Corrective Action Plans

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The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls o...
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls over all Other Than Personal Services (OTPS) expenditures. To ensure full compliance with 2 CFR 200.303 and 200.403, Finance has deployed the following enhancements to our accounts payable workflows: • Strict Electronic Approval Workflow: Finance has established a stringent review and approval protocol that requires direct involvement from Program Directors and Department Heads. All OTPS expenditures are now routed through a formalized electronic workflow, which mandates documented review and secure electronic signatures from authorized leadership prior to any payment processing. • System-Integrated Documentation: The new process strictly requires that all supporting documentation-including invoices, receipts, and evidence of allowability-be provided upfront. These documents are now uploaded and attached directly to the specific transaction within the accounting program, creating a permanent, easily accessible, and audit-ready trail for every federal charge. • Targeted Training and Oversight: To support this modernized workflow, Finance is providing targeted training to all staff responsible for initiating and approving transactions, ensuring a clear understanding of Uniform Guidance requirements. Furthermore, Finance leadership conducts periodic supervisory reviews directly within the accounting system to verify that all electronic approvals are captured and source documents are properly attached.
Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and institut...
Management has reviewed the finding regarding the documentation of program eligibility. We recognize the importance of maintaining clear, audit-ready files that explicitly demonstrate case ownership and supervisory approval. To ensure full alignment with 2 CFR § 200.300, we have drafted and instituted the following corrective actions: • Updated Internal Signature Policy: We have drafted a strict internal policy requiring the primary case manager-and any other staff actively working on a case-to sign and date all required enrollment documents. This explicitly includes signing intake forms and completing the interpreter sections, where applicable. This policy ensures there is never any ambiguity regarding who is handling the case. • Mandatory Supervisory Review: To enforce this new standard, our internal policy now requires Program Managers and Directors to systematically review each individual case file. Leadership must verify that all required staff signatures, interpreter sign-offs, and eligibility approvals are fully documented before a client's enrollment is considered complete. • Standardized Case Coversheet: To immediately resolve the issue of identifying case handlers, we are implementing a standardized enrollment coversheet for all new files. This document clearly assigns the primary case manager on day one and requires a final supervisory signature to formally authorize the eligibility review. • Targeted Training and Spot-Checks: We are conducting immediate refresher training for all program staff to clarify exactly which signatures are required on each document. Furthermore, leadership will conduct routine, random spot-checks of active case files each month to verify that staff are consistently adhering to this policy in real-time. By formalizing our signature requirements and mandating director-level reviews, we are confident this updated workflow establishes clear accountability and fully resolves the finding.
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorpor...
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.
The District acknowledges the failure to submit the Single Audit data collection form for the fiscal year ended June 30, 2023 to the Federal Audit Clearinghouse within the required 30-day post-opinion deadline. The form was never submitted for that fiscal year. Additionally, for the fiscal year ende...
The District acknowledges the failure to submit the Single Audit data collection form for the fiscal year ended June 30, 2023 to the Federal Audit Clearinghouse within the required 30-day post-opinion deadline. The form was never submitted for that fiscal year. Additionally, for the fiscal year ended June 30, 2024, the District’s accounting records were not available until March 2026, causing the audit to extend well beyond the required nine-month completion deadline and resulting in further noncompliance with Single Audit reporting requirements. Current management has improved procedures related to the management of Single Audit compliance obligations. The District, in coordination with the third-party accounting firm and the external auditor, has established a compliance calendar that identifies all Single Audit submission deadlines and assigns responsibility for preparation, certification, and submission of the data collection form. Procedures have been implemented to ensure accounting records are available on a timely basis to support completion of the audit within the required nine-month window, starting with the fiscal year ending June 30, 2026. We plan to ensure that the fiscal year ended June 30, 2023 data collection form is submitted to the Federal Audit Clearinghouse and that the fiscal year ended June 30, 2024 Single Audit is completed and submitted within 30 days of the audit opinion date, and that all future Single Audit data collection forms are submitted in a timely manner. Estimated date of implementation of the corrective action plan: Ongoing Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colora...
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colorado Department of Education, for the fiscal year ended June 30, 2024. Specifically, the District lacked adequate segregation of duties over payroll and human resources processes, both of which were performed by a single employee without a secondary review. In addition, the District did not maintain adequate reimbursement request documentation or regularly reconcile ESSER grant expenditures to reimbursement requests, as required under 2 CFR 200.303. These conditions resulted in material audit 60 adjustments, significant audit delays, and the engagement of a third-party accounting firm to reconstruct grant records. Notwithstanding these control deficiencies, the District was in compliance with allowable activities, allowable costs, and cash management requirements, as allowable costs exceeded the amounts requested for reimbursement. Current management has improved procedures related to the oversight of federal grant compliance and payroll processes. The District has engaged a third-party accounting firm and hired new staff to assist with grants reconciliation, reimbursement request preparation, and internal controls over federal awards. A secondary review process has been established for payroll and human resources transactions to ensure that no single employee has unchecked control over these functions. Grant reconciliation responsibilities have been reassigned to incorporate segregation of duties, and a defined schedule for monthly ESSER reconciliations and reimbursement submissions has been implemented. We plan to have all ESSER grant activity fully reconciled, reimbursement documentation complete and available for review, and monthly reconciliation and secondary review procedures operational and documented for all applicable federal grant programs prior to the start of the audit process. Estimated date of implementation of the corrective action plan: June 30, 2026 Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood
2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...
2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2024-003 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@har...
2024-003 SCDA Eligibility Material Weakness and Non-Material Noncompliance Corrective Action: We've hired competent staff that will maintain records of the 3 (Partner, Training and TEFAP) agreements that Agencies will sign annually for compliance. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2024-002 SCDA Special Tests Significant Deficiency and Non-Material Noncompliance Corrective Action: We've hired competent staff that understand how to reconcile inventory to the general ledger. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
2024-002 SCDA Special Tests Significant Deficiency and Non-Material Noncompliance Corrective Action: We've hired competent staff that understand how to reconcile inventory to the general ledger. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
The Parish has established a subrecipient checklist to assess risk and compliance. The checklist will be completed as an additional measure to ensure the standards outlined in the "Grant Adminstration Policies & Procedures" are met.
The Parish has established a subrecipient checklist to assess risk and compliance. The checklist will be completed as an additional measure to ensure the standards outlined in the "Grant Adminstration Policies & Procedures" are met.
U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional ...
U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional training over fiduciary responsibilities under the CSBG Act. The Neighborhood Service Center, Inc. should adhere to the board composition and vacancy reporting requirements. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Executive Director and Deputy Director of the Neighborhood Service Center are actively recruiting individuals to join the Board. The Deputy Director, or their designee, will provide information to the Maryland Department of Housing and Community Development on the Board composition and vacancies on a monthly basis. Name of the contact persons responsible for corrective action: E. Yvette Robinson, Deputy Director Planned completion date for corrective action plan: For immediate implementation and ongoing.
U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation ...
U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation prior to signing the check. Documentation of that review and approval shold be readily for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: All checks presented for signatures have supporting documentation attached. Authorized check signers are instructed to review all documentation for appropriate authorization, payee name, and amounts prior to signing checks. No checks are signed without supporting documentation. The agency will require check signers to initial the check request page or other supporting documentation when signing checks for grant expenditures. The Neighborhood Service Center, Inc. is implementing a procedure to provide the Finance Committee of the Board with a listing of all checks issued between Board meetings for their review/reference. The Finance Director keeps all check stock locked in their office to avoid any potential misuse of the check stock. Name of the contact persons responsible for corrective action: R. Andrew Hollis, Executive Director Michele Lednum, Finance Director Planned completion date for corrective action plan: For immediate implementation and ongoing.
The Organization reduced the indirect rate charged to the grant to the de minimis 10% during 2024.
The Organization reduced the indirect rate charged to the grant to the de minimis 10% during 2024.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors...
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors will be adjusted each period to ensure that account and ledger totals are properly maintained and recorded. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over bank reconciliations, accounts payable and grants receivable. Controls and the policies and procedures have been reviewed with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely reconciliations. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income doc...
2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2026
The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Prefe...
The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Preference will be included in future contracts where federal funds are expended. The Safety-Service Director will check for SAM exclusions and will request a waiver to this requirement if necessary.
We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.
We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.
CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. Th...
CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-003 Document Policies and Procedures Over Federal Awards Views of responsible officials: The Town agrees with the recommendation to implement written policies and procedures to be in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action: The Town plans to implement recommendations for the next fiscal year. Official Responsible for Implementing Corrective Action: Kurt Ginthwain Finance Director/Town Accountant
Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit...
Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit for the year ended December 31, 2024 within the required nine month deadline under 2 CFR 200.512. As of September 30, 2025, no single audit report has been issued or filed, resulting in noncompliance with federal audit requirements. Views of Responsible Officials and Corrective Action Plan: Management has developed and implemented corrective actions to address this finding. As of January 1, 2026, formal procedures for FAC submission have been established, including defined roles, internal deadlines, and review protocols. A compliance tracking system has been implemented to monitor key reporting deadlines, and staff have received training on federal requirements. Management will continue to monitor adherence to these procedures to ensure timely submission in future reporting periods. Implementation date: January 1, 2026
Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the orga...
Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the organization is in the process of evaluating and implementing an electronic system to streamline and document approvals for accounts payable and credit card transactions. These steps will strengthen internal controls and ensure proper documentation of all approvals in accordance with organizational policies and federal requirements. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: May 31, 2026
CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all requi...
CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all required deadlines. • Assign a designated preparer and reviewer for each reporting cycle. • Provide training on the Treasury reporting portal. • Implement a pre-submission checklist to ensure completeness and accuracy. • Conduct semiannual internal reviews of reporting processes and documentation. Responsible Staff Chief Financial Officer (CFO) Target Completion Date July 31, 2026
Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with ...
Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026
CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be t...
CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be taken: • Developing written procedures for PR28 and CAPER preparation and submission. • Implementing a compliance calendar with required reporting deadlines. • Assigning both primary and secondary preparers to ensure redundancy. • Providing HUD IDIS training to relevant staff. • Conducting supervisory review prior to submission. • Hired a Grants Compliance Specialist to support ongoing compliance.(10/2025) Responsible Staff Grants Administrator Target Completion Date August 31, 2026
Views of Responsible Officials Management agrees with the federal award finding identified in the audit. The System Fund will file the audit reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with audit partner and frequently...
Views of Responsible Officials Management agrees with the federal award finding identified in the audit. The System Fund will file the audit reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline.
Management acknowledges that personnel turnover during the fiscal year resulted in temporary gaps in segregation of duties and continuity of financial oversight. Since September 2024, the accounting team has achieved stability in key positions, significantly improving consistency in financial proces...
Management acknowledges that personnel turnover during the fiscal year resulted in temporary gaps in segregation of duties and continuity of financial oversight. Since September 2024, the accounting team has achieved stability in key positions, significantly improving consistency in financial processes and oversight. In addition, the Organization is implementing Blackbaud Financial Edge in FY2027, which will enhance internal controls through system-based workflows, role-based permissions, and audit trails. These system improvements, combined with stabilized staffing, will strengthen segregation of duties and reduce reliance on manual compensating controls. Management is committed to maintaining appropriate staffing levels, cross-training team members, and clearly defining backup responsibilities to ensure continuity of financial operations and compliance with internal control standards. Actions Taken - Stabilized accounting and finance team staffing beginning September 2024 - Implemented cross-training and defined backup roles for key financial functions - Increased supervisory review and oversight during periods of transition - Initiated implementation of Blackbaud Financial Edge with enhanced internal control capabilities (go-live planned for FY2027)
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