Corrective Action Plans

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The unique relationship between the pass-through entity and the Authority contributed to this oversight. Though the entities have separate governing bodies, the staff for each is identical. Although the recipient of the report would have been the same person as the preparer, the Authority achnowledg...
The unique relationship between the pass-through entity and the Authority contributed to this oversight. Though the entities have separate governing bodies, the staff for each is identical. Although the recipient of the report would have been the same person as the preparer, the Authority achnowledgesthat this is a requirement of receiving these funds and the auditee concurs with the need to complete said reporting.
Name of auditee: Benjamin Hershey Memorial Convalescent Home HUD auditee identification number: 074-11175 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Jessica Ward Position: Chief Financial Officer Telephone number: 402...
Name of auditee: Benjamin Hershey Memorial Convalescent Home HUD auditee identification number: 074-11175 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Jessica Ward Position: Chief Financial Officer Telephone number: 402-333-7373 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-001: Comments on the Finding and Each Recommendation: The Corporation did not provide HUD with a completed annual financial report by March 31, 2026, as required by HUD. Pursuant to the terms of the Regulatory Agreement, within ninety (90) days following the end of each fiscal year, the Corporation shall provide a complete annual financial report based upon an examination of the books and records of the Community prepared in accordance with the requirements of HUD and certified by a Certified Public Accountant or other person acceptable to the Commissioner. As a result, the Corporation was not in compliance with the Regulatory Agreement. The annual financial statements should be issued in a timely manner pursuant to the time frame set forth by HUD. Action(s) taken or planned on the finding: The audit report as of and for the year ended June 30, 2025 has been submitted to HUD. No further action is required.
The City has established a well-designed internal control manual of policies and procedures over the ARPA grant’s full cycle grants management, as well as various templates to evaluate the subrecipients’ risks and monitor their performances. In FY 26, the City will implement its internal controls by...
The City has established a well-designed internal control manual of policies and procedures over the ARPA grant’s full cycle grants management, as well as various templates to evaluate the subrecipients’ risks and monitor their performances. In FY 26, the City will implement its internal controls by conducting timely subrecipient monitoring activities with signed documents.
Repeat finding 2024-005 The City will establish policies, procedures and internal controls to ensure that all subrecipient CAPER reports are reconciled to the IDIS system and submitted to HUD within 90 days of year end.
Repeat finding 2024-005 The City will establish policies, procedures and internal controls to ensure that all subrecipient CAPER reports are reconciled to the IDIS system and submitted to HUD within 90 days of year end.
Repeat Finding 2024-004 The City will continue strengthening its policies, procedures, and internal controls to ensure that all subawards are reported in full compliance with FFATA. The City reported subawards using the subaward obligation date, which is the date the agreement is fully executed, rat...
Repeat Finding 2024-004 The City will continue strengthening its policies, procedures, and internal controls to ensure that all subawards are reported in full compliance with FFATA. The City reported subawards using the subaward obligation date, which is the date the agreement is fully executed, rather than the July 1st performance start date. As a result, obligation dates vary depending on when each agreement is signed.
Repeat Finding 2024-003 The City has established a risk assessment tool that rates each HOPWA subrecipient across 9 factors: 1) award amount, 2) timeliness of reporting, 3) timeliness of invoicing, 4) quality of reporting, 5) program complexity, 6) staff capacity, 7) staff turnover, 8) management ch...
Repeat Finding 2024-003 The City has established a risk assessment tool that rates each HOPWA subrecipient across 9 factors: 1) award amount, 2) timeliness of reporting, 3) timeliness of invoicing, 4) quality of reporting, 5) program complexity, 6) staff capacity, 7) staff turnover, 8) management changes, and 9) grantee history. The City will use this tool to determine the appropriate level and frequency of monitoring for each subrecipient.
Repeat Finding 2024-002 The City will continue strengthening its policies, procedures, and internal controls to ensure that all amounts passed through to subrecipients under subawards, as defined in 2 CFR 200.1 are reported in accordance with the FFATA federal regulations. In addition, the City will...
Repeat Finding 2024-002 The City will continue strengthening its policies, procedures, and internal controls to ensure that all amounts passed through to subrecipients under subawards, as defined in 2 CFR 200.1 are reported in accordance with the FFATA federal regulations. In addition, the City will use obligation date for FFATA reporting.
Period of Performance – Assistance Listing No. 93.958 Recommendation: Management should review and revise its process for allocating costs to federal grants to include additional layers of review and so that costs for which some or all are from outside of the period of performance, may be appropriat...
Period of Performance – Assistance Listing No. 93.958 Recommendation: Management should review and revise its process for allocating costs to federal grants to include additional layers of review and so that costs for which some or all are from outside of the period of performance, may be appropriately excluded from the federal grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will revise cost allocation procedures to add program and finance review steps to ensure that only costs incurred within the applicable period of performance are charged to federal grants. Costs identified as outside the allowable period will be excluded or reclassified. Updated procedures will be communicated to relevant staff and monitored for compliance. Name(s) of the contact person(s) responsible for corrective action: George Pepe Planned completion date for corrective action plan: 6/30/2026
Special Tests and Provisions – Assistance Listing No. 14.267 Recommendation: We recommend program managers verify that rent reasonableness checklists and certifications are fully completed by HUD staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
Special Tests and Provisions – Assistance Listing No. 14.267 Recommendation: We recommend program managers verify that rent reasonableness checklists and certifications are fully completed by HUD staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a supervisory review process requiring program managers to review and formally sign off on rent reasonableness checklists and certifications. Staff will receive refresher training on completion requirements, and management will periodically review files to ensure documentation is complete and properly approved. Name(s) of the contact person(s) responsible for corrective action: Jamie Rotter Planned completion date for corrective action plan: 6/30/2026
Staffing Enhancement - Approval was granted for the hiring of an additional staff member dedicated to the refund process. This action increases operational capacity and strengthens segregation of duties, a key regulatory control to prevent delays in processing Title IV credit balance refunds. Staff ...
Staffing Enhancement - Approval was granted for the hiring of an additional staff member dedicated to the refund process. This action increases operational capacity and strengthens segregation of duties, a key regulatory control to prevent delays in processing Title IV credit balance refunds. Staff Training - Formal training was provided to personnel involved in the refund process to ensure compliance with updated procedures and strengthen internal controls. Technical consultations with Ellucian Banner were conducted to ensure that processes align with system best practices and institutional requirements. Completion of Procedures Manual - The procedures manual was finalized and includes standardized steps that streamline workflow, reduce operational risks, and ensure full traceability of each stage of the refund process. The manual is a mandatory reference for the personnel involved in refund process. Interdepartmental Work Schedule - A coordinated work schedule was established among Financial Aid, Bursar, and Accounting. The schedule outlines specific dates for financial aid disbursements, refund processing in student accounts, and issuance of payments to students. This measure strengthens interdepartmental coordination and supports compliance with required timelines. With the implementation of these corrective and preventive measures, the University reinforces its commitment to meeting all required timelines, improving administrative efficiency, and maintaining strong internal controls to ensure timely and compliant processing of Title IV credit balance refunds.
Upon identification of the issue, the Financial Aid Office conducted a comprehensive review of its internal procedures and implemented corrective measures to ensure full compliance with Title IV regulations. These measures included reinforcing staff training through targeted sessions, strengthening ...
Upon identification of the issue, the Financial Aid Office conducted a comprehensive review of its internal procedures and implemented corrective measures to ensure full compliance with Title IV regulations. These measures included reinforcing staff training through targeted sessions, strengthening internal monitoring controls, and confirming that the new system is properly configured to generate and track disbursement notifications. Additionally, the University is in the process of implementing the ISE system, with an expected full deployment date of April 2026, which will further enhance automation and tracking capabilities related to disbursement notifications. As part of the enhanced monitoring controls, the office has established periodic reviews of disbursement records, monthly reconciliation processes, and the routine generation and review of system reports to verify that notifications are sent timely and accurately. These steps are designed to prevent similar occurrences in the future and ensure that all students receiving Direct Loans are consistently provided with the required disbursement notifications in accordance with regulatory requirements.
Condition: The CMHSP included all contract costs, including amounts over $25,000 in the modified total direct costs. Corrective Action: Those involved in managing and reporting for the grant will review the approved budget to ensure understanding of what has been approved by SAMHSA. Prior to request...
Condition: The CMHSP included all contract costs, including amounts over $25,000 in the modified total direct costs. Corrective Action: Those involved in managing and reporting for the grant will review the approved budget to ensure understanding of what has been approved by SAMHSA. Prior to requesting funds each month, accounting assistant and chief operating officer will review total costs to date to ensure they are accounted properly in line with modified total direct costs. At year end, a final check will occur to ensure all costs are reported according to modified total direct costs methodology. Staff responsible: Kristyn Kostelec, Grant Manager, Karen Watson, Accounting Assistant, and Kelly Jenkins, Chief Operating Officer Anticipated completion date: 12/30/26
Finding 2025-002 – Significant Deficiency in internal control over major programs Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension,...
Finding 2025-002 – Significant Deficiency in internal control over major programs Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). 2 The Town did not have a process in place to check that vendors were not suspended or debarred by checking the System for Award Management (SAM) prior to entering into contracts. Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town became aware of this policy during the fiscal year 2024 audit process. This process has been remedied. Name of Contact Person: Cynthia Varricchio, MBA, Director of Finance and School Business Operations. Projected Completion Date: June 30, 2026.
2025-001 Subrecipient Monitoring Corrective action planned: Management will develop and implement written subrecipient monitoring policies and procedures. These procedures define required monitoring activities, including subrecipient risk assessments, financial and programmatic report reviews, audit...
2025-001 Subrecipient Monitoring Corrective action planned: Management will develop and implement written subrecipient monitoring policies and procedures. These procedures define required monitoring activities, including subrecipient risk assessments, financial and programmatic report reviews, audit review requirements, and follow-up on identified issues. Management will implement a standardized annual risk assessment process for all subrecipients. Risk assessments are completed prior to issuing new subawards and annually for ongoing subawards to determine the appropriate level of monitoring. Management will implement standardized monitoring tools, including financial and programmatic review checklists and site visit templates when applicable. Monitoring activities are now performed based on subrecipient risk level and documented in accordance with established procedures. Anticipated completion date: June 2026 Contact person responsible for corrective action: Mitchell Rhodes, Executive Director
The District has implemented an internal control process that requires the review and approval of detailed expenditure reports and G5 drawdown amounts prior to submission. The review process includes the Director of the Magnet Program, Finance Coordinator, Executive Director of School Leadership, an...
The District has implemented an internal control process that requires the review and approval of detailed expenditure reports and G5 drawdown amounts prior to submission. The review process includes the Director of the Magnet Program, Finance Coordinator, Executive Director of School Leadership, and the Business Manager to ensure accuracy, compliance, and proper authorization before completion.
The Town acknowledges the lack of written policy and procedures for expending federal funds and insuring vendors are not debarred, suspended, or ineligible to receive federal funds. The Town shall (1) Update its written procurement policies and procedures to require verification of vendor eligibilit...
The Town acknowledges the lack of written policy and procedures for expending federal funds and insuring vendors are not debarred, suspended, or ineligible to receive federal funds. The Town shall (1) Update its written procurement policies and procedures to require verification of vendor eligibility through SAM.gov prior to awarding any contract or issuing any purchase order funded with federal awards. (2) Require procurement staff to retain documentation of the suspension and debarment verification. (e.g., dated SAM.gov search results or vendor certifications). (3) Provide training to relevant personnel on federal procurement requirements including suspension and debarment compliance under 2 CFP Part 200.
FINDING 2025-006: FEMA Grants Response: The county finance office has implemented a project number for each grant received and follows other projects according to this numbering schedule. At the time of the initial FEMA grant operations there was not a Finance Officer in place, and all expenditure w...
FINDING 2025-006: FEMA Grants Response: The county finance office has implemented a project number for each grant received and follows other projects according to this numbering schedule. At the time of the initial FEMA grant operations there was not a Finance Officer in place, and all expenditure went into one Fund without description as to what expenditure they were covering. The FEMA grants for events in 2022 and 2023 are near close out with FEMA and the State, all revenue from these grants has been redeemed.
Although the updated MDHHS form 5522 has the same information as the outdated form, MDHHS was contacted to ensure Sacred Heart is on the state listserv to receive all MDHHS email updates and the program leader will contact the Contract Monitor prior to the start of the new contract year and search t...
Although the updated MDHHS form 5522 has the same information as the outdated form, MDHHS was contacted to ensure Sacred Heart is on the state listserv to receive all MDHHS email updates and the program leader will contact the Contract Monitor prior to the start of the new contract year and search the website periodically to ensure there are no updates to forms. All updated forms will be distributed to case managers.
Finding Number: 2025-003 Planned Corrective Action: The City’s Department of Finance and Management concurs with the finding in the State and Local Fiscal Recovery Fund and will take the following actions in response: • Subrecipient monitoring will be performed by contracted CPA consultant for the o...
Finding Number: 2025-003 Planned Corrective Action: The City’s Department of Finance and Management concurs with the finding in the State and Local Fiscal Recovery Fund and will take the following actions in response: • Subrecipient monitoring will be performed by contracted CPA consultant for the one subrecipient (Heart of JOB) who showed no evidence of review of financial reports, site visits, and other oversight activity during the audit period. • Reissue written procurement policies and procedures to incorporate the aforementioned expectation and requirement; and • Although not anticipated due to the expiration of the SLFRF funding, procedures are established for any potential monitoring. Anticipated Completion Date: 11/30/2026 Responsible Contact Persons: Adam Robins, Deputy Director, Finance and Management Kali Harris, Federal Grants Coordinator
Finding Number: 2025-001 Planned Corrective Action: The City concurs with the finding and will take the following action in response: • The Department of Finance and Management, Grants Management section, will work with the Department of Development for collection and submission of HOPWA Subrecipien...
Finding Number: 2025-001 Planned Corrective Action: The City concurs with the finding and will take the following action in response: • The Department of Finance and Management, Grants Management section, will work with the Department of Development for collection and submission of HOPWA Subrecipient information for FFATA FSRS reporting that have not been reported in SAM.gov. • Columbus Public Health (Ryan White) promptly addressed this matter and implemented corrective actions to ensure full compliance with applicable requirements. In accordance with the subaward reporting provisions of the Federal Funding Accountability and Transparency Act (FFATA), the agency has revised its vendor determination form—utilized for all contractual agreements—to incorporate the required reporting criteria. All subawards exceeding $30,000 under UT833926 have been reported in SAM.gov. Data will be entered into the corporate system no later than the month following the execution of the contract. Going forward, all qualifying subawards will be entered into SAM.gov by the Fiscal Analyst in a timely manner, and the Fiscal Manager will perform an annual review to verify compliance with FFATA reporting requirements. Anticipated Completion Date: 6/30/2026 Responsible Contact Persons: Adam Robins, Deputy Director, Finance and Management Lucie McMahon, Grants Management Coordinator, Department of Housing and Urban Development Erin Prosser, Deputy Director, Department of Development Alex Cofield, Development Program Coordinator/Compliance & Special Projects Anticipated Completion Date: 3/24/2026 Responsible Contact Persons: Anita Clark, Assistant Health Commissioner, Columbus Public Health Katie Pettiford, Fiscal Manager
FINDING 2025-006: Program Income Response: This repeat finding is related to the Districts LINKS afterschool program supported by 21st Century funding. The Office of Public Instruction (OPI) performed monitoring of Livingston schools 21st Century program in August of 2024 and determined the District...
FINDING 2025-006: Program Income Response: This repeat finding is related to the Districts LINKS afterschool program supported by 21st Century funding. The Office of Public Instruction (OPI) performed monitoring of Livingston schools 21st Century program in August of 2024 and determined the District was not in compliance with changes to federal regulations made in 2018. The District has made all recommended changes from OPI and is now in compliance with federal regulations.
FINDING 2025-005: Private/Home School Communications Response: This issue was an oversight as we transitioned Curriculum Directors. Communications to private/home school students have been completed in FY26 and we will monitor compliance requirements for federal grants in the future to prevent this ...
FINDING 2025-005: Private/Home School Communications Response: This issue was an oversight as we transitioned Curriculum Directors. Communications to private/home school students have been completed in FY26 and we will monitor compliance requirements for federal grants in the future to prevent this from occurring again.
A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on Finding and Each Recommendation Management agrees with the finding and the transition of responsibilities to the new President has been further identified and understood since ste...
A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on Finding and Each Recommendation Management agrees with the finding and the transition of responsibilities to the new President has been further identified and understood since stepping into the role in November 2024. b. Action(s) Taken or Planned on the Finding Identification and understanding of the reporting deadlines, along with the necessary access to facilitate the transmission of data. Going forward the Data Collection Form will be prepared by the management company and reviewed and approved by the President of the Pelham Corporation prior to submission. This action has been completed during 2025. This will allow the timely submission going forward B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, Questions Costs and Recommendations There were no open findings on the prior audit report.
Condition: On May 15, 2025, ISBE communicated to the District that ARP ESSER recipients had until May 24, 2025 to liquidate obligations and that the District needed to submit its expenditure report to ISBE by May 21, 2025 for ISBE to process and submit to the U.S. Department of Education by the new ...
Condition: On May 15, 2025, ISBE communicated to the District that ARP ESSER recipients had until May 24, 2025 to liquidate obligations and that the District needed to submit its expenditure report to ISBE by May 21, 2025 for ISBE to process and submit to the U.S. Department of Education by the new deadline. On May 21, 2025, the District submitted a claim for reimbursement of expenditures totaling $4,343,814. The expenditures comprising this claim by date incurred and liquidated were as follows: $1,668,710 incurred through May 21, 2025 and liquidated as of that date $31,692 incurred through May 21, 2025 but not liquidated as of that date $325,805 incurred from May 21, 2025 through June 30, 2025 and liquidated as of June 30, 2025 $531,321 incurred from May 21, 2025 through June 30, 2025 but not liquidated as of June 30, 2025 $1,786,286 incurred after June 30, 2025 At May 21, 2025 and June 30, 2025, expenditures totaling $2,675,104 and 2,349,299, respectively, out of the $4,343,814 claimed for reimbursement were not incurred, not liquidated or both and, therefore, did not qualify for reimbursement based on the Federal statutes, regulations and the terms and conditions of the Federal award in effect at those dates. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over compliance. Responsible Person: Dr. Maureen M. White, Superintendent Anticipated Completion Date: June 30, 2026
Finding #2025-001: Comments on the Finding and Each Recommendation: During the year ended December 31, 2025, the Corporation did not make the HUD required total amount of deposits to the reserve for replacements. Management should transfer $19,826 from the operating account to the reserve for replac...
Finding #2025-001: Comments on the Finding and Each Recommendation: During the year ended December 31, 2025, the Corporation did not make the HUD required total amount of deposits to the reserve for replacements. Management should transfer $19,826 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. On February 3, 2026, management transferred $20,258 from the operating account to the reserve for replacements. 35
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