Corrective Action Plans

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Name of auditee: THF San Gabriel Holdings, LLC HUD auditee identification number: 115-11319 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Allison Milliorn Position: Chief Executive Officer Telephone number: 830-693-8...
Name of auditee: THF San Gabriel Holdings, LLC HUD auditee identification number: 115-11319 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Allison Milliorn Position: Chief Executive Officer Telephone number: 830-693-8100 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2024-001: Comments on the Finding and Each Recommendation: For the year ended December 31, 2023, the Company did not submit the Data Collection Form (SF-SAC) to the Federal Audit Clearinghouse in the time period required by Uniform Guidance Section 2 CFR 200.512. Action(s) taken or planned on the finding: The Data Collection Form was submitted to the Federal Audit Clearinghouse on May 10, 2024 and management will submit the Data Collection Form timely going forward.
Finding 1156663 (2024-003)
Material Weakness 2024
The Commissioner’s office will implement additional policies to ensure verification is performed to ensure a vendor is not suspended, debarred, or otherwise excluded from a project and to ensure documentation is maintained.
The Commissioner’s office will implement additional policies to ensure verification is performed to ensure a vendor is not suspended, debarred, or otherwise excluded from a project and to ensure documentation is maintained.
Finding 2024-005- Suspension and Debarment Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Respo...
Finding 2024-005- Suspension and Debarment Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All contracts over $25,000 will now include a Suspension and Debarment Clause. Anticipated Completion Date: Immediately
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of ...
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of Responsible O􀆯icials: We concur with the findings. Description of Corrective Action Plan: The Grant Administrator will monitor all claims that will be used for the quarter and send them to the reporting agent to report after the quarter ends. She will be diligent to track any claims coming in outside of that quarter so that reporting is accurate. She will provide the reporting agent with all claims relevant to that quarter’s report. Anticipated Completion Date: This will be done quarterly starting with the quarter ending on September 30th, 2025. The Grant Administrator will submit these claims to the reporting agent one week after the quarter ends. The Financial Administrator will sign o􀆯 on the LOW report to verify the claims match.
FINDING 2024-003 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / asta...
FINDING 2024-003 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Procurement and Suspension and Debarment Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of Responsible O􀆯icials: We concur with the findings. Description of Corrective Action Plan: To prevent future mishaps, the Grant Assistant will email department heads educating them on the procedures and expectations for suspension and debarment assessment. The email will be a step-by-step process for those responsible for checking suspension and debarment. This will prevent subrecipients from being missed. She will also check for suspension/debarment for each contractor/subrecipient through the County within a month of receiving a signed contract. This will ensure all contracts with the County are complying. Anticipated Completion Date: The Grant Assistant will begin this corrective action plan on October 1st, 2025.
Management agrees with the finding and is working on submission of the federal reporting package for the year ended December 31, 2023. The submission of the December 31,2024 federal reporting package will be completed prior to its due date.
Management agrees with the finding and is working on submission of the federal reporting package for the year ended December 31, 2023. The submission of the December 31,2024 federal reporting package will be completed prior to its due date.
Action taken in response to finding: The County will review the subrecipient monitoring requirements and work with the County Auditor to develop a formal policy that includes internal controls, monitoring procedures, and documentation requirements.
Action taken in response to finding: The County will review the subrecipient monitoring requirements and work with the County Auditor to develop a formal policy that includes internal controls, monitoring procedures, and documentation requirements.
Action taken in response to finding: The County will identify all federal awards that FFATA reporting is required. Once all the requirements are identified, the County will then determine if there are eligible subrecipients or contracts that need to be reported on the FFATA website.
Action taken in response to finding: The County will identify all federal awards that FFATA reporting is required. Once all the requirements are identified, the County will then determine if there are eligible subrecipients or contracts that need to be reported on the FFATA website.
Finding 1156582 (2024-003)
Material Weakness 2024
FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corrective Action: W...
FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corrective Action: We concur with the finding. Description of Corrective Action Plan: The annual reporting for fund 8950 – Coronavirus State and Local Fiscal Recovery Funds with the Treasury shall be prepared by the First Deputy, reviewed by an independent accountant to verify and consult that all the information is correct, and the final report will be reviewed and approved by the County Auditor before submission. Anticipated Completion Date: Next annual reporting Due April 30, 2026 for 2025
Finding 1156581 (2024-002)
Material Weakness 2024
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corre...
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Lisa Clark/Benock Contact Phone Number and Email Address: 812-885-2502 lcbenock@knoxcounty.in.gov Views of Responsible for Corrective Action: We concur with the finding. Description of Corrective Action Plan: The County will provide documentation that the vendor/contractor is not suspended or disbarred from participation in federal award programs. The First Deputy will review the website www.sam.gov, a tool to use to look for active exclusions for the contractor/vendor, for any active exclusions, and the County Auditor will review the verification. Anticipated Completion Date: Immediately
Finding 1156559 (2024-002)
Material Weakness 2024
The Mental Health and Recovery Board corrected finding 2023-002 on 9/30/24 by adding Suspension and Debarment language to all Contracts and Service Agreements as stated in the 2023 Corrective Action Plan. The contract that was cited in finding 2024-002 was executed on 6/12/2024 which was prior to th...
The Mental Health and Recovery Board corrected finding 2023-002 on 9/30/24 by adding Suspension and Debarment language to all Contracts and Service Agreements as stated in the 2023 Corrective Action Plan. The contract that was cited in finding 2024-002 was executed on 6/12/2024 which was prior to the notification of the 2023 finding.
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025
View Audit 368884 Questioned Costs: $1
Views of Responsible Officials: We acknowledge this lapse. We have already updated procedures to ensure that we are registering subgrants correctly.
Views of Responsible Officials: We acknowledge this lapse. We have already updated procedures to ensure that we are registering subgrants correctly.
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends amending existing subaward agreements to include the award information required by CFR 200.332(b) and to verify all future subawards agreements include all necessary information prior to iss...
USAID Foreign Assistance for Programs Overseas – Assistance Listing No. 98.001 Recommendation: CLA recommends amending existing subaward agreements to include the award information required by CFR 200.332(b) and to verify all future subawards agreements include all necessary information prior to issuance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: SFP will revise its subaward agreement template to include all necessary award information as required by CFR 200.332(b). Name(s) of the contact person(s) responsible for corrective action: Annie Haylon Planned completion date for corrective action plan: October 31, 2025
Federal Award Finding: 2024-001 Material Weakness in Internal Control over Cash Management Name and Contact Person: Laurie Stuart, Executive Director Corrective Action: The Organization has evaluated and revised the processes and procedures regarding cash management and reporting, in efforts to mini...
Federal Award Finding: 2024-001 Material Weakness in Internal Control over Cash Management Name and Contact Person: Laurie Stuart, Executive Director Corrective Action: The Organization has evaluated and revised the processes and procedures regarding cash management and reporting, in efforts to minimize the time elapsing between the transfer of funds from the awarding agency and disbursement by the Organization. The Organization also has processes in place for maintaining detailed records supporting all grant payments, disbursements to vendors, and tracking of grant advances still outstanding. Additionally, the Organization is monitoring interest earned on grant advances and has processes in place to remit interest as appropriate when required in accordance with Uniform Guidance. Management has appointed an individual to oversee these processes for each grant. Management will also submit a revised annual financial report [FFR] for USFWS Agreement No. F23AC02320 to correct any errors related to cash on hand amounts reported. Proposed Completion Date: December 31, 2025
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.
Corrective Action Plan Year Ended December 31, 2024 Finding 2024-001 – Cash Management – Pass-Through Entities Condition: Texas Biomed Research Institute (Texas Biomed) did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days ...
Corrective Action Plan Year Ended December 31, 2024 Finding 2024-001 – Cash Management – Pass-Through Entities Condition: Texas Biomed Research Institute (Texas Biomed) did not provide evidence of effectively designed internal controls to ensure subrecipients are paid by Texas Biomed within 30 days of requests for reimbursement received by Texas Biomed. In 18 instances, Texas Biomed paid subrecipients after 30 days of receipt of the request for reimbursement from the subrecipient, resulting in noncompliance with 2 CFR 200.305(b)(3). Corrective Action Plan: Effective June 1, 2023 Texas Biomed implemented enhanced controls to ensure timely entry of subrecipient invoices into the financial system and timely approvals by Principal Investigators (PIs) of invoices. While these controls were operating effectively after the implementation date, turnover within the Accounts Payable team had not been anticipated and led to delayed payment processing. In mid-2024, Texas Biomed implemented a new electronic AP/invoice system as part of a comprehensive Enterprise Resource Planning system (and associated supporting systems) conversion to enhance efficiencies and functionality. With implementation of new systems, control enhancements enabled by the systems were implemented. This included setting up subawards as Purchase Orders, which enabled automation of a previously manual process to secure PI approval of invoices. Accounts Payable staff have been trained on how to properly enter subaward invoices into the system to trigger electronic routing to the PI for approval. While these steps will streamline the approval process, a further mitigating control will be implemented, with Accounts Payable staff periodically tracking approvals of pending subrecipient invoices and notifying the appropriate Sponsored Program Administrator for follow up with PIs in the event of delayed approvals. Responsible Parties: Eva Zepeda, Director, Finance; Michelle Hyde, Controller Completion Date: September 30, 2024
Report period: 12/31/2024 Title of result and comment FY24 Audit Corrective Action Plan Contact person Responsible for Sabrina Bollinger Corrective Action: Contact's Phone Number 248-593-4611 Contact's Email Address: sbollinger@fourmidable,com Views of Responsible Official: Management agrees with th...
Report period: 12/31/2024 Title of result and comment FY24 Audit Corrective Action Plan Contact person Responsible for Sabrina Bollinger Corrective Action: Contact's Phone Number 248-593-4611 Contact's Email Address: sbollinger@fourmidable,com Views of Responsible Official: Management agrees with the auditor's finding and will implement the auditor's recommendations. Description of Corrective Action Plan The Commission should implement internal controls over tenant files to ensure accountability. Allcertifications and the required documentation should be maintained in the tenant's current file. Additionally,in order to ensure certifications are performed timely and tenant information is input correctly, theCommission should have a second party review files in a timely manner. Anticipated Completion Date: The plan is to implement the corrective action within six months of the audit date. If applicable: Document reason issue will NOT be corrected with 6 months: N/A
View Audit 368862 Questioned Costs: $1
Subrecipient Monitoring and Suspension & Debarment. Neighborhood & Community Services (NCS) has existing processes to ensure subrecipient monitoring requirements and suspension and debarment requirements. While not all JAG subrecipients had previously been included, beginning in 2025, all subrecipie...
Subrecipient Monitoring and Suspension & Debarment. Neighborhood & Community Services (NCS) has existing processes to ensure subrecipient monitoring requirements and suspension and debarment requirements. While not all JAG subrecipients had previously been included, beginning in 2025, all subrecipients of JAG funding are being included in NCS processes. Specifically, one position (Contract/Program Auditor) is assigned to each contract and is responsible for verifying and documenting suspension and debarment at award and at the annual renewal and also for ensuring monitoring is completed. Prior to the audit, NCS had begun scheduling with the subrecipient that had not been monitored, consistent with NCS processes. NCS is currently also developing a grant handbook to ensure that all staff are aware of general and specific grant requirements and processes for managing grants. Procurement. The City’s procurement policies and procedures outline the process for the competitive procurement of services using federal funds, in alignment with federal regulations. However, the City acknowledges that certain aspects of the current policies maybe unclear or inconsistence with existing procedures. Additionally, the City recognizes that its internal controls are not fully effective in ensuring that all departments consistently comply with these policies and procedures. To strengthen internal control, the City will revise its procedure and develop and implement training around federal grants for staff responsible for managing or overseeing these contracts.
To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will take the following actions: Update training material for all accounting staff and City departments managing federal grants. Update and distribute monthly email to departments to clarify the required informatio...
To meet Federal Funding and Transparency Act (FFATA) reporting requirements, the City will take the following actions: Update training material for all accounting staff and City departments managing federal grants. Update and distribute monthly email to departments to clarify the required information for FFATA filing and require responses with supporting documentation for review. If responses are not received in a timely manner, a second email will be sent to those individuals, requiring an immediate action. Periodically review federal reporting requirements for any updates and adjust the reporting process as needed, utilizing resources such as the State Auditor’s Office (SAO) Newsletter, conferences, and trainings.
Corrective Action:  Housing service leadership staff have developed a HUD‐compliant Rent Reasonableness Policy to ensure that each lease served through NWYS will have documentation supporting compliance with federal reasonable rental rates. NWYS housing service leadership staff will follow this pol...
Corrective Action:  Housing service leadership staff have developed a HUD‐compliant Rent Reasonableness Policy to ensure that each lease served through NWYS will have documentation supporting compliance with federal reasonable rental rates. NWYS housing service leadership staff will follow this policy and procedure to ensure rental rates fall within federal grant compliance requirements at the time of each lease signing or renewal. Documentation of rent reasonableness certification will be performed by NWYS housing staff, reviewed by NWYS housing service leadership, and maintained in the client’s permanent file, as defined in the NWYS Rent Reasonableness Policy. Name(s) of Responsible Party:  NWYS Housing leadership staff – Luis Reyna, Addison Ausley, Daniel Pry Anticipated Completion Date:  9/5/25
View Audit 368841 Questioned Costs: $1
Finding 1156477 (2024-002)
Material Weakness 2024
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.
Finding 1156474 (2024-001)
Material Weakness 2024
Rent Reasonableness forms for rental payments made with CoC funds were not always completed in a timely fashion. Additionally, there was inadequate evidence of internal review and approval. In late 2024, LifeWire’s Controller began requiring Rent Reasonableness forms to be provided with every rental...
Rent Reasonableness forms for rental payments made with CoC funds were not always completed in a timely fashion. Additionally, there was inadequate evidence of internal review and approval. In late 2024, LifeWire’s Controller began requiring Rent Reasonableness forms to be provided with every rental payment request made with public funds. LifeWire’s AP approval process requires review and approval by members of the Director team before payments can be issued. In 2025, all rental payments made with CoC funds now have documented evidence of internal approval and review. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: The new process was rolled out in November 2024.
We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.
We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.
View Audit 368800 Questioned Costs: $1
Corrective Action Plan Finding Reference: Finding No. 2024-001 – Federal Funding Accountability and Transparency Act Reporting (FFATA) Date of finding: Financial Audit 2024 Responsible Parties: Amy Frizzi and David Mangene 1. Management's Response Management accepts the finding and agrees with the a...
Corrective Action Plan Finding Reference: Finding No. 2024-001 – Federal Funding Accountability and Transparency Act Reporting (FFATA) Date of finding: Financial Audit 2024 Responsible Parties: Amy Frizzi and David Mangene 1. Management's Response Management accepts the finding and agrees with the auditor's recommendations and further acknowledges that a subaward contract under which FFATA reporting was required was not submitted within the required 30 days after the subaward was executed. 2. Corrective Action FFATA Reporting: Wadhwani Institute for Artificial Intelligence Foundation (WIAI) is working to gain access to the SAM.gov reporting capabilities for the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) to ensure proper reporting for any and all required FFATA reporting is met for new federal subawards. Process Enhancement: WIAI will ensure comprehensive reporting processes for federal grants are in place prior to engaging as a prime or subrecipient, including tracking reporting and other significant deadlines. 2024 Finding Resolution: The specific grant referenced in this finding was terminated in January 2025. The awarding agency (USAID) has since been functionally dismantled by the Trump administration, with 83% of programs eliminated as of March 2025 and remaining functions transferred to the State Department. Given the agency's operational dissolution and the grant's termination, late FFATA reporting for the 2024 subaward is not feasible through normal channels. Management will monitor for any guidance from the State Department regarding reporting obligations for grants from the former USAID structure. 3. Timeline FSRS Access: Target completion by December 2025 (pending SAM.gov registration resolution) Process Documentation: Within 60 days of FSRS access being obtained Full Implementation: Upon receipt of next federal subaward requiring FFATA reporting Ongoing Monitoring: Monthly grant reviews and comprehensive year-end validation Prepared by: Ann Marie Ilibasic, Grants & Compliance Consultant Reviewed by: David Martin, Audit Committee Chair Next Review Date: Fiscal Year End 2025
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