Corrective Action Plans

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Finding 485172 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a ...
Finding 2024-002 Personnel Responsible for Corrective Action: Cathy Gorrell, Registrar Anticipated Completion Date: September 30, 2024 Corrective Action Plan: The Office of the Registrar recognizes the systematic programming of a pseudo academic program after a pseudo course has been added with a future date after the student’s current program has been inactivated or graduated. This process has been at the request of the Office of Student Accounts for the graduation fee. The Office of the Registrar will work with the Office of Student Accounts to move to the system Graduation Application process rather than the customized and manual process of pseudo courses. Further, the Office of the Registrar has increased its data quality checks on the pseudo programs and courses. In conjunction, this should eliminate the reporting of active programs when the student has graduated.
Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the...
Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization recognizes the deficiency of internal controls regarding determination, recording, and monitoring of the sliding fee process from application through adjustment. The Organization has acknowledged that along with our Finance Team being new to the position for all of 2023 along with the realization that our electronic medical record was making an automatic adjustment on the Federal Poverty Level. This automatic adjustment issue has been resolved. We also reviewed the monthly adjustments and have implemented a monthly oversight process to review adjustments made to patient accounts. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.
Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 from the operating account to the reserve for replacements account. Action(s) tak...
Finding #2024-001 Comments on Findings and Recommendation: During the year ended March 31, 2024, deposits to the reserve for replacements account were $236 less than the required amount. Management should transfer $236 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.
View Audit 310491 Questioned Costs: $1
Financial Statement Finding: 2023-004 Material Weakness in Internal Control over Compliance and Noncompliance – Subrecipient Monitoring – Repeat Finding Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: A process will be developed to ensure that there is a review perfor...
Financial Statement Finding: 2023-004 Material Weakness in Internal Control over Compliance and Noncompliance – Subrecipient Monitoring – Repeat Finding Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: A process will be developed to ensure that there is a review performed and documentation retained for all subawardee’s risk assessments through reviewing their status via sam.gov. Proposed Completion Date: March 2027
The County will engage in competent consulting services to advise prior to audit findings of any deficiencies in the County's policies, procedures or recording keeping required of the federal funds.
The County will engage in competent consulting services to advise prior to audit findings of any deficiencies in the County's policies, procedures or recording keeping required of the federal funds.
The County Board is continuously monitoring award recipients and bas a process established that prevents disbursement of fonds until proof of use is provided to the County Board.
The County Board is continuously monitoring award recipients and bas a process established that prevents disbursement of fonds until proof of use is provided to the County Board.
The County Board does not believe the finding is appropriate. The Recipient "partner" was not an elected official at the time of application or award. The funds were utilized to restore a building located in the County and owned by a County resident. The County Board believes that this award falls w...
The County Board does not believe the finding is appropriate. The Recipient "partner" was not an elected official at the time of application or award. The funds were utilized to restore a building located in the County and owned by a County resident. The County Board believes that this award falls within the parameters of economic development, one of the allowable uses of the funds. Again, the Auditor has failed to provide any legal basis for the belief of the Auditing Firm or what legal opinion they relied upon in forming their beliefs.
The Organization agrees with the audit finding. There were gaps in information flow due to staff turnover. The Organization already has a process in place to maintain documentation in a logical manner with adequate access.
The Organization agrees with the audit finding. There were gaps in information flow due to staff turnover. The Organization already has a process in place to maintain documentation in a logical manner with adequate access.
We agree with this finding and will document approval for changes in budgets with subgrantees.
We agree with this finding and will document approval for changes in budgets with subgrantees.
We agree with this finding and will include the relevant information in our subawards in the future.
We agree with this finding and will include the relevant information in our subawards in the future.
The City of North Bend acknowledges that a contract utilizing SLFR funds, and awarded to a software vendor, did not include within the contract, a required self-attestation concerning Suspensions and Debarment. The self-attestation was used in lieu of a documented review of the SAM.gov portal for su...
The City of North Bend acknowledges that a contract utilizing SLFR funds, and awarded to a software vendor, did not include within the contract, a required self-attestation concerning Suspensions and Debarment. The self-attestation was used in lieu of a documented review of the SAM.gov portal for suspensions and debarment. This was an oversight of the contract review process. Other contracts issued during the same period included self-attestation language from 2 CFR 200.317 through 2 CFR 200.327. In 2024 and 2025, the Public Works Deputy Director, Contract Specialist, and Capital Staff Accountant ensure adherence to all applicable local, State, and federal procurement laws and regulations as provided in the Uniform Guidance at 2 CFR 200.214, 2 CFR Part 180, and Treasury’s implementing regulations at 31 CFR Part 19, prohibiting recipients from entering into contracts with suspended or debarred parties. The City of North Bend understands the significance of the finding and immediately took steps to review all subsequent contracts for compliance.
Special Tests and Provisions - SEMAP Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: The Authority was under Troubled Status with HUD for its Housing Choice Voucher program during the 2023 fiscal year. There were multiple fi ndings from HUD with a Cor...
Special Tests and Provisions - SEMAP Housing Voucher Cluster Material Weakness in Internal Controls Material Noncompliance Condition: The Authority was under Troubled Status with HUD for its Housing Choice Voucher program during the 2023 fiscal year. There were multiple fi ndings from HUD with a Corrective Action Plan implemented covering areas typically monitored through SEMAP self-assessment process. A uditor Recommendations: The Authority should evaluate and update its internal control policies and procedures related to HCV compliance requirements. The Authority should continue to work on its Corrective Action Plan with HUD to move out of Troubled Status. Action Taken: On the same note and based on a HUD review of operations, HACM entered into a SEMAP Corrective Action Plan with HUD with the goal to improve the SEMAP performance indicator scores. Via a nationwide Request for Proposal, HACM hired the contractor, CVR Associates, Inc. (CVR) to manage and operate the entire Housing Choice Voucher program for HACM, effective January 2, 2025. This contract is currently overseen by the Acting Secretary- Executive Director and will be overseen by the Chief Operations Officer once a new one is hired. CVR was selected as the contractor in part due to their extensive experience in m anaging similar voucher programs nationwide and on their tools/software that they have developed to manage items, such as quality control testing in the areas such as the items n oted above. CVR provided additional training to staff, prepared new standard operating procedures, a nd perform quality control testing over the course of the entire year. Many of the SEMAP indicators have improved, but some have additional improvement still needed based on the 2025 SEMAP results. When there are issues, the CVR Quality Control team follows up with the staff person to correct the issue, and to provide guidance or additional training with the goal to reduce the error rate in the future. We believe that HACM will be back to being a standard performer or higher in 2026. Name of Responsible Person: Ken Barbeau, Acting Secretary-Executive Director; Chief Operations Officer (once hired); Projected Completion Date: December 31, 2026
Reference Number: 2023-06 Finding Type: Noncompliance with Uniform Guidance Requirements Description of Finding: 2 CFR section 200.512(a) requires auditees to submit the Single Audit reporting package to the Federal Audit Clearinghouse (FAC) no later than the earlier of: 30 calendar days after recei...
Reference Number: 2023-06 Finding Type: Noncompliance with Uniform Guidance Requirements Description of Finding: 2 CFR section 200.512(a) requires auditees to submit the Single Audit reporting package to the Federal Audit Clearinghouse (FAC) no later than the earlier of: 30 calendar days after receipt of the auditor’s report(s), or 9 months after the end of the audit period. The Organization did not submit the single audit reporting package to the FAC within the required timeframe. The late filing resulted from delays in completing the audit caused by the identification and remediation of internal control matters during the audit process, combined with staff turnover in key financial reporting positions. Failure to timely submit the reporting package causes the Organization to be out of compliance with Uniform Guidance requirements and may result in increased federal oversight, potential sanctions or withholding of federal funds. Statement of Concurrence: Management agrees with the finding. Corrective Action: The organization recognizes that the Single Audit Report will be delayed for the 18-month period ended June 30, 2025, as the deadline to submit is March 31, 2026 and the audit has not yet commenced. The organization will ensure that the Single Audit Report will be submitted by August 31, 2026, and subsequent Single Audit Reports will be submitted by the deadline. Completion Date: August 31, 2026 Name of Contact Person: Maureen Thomas Chief Financial Officer 917-405-7185 maureen@frfive.org
Reference Number: 2023-03 Finding Type: Noncompliance with Major Program Requirement Description of Finding: Franklin County Department of Job and Family Services (the pass-through grantor) requires submission of monthly invoicing within 15 calendar days of each month-end. Additionally, a program re...
Reference Number: 2023-03 Finding Type: Noncompliance with Major Program Requirement Description of Finding: Franklin County Department of Job and Family Services (the pass-through grantor) requires submission of monthly invoicing within 15 calendar days of each month-end. Additionally, a program report is required to be submitted monthly under the subaward agreement. One monthly invoice was identified as being submitted to the pass-through grantor after the deadline. No monthly program report was submitted for December 2023. The reason for the finding is resource constraints and lack of timeliness in the Organization’s cost reconciliation process. The requirement to submit the monthly program report was informally waived by the pass-through grantor. Failure to submit reports timely causes the Organization to be out of compliance with grant requirements. Statement of Concurrence: Management agrees with the finding. Corrective Action: The pass-through grantor informally granted that invoices and program reports be submitted quarterly. The pass-through grantor has since provided formal documentation to the auditors that it has allowed invoices and program reports to be submitted quarterly. Completion Date: February 2026 Name of Contact Person: Maureen Thomas Chief Financial Officer 917-405-7185 maureen@frfive.org
Contact Person: Chief Financial Officer Contact Person: Iftin Hagimohamed; Chief Financial Officer Stephanie Sosa: Finance Manager Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Management concurs with the finding. ...
Contact Person: Chief Financial Officer Contact Person: Iftin Hagimohamed; Chief Financial Officer Stephanie Sosa: Finance Manager Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Management concurs with the finding. FFATA reporting was not completed for applicable subawards as required under 2 CFR Part 170. Status: Corrective Action Taken Corrective action planned: The revised policy includes tracking of allocation shared cost and perform FFATA review. • Develop and implement a formal FFATA reporting policy. • Confirm FSRS system access and assign reporting responsibility. • Establish a compliance calendar for timely submission. • Complete any outstanding required FFATA filings. • Conduct quarterly review of subawards for FFATA applicability. Anticipated completion date: February 2026
Contact Person: Iftin Hagimohamed; Chief Financial Officer Stephanie Sosa: Finance Manager Corrective Action Plan For the Year Ended 2023 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Management concurs with the fi...
Contact Person: Iftin Hagimohamed; Chief Financial Officer Stephanie Sosa: Finance Manager Corrective Action Plan For the Year Ended 2023 Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): Management concurs with the finding. Subaward agreements did not consistently include all required elements under 2 CFR §200.332. Status: Corrective Action Taken Corrective action planned: Management has revised its internal policies and procedures regarding subrecipient monitoring to follow 2 CFR 200.332. Ensure that subward are clearly identified and included in subrecipient agreement. • Develop and adopt a standardized subaward agreement template including Assistance Listing Number, federal award name, award ID, performance period, and required compliance provisions. • Implement a documented subrecipient risk assessment process. • Establish a subrecipient monitoring checklist for invoice review and compliance tracking. • Amend active subaward agreements where required. Anticipated completion date: April 30,2026
The Organization concurs with the finding and management will implement procedures to ensure appropriate internal control procedures are in place for reporting. Management will implement additional internal controls to ensure appropriate segregation of duties between report preparation and review.
The Organization concurs with the finding and management will implement procedures to ensure appropriate internal control procedures are in place for reporting. Management will implement additional internal controls to ensure appropriate segregation of duties between report preparation and review.
Planned Corrective Action: We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the website. We are currently waiting to receive the correct FAIN numbers from the United States Department of Agriculture (USDA) for all our awards so we can file the repor...
Planned Corrective Action: We have a remediation plan in place to ensure that all past grantees over $30,000 are registered on the website. We are currently waiting to receive the correct FAIN numbers from the United States Department of Agriculture (USDA) for all our awards so we can file the reports correctly. Once this information is received from the USDA we are ready to submit the required reporting. We have begun reporting for the few FAIN numbers we have that seem to be correct. We have also included FFATA registration as a step in our grants compliance process for the creation of all future HFFI grantees to prevent this finding from re-occurring. Completion date: May 2, 2024 Name of Contact Person: Sara Vernon Sterman, Chief Program Officer
Finding ref number: 2023-002 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Scott Renick, Financial Manager 350 Orondo Avenue Ste 306 Wenatchee, WA 98801...
Finding ref number: 2023-002 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of County contact person: Scott Renick, Financial Manager 350 Orondo Avenue Ste 306 Wenatchee, WA 98801 (509) 667-6655 Corrective action the auditee plans to take in response to the finding: SAM.gov was used for suspension and debarment verifications, however the wrong page was printed and there was no time/date stamp. The correct procedure has been taught and will be used properly, and the verifications will be recorded properly, in the future. Anticipated date to complete the corrective action: Completed
Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that the timely filing of the annual reports to ensure proper program compliance. Proposed Completion Date September 30, 2026
Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that the timely filing of the annual reports to ensure proper program compliance. Proposed Completion Date September 30, 2026
Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that proper internal control procedures and expenditure approval forms are filled out. Proposed Completion Date September 30, 2026
Name of Contact Person Lillian Harrison, Executive Director Management’s Response/Corrective Action The Organization will develop policies and procedures to ensure that proper internal control procedures and expenditure approval forms are filled out. Proposed Completion Date September 30, 2026
Corrective action planned: Management has revised its internal policies and procedures regarding subrecipient monitoring to follow 2 CFR 200.332. Ensure that subward are clearly identified and included in subrecipient agreement.
Corrective action planned: Management has revised its internal policies and procedures regarding subrecipient monitoring to follow 2 CFR 200.332. Ensure that subward are clearly identified and included in subrecipient agreement.
A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and iss...
A. Strengthening Recertification Compliance 1. Implementation of a Recertification Tracking System: a. A digital tracking log will be used to monitor upcoming recertifications with alerts at 90, 60, and 30 days before due dates. b. The Senior Housing Specialist will oversee timely completion and issue weekly progress reports to the Director of Asset Management. c. Non-compliant files will be flagged for immediate follow-up with tenants. d. PMCS, a third-party group, will assist with recertifications. 2. Enforcing Timely Recertifications: a. Recertifications must be completed no later than 30 days before expiration. b. Staff will receive monthly reminders, and escalation measures will be implemented for delays. 3. Quarterly Internal Audits: a. PMCS and internal staff will conduct random file audits every three months to ensure adherence. b. Deficiencies will be addressed in real-time, and corrective steps will be logged. B. Ensuring EIV System Compliance 1. Standardizing EIV Compliance Procedures: a. A formal checklist will be created for EIV report reviews, ensuring all required reports are generated before lease renewals. b. EIV data will be cross-referenced with tenant files every quarter to ensure completeness. 2. Internal Monthly EIV Reviews: a. The Senior Housing Specialist will generate and review EIV reports on the 1st of each month. b. The Director of Asset Management, Third-Party Compliance Officer (PMCS), and Senior Housing Specialist will verify compliance before reports are finalized. 3. Quarterly Compliance Reports: a. The Compliance Officer will submit a quarterly compliance report documenting completion rates and deficiencies. C. Enhancing Staff Training and Accountability 1. Mandatory Quarterly Training: a. Staff will undergo quarterly compliance training covering HUD Handbook 4350.3, recertifications, and EIV compliance. b. Training sessions will be documented, and staff performance assessed. 2. Clarification of Responsibilities: a. Staff roles will be clearly outlined in a Standard Operating Procedure (SOP) document. b. Staff will be required to acknowledge their roles in compliance processes. 3. PMCS Involvement for Training Support: a. PMCS will offer supplementary training sessions as needed. D. Documentation and Oversight Enhancements 1. Maintaining Complete and Auditable Files: a. All lease and EIV documentation will be stored both physically and digitally. b. A real-time compliance dashboard will track completion rates. 2. Routine Management Reviews: a. The Senior Housing Specialist and Director of Asset Management will conduct monthly spot checks to verify document accuracy and completion. b. Non-compliance will result in formal corrective actions.
1. Management will establish an administrative calendar of required filings for the submission of the single audit reporting package and data collection form. 2. A Single Audit reporting package and data collection form will be sent to the Federal Audit Clearinghouse (FAC) by the due date.
1. Management will establish an administrative calendar of required filings for the submission of the single audit reporting package and data collection form. 2. A Single Audit reporting package and data collection form will be sent to the Federal Audit Clearinghouse (FAC) by the due date.
Summary of Findings Auditors noted there was missing documentary evidence of the following subrecipient monitoring requirements: obtain budgets for reasonable expenses from subrecipients, monitoring of quarterly subrecipient reports, subrecipient contract agreements, site visits, and receiving updat...
Summary of Findings Auditors noted there was missing documentary evidence of the following subrecipient monitoring requirements: obtain budgets for reasonable expenses from subrecipients, monitoring of quarterly subrecipient reports, subrecipient contract agreements, site visits, and receiving updated audit reports from subrecipients and issuing management decisions over federal award findings for pass through entities. We consider this condition to be a material weakness to the Subrecipient Monitoring compliance requirement and is not a repeated finding. Statistical sampling was not used in making sample selections. There were no questioned costs. Statement of Concurrence or Nonconcurrence MNADV concurs with the finding and recommendation labeled 2023-006. The organization served as a passthrough entity for federal grant funds. MNADV believed that it was in compliance with monitoring responsibilities as outlined in the grant agreement from the Maryland Governor’s Office on Crime Prevention, Youth and Victim Services (GOCPYVS) which stated: 3.7. MNADV Monitoring and Reporting of Subrecipients Sub-recipients will be required to submit quarterly programmatic reports to MNADV regarding grant activities, goals, objectives, and performance measures. MNADV will monitor the subrecipient receiving funds, including those that serve underserved populations. This may include reviewing progress reports, reasonable performance measures, financial reports, standard FVPSA required statistics, desk site visits, audits, regular communications, or other monitoring activities as required by federal or state regulation. Information regarding sub-recipients’ activities will be included in MNADV’s quarterly program reports to GOCPYVS. MNADV did employ the following monitoring activities outlined above: • Collected and reviewed progress reports • Collected and reviewed reasonable performance measures • Collected and reviewed financial reports • Collected and reviewed standard FVPSA required statistics • Maintained regular communications with subgrantees Because the grant award language uses the term ‘may include’, we did not interpret this language as requiring us to conduct audits or site visits. Information regarding sub-recipients’ activities based on information gathered during monitoring was included in MNADV’s quarterly program reports to GOCPYVS. However, the organization does concede that it did not meet all the monitoring requirements outlined in 2 CFR 200. Corrective Action A. Immediate Corrective Actions Taken No immediate action could be taken as all subgrants subject to this audit were closed at time of audit. B. Long-Term Corrective Action Plan MNADV will develop and implement a comprehensive written Subrecipient Monitoring Policy that complies with 2 CFR 200.331–200.333 and clearly distinguishes between grant agreement language and federal compliance requirements. Responsible Parties: Executive Director and Subgrantee Program Monitor Completion Target: Within 60 days of the date of this memo.
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