Corrective Action Plans

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Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Finding 1162353 (2024-002)
Material Weakness 2024
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Report...
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Reports are expected to be filed correctly and timely, with future education being sought as needed.
Finding 1162350 (2024-001)
Material Weakness 2024
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. ...
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. The Director reports several calendaring mechanisms are in place and the reports are being tracked by duplicative methods since that error.
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action wi...
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action with a Target Completion Date of December 31, 2025: The Town will draft and present a formal policy addressing this finding to the Board of Selectmen for review and approval prior to December 31, 2025. Responsible Party: Tammy Penny, Finance Director 6 Village Green Pelham, NH 03076 Phone: 603-508-3072 Email: TPenny@Pelhamweb.com Implementation of this policy will ensure that the Town is in compliance with applicable requirements and will prevent recurrence of the cited issue in future audits.
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.
The City of Royal City is committed to meeting all federal grant requirements and thanks SAO for providing guidance regarding this matter. We will proceed with developing written procurement procedures for purchases, services and public works contracts. It is our goal to ensure all stipulations are ...
The City of Royal City is committed to meeting all federal grant requirements and thanks SAO for providing guidance regarding this matter. We will proceed with developing written procurement procedures for purchases, services and public works contracts. It is our goal to ensure all stipulations are met for solicitation and award of Architectural and Engineering Services and Public Works contracts as required by state and federal granting agencies.
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- ...
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- Patient Service Representative Team Lead. This staff member oversees and trains the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, which is ongoing from Oct. 15, 2024. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Bob Rodriguez, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15, 2024.
Finding 1162268 (2024-013)
Material Weakness 2024
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
Finding 1162267 (2024-012)
Material Weakness 2024
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
Finding 1162266 (2024-007)
Material Weakness 2024
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
Finding 1162265 (2024-006)
Material Weakness 2024
We will work to implement a Risk Assessment plan. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to w...
We will work to implement a Risk Assessment plan. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
The District will ensure that any future contracts in excess of $2,000 using federal monies will contain provisions that require the contractor to comply with wage rate requirements and provide certified payroll reports on a weekly basis. This will allow the District to review these reports to ensur...
The District will ensure that any future contracts in excess of $2,000 using federal monies will contain provisions that require the contractor to comply with wage rate requirements and provide certified payroll reports on a weekly basis. This will allow the District to review these reports to ensure there are no violations.
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. Corrective Action: Fair Haven has internal records with tracking assets but will ensure that all qualifying capital asset purchases are properly capitalized and recorded on the balance sheet in accord...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. Corrective Action: Fair Haven has internal records with tracking assets but will ensure that all qualifying capital asset purchases are properly capitalized and recorded on the balance sheet in accordance with GAAP and added to the fixed asset register. Management will review significant purchases at acquisitions to confirm proper treatment going forward.
CONDITION: The Regional Office of Education No. 39 did not have adequate controls over subrecipient monitoring in compliance with the Code. PLAN: The Regional Office of Education No. 39 drafted subrecipient monitoring policies and procedures for Fiscal Year 2024 after receiving the Fiscal Year 2022 ...
CONDITION: The Regional Office of Education No. 39 did not have adequate controls over subrecipient monitoring in compliance with the Code. PLAN: The Regional Office of Education No. 39 drafted subrecipient monitoring policies and procedures for Fiscal Year 2024 after receiving the Fiscal Year 2022 audit finding on December 2023. Policies and procedures included reporting, monitoring, and award notification for the subrecipients of the ARP- Social Emotional Learning and Trauma Response grant. Some of the subrecipient information was received late from subrecipients. The Regional Office of Education No. 39 will follow up with subrecipients to ensure that all information is received and in a timely manner whenever possible. ANTICIPATED DATE OF COMPLETION: Implemented August 2025
FINDING 2024-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audi...
FINDING 2024-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Material Weakness, Noncompliance Condition: The District did not have proper controls in place to ensure that the RD442-2 and RD 442-3 forms were filled out and submitted. Context: Form RD442-2 and Form RD442-3 were not submitted to the granting agency. The District may submit the financial data in other forms, however, the required reporting information was not submitted at all for the year under audit. The forms are required to be submitted on GAAP accrual basis. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will prepare the required forms which will be reviewed by the Board of Directors prior to submission. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect with the next required submission for 2025.
Views of Responsible Officials and Planned Corrective Actions: As Invisible Children continue to build longstanding partnerships with subrecipients, the organization will ensure proper documentation of risks on a regular basis, particularly at moments of award extension. Updated risk assessments wil...
Views of Responsible Officials and Planned Corrective Actions: As Invisible Children continue to build longstanding partnerships with subrecipients, the organization will ensure proper documentation of risks on a regular basis, particularly at moments of award extension. Updated risk assessments will be filed at time of any new federal award even if continuing with existing partners. As part of the annual audit process, Invisible Children will receive formal attestations from all subrecipients regarding their Uniform Guidance audit requirements. Invisible Children has already begun to receive this documentation from active subrecipients ahead of the FY25 audit process.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Cowlitz-Wahkiakum Council of Governments January 1, 2024 through December 31, 2024 This schedule presents the corrective action the Council is planning to take for findings included in this report in accordance with Title 2 U.S. Cod...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Cowlitz-Wahkiakum Council of Governments January 1, 2024 through December 31, 2024 This schedule presents the corrective action the Council is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2024-002 Finding caption: The Council did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of Council contact person: William A. Fashing, Executive Director / Anisa Kisamore, Administrative Director Cowlitz-Wahkiakum Council of Governments PO Box 128, Kelso, WA 98626 (360) 577-3041 Corrective action the auditee plans to take in response to the finding: The Council of Governments has a process to verify the suspension and debarment status of contractors paid above $25,000. The Council followed this process as usual, which includes not only checking with SAM.gov but also with state listings as well, and felt at that time that it had properly documented and ensured that the contractor hired was not debarred or suspended before commencing with a contractual agreement. These documents were provided to the auditing team upon request. During the audit process, however, the reviewing auditor discovered that though the permissible SAM.gov documentation included both the name and UBI number, the combination of a typo in the contractor’s business name and the choice of searching for “all” words (system default) versus changing to “any” words returned a false narrative. Thus, the determination that the Council did not properly verify the contractor’s status within the acceptable forms of documents. To ensure that the Council no longer relies on just one level of verification and shores up effective controls, the Council will immediately implement two (2) additional processes into its contractor procurement policy. Not only will staff continue to verify contractors’ status through SAM.gov and state listings, but the Council will 1) require all contractors to submit a written certification prior to contractual negotiations and 2) request the agency’s attorney to draft a debarment and suspension clause that will be added to all contract templates and future agreements. Anticipated date to complete the corrective action: Immediately
VIEWS OF RESPONSIBLE OFFICIALS The PRDE acknowledges the auditor’s finding. It Is important to note that information requested is available and exists just that it was not provided in a timely manner for evaluation. The PRDE and the area accepts the recommendations and will work on corrective action...
VIEWS OF RESPONSIBLE OFFICIALS The PRDE acknowledges the auditor’s finding. It Is important to note that information requested is available and exists just that it was not provided in a timely manner for evaluation. The PRDE and the area accepts the recommendations and will work on corrective action plans that help mitigate the delay in providing information per auditors’ requests. IMPLEMENTATION DATE None RESPONSIBLE PERSON Luis M. Oppenheimer Rosario Program Coordinator María de los Ángeles Lizardi Valdés Office of Federal Affairs Director
VIEWS OF RESPONSIBLE OFFICIALS In response to the finding regarding the untimely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports, the Puerto Rico Department of Education (PRDE) acknowledges the observation made by the auditors. While the audit notes that program...
VIEWS OF RESPONSIBLE OFFICIALS In response to the finding regarding the untimely submission of the Federal Funding Accountability and Transparency Act (FFATA) reports, the Puerto Rico Department of Education (PRDE) acknowledges the observation made by the auditors. While the audit notes that program staff were unaware of the FFATA reporting requirement, we would like to clarify that the staff was aware of the requirement; however, the program was in the process of gathering the necessary data and ensuring a full understanding of the report components and submission procedures in order to comply accurately with the federal guidelines. Nevertheless, PRDE recognizes that this does not justify the delay in the submission of the reports. To prevent future occurrences, PRDE is currently developing and scheduling a comprehensive training for all program and fiscal staff involved in the Child Nutrition Cluster. This training will cover the FFATA reporting requirements, data collection procedures, submission timelines, and documentation standards to ensure full and timely compliance with the reporting process moving forward. PRDE will continue strengthening internal controls and monitoring procedures to ensure that all applicable FFATA reports are submitted accurately and on time in the FSRS portal. IMPLEMENTATION DATE December 30, 2025 RESPONSIBLE PERSON Odalis Menard AESAN Director Lourdes García Santiago AESAN Sub-Director
VIEWS OF RESPONSIBLE OFFICIALS Management agrees with the audit finding. The Puerto Rico Department of Education (PRDE) acknowledges that the requested procurement documentation was not fully available at the time of the auditors’ review. However, management made every effort to gather and reconstru...
VIEWS OF RESPONSIBLE OFFICIALS Management agrees with the audit finding. The Puerto Rico Department of Education (PRDE) acknowledges that the requested procurement documentation was not fully available at the time of the auditors’ review. However, management made every effort to gather and reconstruct the information for all the selected transactions, and the complete documentation will be available. Furthermore, the PRDE is taking actions to improve the accessibility and organization of procurement files to ensure that all documentation is readily available for review in a timely manner. Internal controls over document retention and filing procedures are being reinforced to prevent recurrence of this situation. It is important to note that the procurement processes followed by the PRDE comply with the applicable requirements established under the Code of Federal Regulations (2 CFR Part 200 – Uniform Guidance). Management remains committed to strengthening its internal controls, ensuring full compliance with federal and state requirements, and maintaining complete and timely documentation to support all procurement activities. IMPLEMENTATION DATE Current Fiscal Year. RESPONSIBLE PERSON María de los A. Lizardi Valdés Office of Federal Affairs Director Edgar Delgado Serrano Office of Federal Affairs Associate Director
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