meal observation fields and other required elements before marking a report complete; document deficiencies and follow-up. 12. Supervisory accountability. Assign the Senior Monitor responsibility for staff scheduling, report receipt, completeness checks, central filing, training needs and escalation to senior administration. 13. Staff training and coverage. Provide written training and cross-coverage procedures so absences or personnel transitions do not leave monitoring requirements unassigned. 14. Retrospective scope assessment. Examine the 2024 center-by-center monitoring records for additional omitted meal observations or documentation gaps; document the population, exceptions, follow-up and any necessary claim impact assessment. Do not presume questioned costs absent a supported determination. 15. Operating-effectiveness review. Perform and retain periodic supervisory spot-checks of monitoring records and reconcile the monitoring matrix against filed reports and outstanding corrective actions.
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Pohnpei has agreed to the findings and is committed to implementing the recommendations. Ongoing Director of Treasury and Administration Sihna N. Lawrence sihna.lawrence@pohnpeidota.fm
Finding 2024-001: Subrecipient Monitoring Federal Agency: U.S. Department of Housing and Urban Development Program Name: COVID 19 — HOME Investment Partnerships Program and HOME Investment Partnerships Program (HOME) - ALN 14.239; Award Identification Number: MC420501 Criteria of Specific Requiremen...
Finding 2024-001: Subrecipient Monitoring Federal Agency: U.S. Department of Housing and Urban Development Program Name: COVID 19 — HOME Investment Partnerships Program and HOME Investment Partnerships Program (HOME) - ALN 14.239; Award Identification Number: MC420501 Criteria of Specific Requirement: Per 2 CFR 200.332, a pass-through entity must monitor the activities of subrecipients as necessary to ensure that the subaward is used for authorized purposes, in compliance with federal statutes, regulations, and the terms and conditions of the subaward. Condition: During our testing of subrecipient monitoring, we noted that the City did not perform required monitoring procedures during the year. Questioned Costs: Unknown Cause: The City did not have adequate internal controls in place to ensure compliance with subrecipient monitoring requirements, and staffing turnover contributed to the lack of oversight. Effect: The City was not in compliance with subrecipient monitoring requirements. Identification as a Repeat Finding: This is not a repeat finding from the prior audit. Recommendation: We recommend the City implement controls to ensure compliance with subrecipient monitoring, documenting monitoring activities performed and following up on any identified deficiencies in a timely manner. Views of Responsible Officials and Planned Corrective Actions: Management agrees; see corrective action plan below. History The City initiated monitoring of the HOME program in March 2023, and the local office of the Department of Housing and Urban Development (HUD) initiated its own monitoring in June 2023. To avoid duplicative work, the City shifted its approach and reviewed closed programs while HUD monitored open programs. These monitoring efforts resulted in significant updates to program policies and procedures. The City's monitoring was completed in October 2023 and HUD's monitoring was finalized in October 2024. Corrective Action Plan Since October 2024, the City has collaborated with its subrecipient, the Urban Redevelopment Authority (URA), to implement a streamlined, informal quarterly review process. While formal HOME monitoring has not occurred since the end of the HUD monitoring, the City will initiate a review before the end of 2025 to return to compliance. Monitoring will occur annually moving forward.
2024-010 Material Weakness in Internal Control and Compliance over Major Programs Management Response: Head Start has established monthly meetings with the Board President, CFO, Controller, and Executive Director. Both the Board President and Executive Director completed additional training in Augus...
2024-010 Material Weakness in Internal Control and Compliance over Major Programs Management Response: Head Start has established monthly meetings with the Board President, CFO, Controller, and Executive Director. Both the Board President and Executive Director completed additional training in August 2026 to support compliance with Head Start requirements. Additional training is scheduled through December 2026. The Board is in the final stage of confirming the Finance/Audit Committee Chair, with an expected completion date of October 31, 2026. Staff responsible: Executive Director Anthony Ives aives@kcr.org and CFO Irmgard Davis irmgardd@kcr.org.
2024-008 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions, to addr...
2024-008 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: KCR is working on updating all internal controls, as we have new members throughout the organization, by providing cross training to identify who is responsible for specific functions, to address the specific finding, to prevent further incidents KCR is requiring that anytime a change is made on an employee a new PAF is required from the program, the current PAF form will updated and completion date 11/30/2026. Staff responsible: CFO Irmgard Davis irmgardd@kcr.org.
2024-006 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: As of August 2026, KCR has begun reconciling the bank account statements each month. As part of the reconciliation process, the finance team is reviewing all outstanding checks/payments and fo...
2024-006 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: As of August 2026, KCR has begun reconciling the bank account statements each month. As part of the reconciliation process, the finance team is reviewing all outstanding checks/payments and following up with vendors to confirm if the check/payment needs to be voided and resubmitted. KCR is also paying special attention to any check/payment that is being expensed to a federal program, ensuring that only checks/payments that have been negotiated with the bank are refunded by federal awards. Staff responsible: CFO Irmgard Davis irmgardd@kcr.org.
Finding: 2024-003 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Treasury Federal Financial Assistance Listing 21.027 Subrecipient Monitoring Finding Summary: During our testing, we evaluated the procedures for evaluating subrecipient’s risk of no...
Finding: 2024-003 Material Weakness in Internal Control over Compliance and Material Noncompliance U.S. Department of Treasury Federal Financial Assistance Listing 21.027 Subrecipient Monitoring Finding Summary: During our testing, we evaluated the procedures for evaluating subrecipient’s risk of noncompliance with Federal statutes, regulations and the terms and conditions of the subaward. We noted the following:  For three (3) of three (3) subrecipients selected, the required evaluation of the subrecipient’s risk of noncompliance was not documented.  For one (1) of three (3) subrecipients selected, the County did not provide a formal subrecipient agreement including the required information noted in 2 CFR 200.332. Responsible Individuals: Dana Aschenbrenner, Finance Director Corrective Action Plan: The understanding of current staff is that the risk assessments were completed as appropriate, however, due to staff turnover the documents have been misplaced and no longer seem to be available. Applicable County teams are working to adopt standards for what documentation is necessary to establish the basis for a transaction, as well as standardizing the repository for such documentation. Anticipated Completion Date: Ongoing
Matching Recommendation: Recommended Recovery Connections of Central Florida, Inc. create formal procedures to track grant matching and ensure that there is a monthly review of matching requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...
Matching Recommendation: Recommended Recovery Connections of Central Florida, Inc. create formal procedures to track grant matching and ensure that there is a monthly review of matching requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review each agreement to confirm the matching requirements that must be followed. A designated team member will be responsible for tracking compliance with the required match. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial and performance reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the a...
Reporting Recommendation: Recommended Recovery Connections of Central Florida, Inc. submit its financial and performance reporting as noted in the agreements and maintain documentation of the approval and submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review each agreement to confirm the reporting requirements, deadlines, and any specific formats or templates that must be followed. A designated team member will be responsible for preparing, reviewing, and submitting the required reports. We will to track submission deadlines and ensure that reports are submitted on time. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026
State Opioid Response Discretionary Grant-Assistance Listing No. 93.788 Allowable Costs, Period of Performance, and Cash Management Recommendation: Recommended Recovery Connections of Central Florida, Inc. maintain a copy of all contracts, documentation of disbursement approval and supporting docume...
State Opioid Response Discretionary Grant-Assistance Listing No. 93.788 Allowable Costs, Period of Performance, and Cash Management Recommendation: Recommended Recovery Connections of Central Florida, Inc. maintain a copy of all contracts, documentation of disbursement approval and supporting documentation of costs included within requests for payment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will implement a more structured process for documenting the approval of disbursements. This includes ensuring that all underlying contracts are maintained and disbursements are formally approved by the appropriate authority within the organization. We will also maintain a written record of the approval, including the name of the individual who authorized the disbursement and the date of approval, includin the name of the individual who authorized the disbursement and the date of the approval. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026
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