Corrective Action Plans

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Management agrees with the finding. The report was submitted late due to an oversight. Management has reviewed the reporting requirements and established a tracking process to ensure that required reports and their due dates are monitored. Responsibility for each report has been clearly assigned, an...
Management agrees with the finding. The report was submitted late due to an oversight. Management has reviewed the reporting requirements and established a tracking process to ensure that required reports and their due dates are monitored. Responsibility for each report has been clearly assigned, and management will review the status of upcoming submissions to help ensure that reports are submitted timely. Management will continue to monitor compliance with reporting deadlines and take appropriate action if a potential delay is identified. Person responsible for Corrective Action: Sonya Birdshead, Executive Director. Anticipated Completion Date: August 31, 2026
Clinic management team acknowledges that from the audit selection made of 60 patients, 15 selections had findings. We agree with you that seven (7) of the 15 did not meet either, the six-month recertification requirements or had missing proof of income findings. We agree and are not contesting patie...
Clinic management team acknowledges that from the audit selection made of 60 patients, 15 selections had findings. We agree with you that seven (7) of the 15 did not meet either, the six-month recertification requirements or had missing proof of income findings. We agree and are not contesting patient selection numbers: 25, 27, 31, 38, 52, 56 and 59. We will address this in our corrective action plan. Staff have completed the six-month recertifications and gathered the missing income data Four (4) of the findings related to certification data being collected and uploaded in the hospital EPIC electronic medical records but were not formally signed by a case manager. We are in partial compliance with the data requirements, but we needed to finalize and ensure that controls are in place, so the service provider must sign the note. We had situations where the provider passed away or left the Peter Ho clinic, due to relocation. Staff have since completed the notes and we have developed a report within our EMR to notify the service provider that the note requires signature. The four missing signatures by the service provider were patient selections: 9, 24, 29, 41. Four (4) of the findings related to not having the original HIV diagnosis confirmed on the patient not successfully migrated into the new electronic medical record, EPIC. For three of these patients, the staff could not find the original HIV diagnosis on the chart. The patients were treated properly, but the original data was not retained. This was caused by not all data being successfully migrated when Peter Ho updated its EMR during CY 2021. The Peter Ho Clinic switched from Centricity to EPIC during 2021. The selected patients have been treated at Peter Ho prior to CY 2021. We did provide other supporting documentation that the patient has HIV, but we could not find the original documentation. The four patient selections that fell into this category are: 19, 30, 34 and 39. The corrective action plan as developed for CY 2024 will be continued to be reinforced and followed. A few new bullets have been added below to further assist in meeting the compliance guidance. A detailed plan of correction is identified below: • Quality management process, where Clinic clients are called ahead of time to notify them of their recertification requirements. This process will remain in place. • Assistant Manager will implement an EPIC (EMR) precheck process for current assessments. All future assessments will have proof of diagnosis, proof of income, proof of ID, proof of address and proof of insurance on the template to include the dates in which those documents were collected. (new) • Data Analyst(s) generate a report of patients due for recertification 60 days in advance of the due date. The CCC-Lead will remain directly accountable to review the progress of re-certifications. Further monitoring by the Assistant Manager of the clinic will continue. • An EPIC (EMR) report of unsigned encounters will be generated biweekly and reviewed by staff for open encounters and notes to be signed. (new) • The CCC-Lead and the Assistant Manager will continue to monitor retention of income verification documentation to ensure compliance purposes. • Document scanners will be provided to individual Certified Case Counselors to alleviate late or missed filings, documents will be scanned directly into EMR at the time of capture. • The Clinic staff will continue follow up with the patients that were non-compliant during the prior year audit and asked for the missing information. The medical record will be updated with any new information received. • Chart review for all upcoming appointments will be performed to capture/locate missing diagnosis because of data transfer failure from old EMR. If diagnosis is missing, rapid testing to be performed by the Counseling and Testing Department at that time to continue current treatment. (new) Contact Person: Mark Brown, Office Manager, Peter Ho Memorial Clinic Expected Completion Date: September 30, 2026
Finding Number: 2025-002 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we identified four instances in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, in two instances, sliding fee adjustments we...
Finding Number: 2025-002 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we identified four instances in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, in two instances, sliding fee adjustments were applied based on individual procedure codes rather than the date of service. In one additional instance, an incorrect sliding fee adjustment was applied to the patient's balance. Collectively, these three errors resulted in patients being charged $311 more than required under the Organization's sliding fee discount program. We also identified one patient who received a sliding fee discount without an active sliding fee application for the applicable date of service and was therefore not eligible for the discount. Individual(s) Responsible for Corrective Action: Dean Correnti, CFO Planned Corrective Action: Sliding fee schedule is completed by the Dental Practice Manager on a case-by-case status. On a monthly basis, they are to be presented to the CFO for him to sign off on to verify all is correct. Any adjustments will be made quickly and correctly. The current policy for sliding fees has been updated, reviewed, and signed off by all parties involved. Anticipated Completion Date: Completed on March 1, 2026
Finding #2025-004 - Reporting; Procurement and Suspension and Debarment; Subrecipient Monitoring; Allowable Costs/Cost Principles Corrective Action Planned: Since the Finance Manager's arrival, a process has been implemented to reconcile quarterly expenditure reports submitted to the State of Michig...
Finding #2025-004 - Reporting; Procurement and Suspension and Debarment; Subrecipient Monitoring; Allowable Costs/Cost Principles Corrective Action Planned: Since the Finance Manager's arrival, a process has been implemented to reconcile quarterly expenditure reports submitted to the State of Michigan against the general ledger; this reconciliation has become clearer and more consistent with each subsequent period. Beginning in September 2025, suspension and debarment checks on SAM.gov are performed for every new vendor and subrecipient - owned by the Executive Director of the Center for Adult College Success for Center vendors and the Finance Manager for TalentFirst vendors, with all checks reviewed by the Finance Manager. Employee wage allocations are now supported by timesheets and documented on the monthly journal accrual e-signature form, which retains the allocation and its approval electronically. Anticipated Completion Date: Already implemented. Responsible Party: Finance Manager, with oversight by the President.
Segregation of Duties Condition/Context-Council staff have limited segregation of duties for all transactions of the entity. The Council's staff is not large enough to permit adequate segregation of duties. This lack of segregation of duties does not allow management to detect and correct a material...
Segregation of Duties Condition/Context-Council staff have limited segregation of duties for all transactions of the entity. The Council's staff is not large enough to permit adequate segregation of duties. This lack of segregation of duties does not allow management to detect and correct a material misstatement, if present. Due to the size of the Council's staff, it is anticipated that this will be an ongoing finding. Compensating controls are in place; however, this continues to be an ongoing finding. Recommendation-In our judgment, management and those charged with governance need to understand the importance of this communication. However, due to the lack of resources available to management to correct this weakness, we recommend that management mitigate this weakness with possible compensating controls such as close supervision and monitoring by management and the Board of Directors. Corrective Action Planned- The Council of Community Services has a full-time bookkeeper with adequate experience, continues to have Board involvement, and actively seeks new Board members with financial expertise. We also have a board member who is a Certified Public Accountant that also sits on the Finance Committee of the Board. This additional oversight adds layers of supervision and monitoring which should allow any intentional fraud or unintentional errors to be prevented and detected and corrected in a timely manner. Contact-Mikel Scott, Executive Director Anticipated Completion Date-Due to the size of the staff, this is expected to be an ongoing finding, all compensating controls have been in place since 2015.
The attorney in this case obtained a documented verbal agreement to a retainer before meeting the client in person and then obtained a signed retainer at a courthouse meeting and documented that in a case note, but he never uploaded the signed retainer and couldn't find it when Compliance asked for ...
The attorney in this case obtained a documented verbal agreement to a retainer before meeting the client in person and then obtained a signed retainer at a courthouse meeting and documented that in a case note, but he never uploaded the signed retainer and couldn't find it when Compliance asked for it. He received one-on-one instructions on the importance of immediately uploading signed retainers to clients' case files. In addition, the Compliance Office training all emphasizes the importance of uploading signed retainers as soon as they are obtained, and he will continue to do so.
Failure to Identify All Federal Awards and Prepare a Complete Schedule of Expenditures of Federal Awards (SEFA) Finding Type: Material Weakness in Internal Control Over Compliance Corrective Action: The Organization will establish formal procedures for identifying, tracking, and reporting all federa...
Failure to Identify All Federal Awards and Prepare a Complete Schedule of Expenditures of Federal Awards (SEFA) Finding Type: Material Weakness in Internal Control Over Compliance Corrective Action: The Organization will establish formal procedures for identifying, tracking, and reporting all federal awards. Actions include: 1. Creation and maintenance of a centralized Federal Grant Register containing: o Assistance Listing Number o Federal agency o Pass-through entity o Award number o Award period o Award amount o Reporting requirements 2. Development of written SEFA preparation procedures. 3. Annual reconciliation of federal expenditures to the general ledger prior to audit commencement. 4. Annual review of all grant agreements to identify federal funding sources and pass-through awards. 5. Training for finance and program staff on Uniform Guidance requirements and federal award identification. 6. CFO review and approval of the SEFA before submission to auditors. Responsible Person: CFO and Executive Director Implementation Date: September 30, 2026 Expected Outcome: All federal awards will be accurately identified and reported, and a complete and accurate SEFA will be prepared prior to each annual audit.
Commingling of Federal Award Funds in the General Ledger Finding Type: Material Weakness in Internal Control Over Compliance Corrective Action: The Organization will redesign its accounting structure to separately identify federal grant activity. Specific actions include: 1. Establishing grant-speci...
Commingling of Federal Award Funds in the General Ledger Finding Type: Material Weakness in Internal Control Over Compliance Corrective Action: The Organization will redesign its accounting structure to separately identify federal grant activity. Specific actions include: 1. Establishing grant-specific codes within the chart of accounts. 2. Tracking revenues and expenditures by: o Federal program o Funding source o Assistance Listing Number o Grant period 3. Requiring transaction-level coding for all federal grant activity.4. Generating reimbursement requests and financial reports directly from grant-specific accounting records. 5. Implementing written grant accounting policies and procedures. 6. Providing grant accounting and Uniform Guidance training to accounting and program personnel. Responsible Person: CFO Implementation Date: September 30, 2026 Expected Outcome: Federal expenditures will be separately tracked and readily identifiable, improving compliance with Uniform Guidance requirements and supporting accurate reporting and monitoring of grant funds.
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 23...
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-004: The Corporation made payments on entity expenses in the amount of $21,398 and did not obtain the required HUD approval. Comments on the Finding and Each Recommendation: The Corporation should request retroactive HUD approval to make the payments or request reimbursement from the Board of Directors. Action(s) taken or planned on the finding: Management has requested approval from HUD. As of the report date, no response has been received.
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 23...
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-003: The Corporation did not furnish HUD with a complete annual financial report within ninety (90) days or 9 months if owner certified following the year ended June 30, 2025. Comments on the Finding and Each Recommendation: The Corporation should ensure the annual financial report is filed within 90 days of year end. Action(s) taken or planned on the finding: The audited financial statements have been submitted to HUD. No further action is required.
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 23...
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-002: For the year ended June 30, 2024, the Corporation did not submit audited financial statements to the Federal Audit Clearinghouse within 9 months after the end of the audit period. The audited financial statements were submitted to the Federal Audit Clearinghouse on April 25, 2025 Comments on the Finding and Each Recommendation: The Corporation should submit audited financial statements to the Federal Audit Clearinghouse within the time frames required. Action(s) taken or planned on the finding: The audited financial statements have been submitted to the Federal Audit Clearinghouse. No further action is required.
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 23...
Name of auditee: Arirang Housing, Inc. HUD auditee identification number: 122-EH518-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Noel Sweitzer Position: President, HDSI Management, Inc. Telephone number: (323) 231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: During the year ended June 30, 2025, the Corporation did not make the require deposits to the reserve for replacements. Comments on the Finding and Each Recommendation: Management should make a deposit to the reserve for replacements for $2,423 for the delinquent deposits. In future periods, management should fund the reserve for replacements on an annual basis as required by the HUD regulatory agreement or request HUD approval for a suspension of deposits Action(s) taken or planned on the finding: Management made a deposit of $2,423 in July 2025 for the delinquent deposits.
Corrective Action Plan: Management agrees with the finding. To ensure timely submission of required grant reports, management will enhance its grant compliance monitoring process by implementing a centralized reporting calendar that identifies all reporting requirements, responsible personnel, and d...
Corrective Action Plan: Management agrees with the finding. To ensure timely submission of required grant reports, management will enhance its grant compliance monitoring process by implementing a centralized reporting calendar that identifies all reporting requirements, responsible personnel, and due dates for each grant. Management will assign responsibility for maintaining and monitoring the reporting calendar and will implement periodic reviews of upcoming deadlines with finance and program personnel. In addition, management will establish a supervisory review process to verify that required reports have been completed and submitted prior to applicable deadlines. Management believes these procedures will strengthen compliance with grant reporting requirements and help prevent future late submissions. Anticipated Completion Date: June 30, 2027
Assistance Listing Number (ALN) & Program Name: 11.472 Unallied Science Program (U.S. Dept. of Commerce, NOAA) Fiscal Year: FY2025 Finding: Significant Deficiency in Internal Control over Compliance and Noncompliance Related to Management Decisions for Subrecipient Audit Findings. NPRB has taken sig...
Assistance Listing Number (ALN) & Program Name: 11.472 Unallied Science Program (U.S. Dept. of Commerce, NOAA) Fiscal Year: FY2025 Finding: Significant Deficiency in Internal Control over Compliance and Noncompliance Related to Management Decisions for Subrecipient Audit Findings. NPRB has taken significant corrective action to strengthen its subrecipient monitoring procedures. Effective October 1, 2025, NPRB transitioned its accounting, financial operations, and grants management and reporting from its former fiscal agent to direct management by NPRB staff. NPRB is updating its written subaward procedures to establish a formal process for monitoring subrecipient compliance with applicable Single Audit requirements under 2 CFR Part 200. The procedures require NPRB to determine the applicability of Single Audit requirements to its subrecipients, obtain and review applicable subrecipient Single Audit reports, document the results of those reviews, and retain supporting documentation. NPRB has also established a tracking process and calendar for subrecipient monitoring. Identified audit findings related to NPRB’s subawards will be evaluated and documented, required management decisions will be issued and communicated to the subrecipient, and corrective actions will be tracked through resolution. Documentation of NPRB’s review, management decisions, follow-up, and resolution will be retained as part of the applicable subaward file.
Assistance Listing Number (ALN) & Program Name: 11.472 Unallied Science Program (U.S. Dept. of Commerce, NOAA) Fiscal Year: FY2025 Finding: Significant Deficiency in Cash Management Compliance Documentation NPRB has already taken significant corrective action to strengthen its cash management contro...
Assistance Listing Number (ALN) & Program Name: 11.472 Unallied Science Program (U.S. Dept. of Commerce, NOAA) Fiscal Year: FY2025 Finding: Significant Deficiency in Cash Management Compliance Documentation NPRB has already taken significant corrective action to strengthen its cash management controls. Effective October 1, 2025, NBPR transitioned its accounting, financial reporting, cash management, accounts payables, grant accounting, and all related financial operations from its former fiscal agent to direct management by NPRB staff. NPRB continues to use an external accounting firm to assist with reconciliations, and provide review and internal-control advisory support Beginning October 1, 2025, NPRB implemented procedures requiring detailed supporting documentation for each federal cash draw request. Each draw support packet identifies the specific allowable expenditures being reimbursed and provides documentation sufficient to reconcile the amount requested to the underlying expenditures and NPRB’s accounting records. Draw support packets are retained electronically in accordance with NPRB’s document-retention procedures. NPRB has also implemented periodic reconciliations between federal draw activity and the general ledger, including cumulative draw activity, as well as between cumulative federal draw activity and federal expenditures reported on the SEFA. These procedures are being incorporated into NPRB's formal financial policies and procedures, including defined approval authorities, segregation-of-duties requirements, internal-control responsibilities, and documentation and retention requirements.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Coupeville School District No. 204 September 1, 2024 through August 31, 2025 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal R...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Coupeville School District No. 204 September 1, 2024 through August 31, 2025 This schedule presents the corrective action planned by the District for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort and procurement requirements. Name, address, and telephone of District contact person: Stacy Larsen 501 S Main St Coupeville, WA 98239 (360) 678-2404 Corrective action the auditee plans to take in response to the finding: The District acknowledges the above finding related to time-and-effort documentation and procurement requirements under the Special Education program cluster (CFDA 84.027 – Special Education Grants to States and CFDA 84.173 – Special Education Preschool Grants), pass-through award GT-03882 administered by OSPI. The District acknowledges that due to turnover in key positions, time-and-effort documentation for two employees whose payroll and benefits costs totaling $83,902 were charged to the program was not retained and readily available. The District has since obtained and provided signed time-and-effort records to the auditor to support all payroll costs charged to the program. To prevent recurrence, the Business Manager has implemented a monthly checklist to ensure time-and-effort certifications are completed and signed by applicable staff within required timeframes, in compliance with OSPI Bulletin 039-24 and 2 CFR Part 200, Subpart E. This checklist will be maintained on file as documentation of ongoing compliance.The District acknowledges that price or rate quotations were not retained for two contractors providing speech-language pathology and occupational therapy services, totaling $134,444 in federal program funds, as required for personal services contracts between $10,000 and $250,000 under 2 CFR Part 200, section 320, and Board Policy 6220. To address this, the Business Manager will provide written guidance to special education leadership and applicable staff by June 12, 2026, outlining price and rate quotation requirements for personal services contracts and the District's documentation retention obligations under Board Policy 6220 and federal procurement standards. Going forward, the Business Manager will verify that all personal services contracts procured with federal funds include required price or rate quotation documentation prior to execution. The District is committed to maintaining these strengthened internal controls to ensure full and ongoing compliance with federal program requirements under the Special Education program cluster. Anticipated date to complete the corrective action: June 12, 2026
Response and Views of Responsible Officials Management concurs with this finding. Management acknowledges that, during the audit period, the Organization did not maintain federally compliant written procurement procedures that addressed the requirements of Uniform Guidance for procurement transactio...
Response and Views of Responsible Officials Management concurs with this finding. Management acknowledges that, during the audit period, the Organization did not maintain federally compliant written procurement procedures that addressed the requirements of Uniform Guidance for procurement transactions charged to federal awards. While the Organization generally followed purchasing and approval practices, those procedures were not formally documented and did not specifically address federal procurement standards, suspension and debarment verification, or procurement documentation requirements. Since the audit period, the Organization has substantially strengthened its procurement policies and internal controls. The Financial Policies Manual has been revised to include formal procurement procedures, purchasing approval requirements, competitive purchasing expectations, documentation standards, and financial oversight responsibilities. In addition, purchasing responsibilities have been incorporated into the Organization's strengthened internal control structure, including review by the internal bookkeeper, Executive Director, Executive Committee, and Board of Directors, as appropriate. Management also notes that strengthening procurement procedures was identified through the MIECHV monitoring process and was incorporated into the Organization's broader financial management improvements. Management believes these actions substantially improve compliance with federal procurement requirements and reduce the risks identified during the audit. Management has completed the following corrective actions: • Revised and expanded the Financial Policies Manual to include federally compliant procurement procedures and purchasing controls. • Established documented approval thresholds and purchasing authority for procurement transactions. • Implemented procurement documentation requirements, including supporting invoices, approval documentation, and retention of procurement records. • Strengthened internal review of procurement transactions through involvement of the internal bookkeeper, Executive Director, Executive Committee, and Board of Directors, as appropriate. • Incorporated procurement procedures into the Organization's broader system of internal financial controls and oversight. Management will complete the following additional actions: • Develop and implement written procedures for suspension and debarment verification for applicable federally funded purchases, including documentation of SAM.gov verification. • Develop a standardized Federal Procurement Checklist to document procurement method, approvals, required competition, suspension and debarment verification, and supporting documentation for federally funded purchases. • Establish standardized procurement files to ensure all required procurement documentation is maintained in accordance with the Organization's record retention policy. • Provide training to employees responsible for initiating, approving, or documenting procurement transactions charged to federal awards. • Conduct an annual review of procurement policies and procedures to ensure continued compliance with Uniform Guidance and federal grant requirements. Responsible Official: Josie Brittain Anticipated Completion Date: September 30, 2026
Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of the Treasury Award Number and Year: 2021 Compliance Requirement: Subrecipient Monitoring Management’s Response: We concur. Views of Responsibl...
Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of the Treasury Award Number and Year: 2021 Compliance Requirement: Subrecipient Monitoring Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The program managers lacked understanding of federal grant requirements and overlooked this procedure. To resolve the matter, the City Manager and department leaders convened and suggested that staff receive proper training. They will continue to review the training schedule, factoring in staff availability, venue options, and budget limits. Name of Responsible Person: City of Merced’s Leadership and Grant Program Managers Projected Implementation Date: June 30, 2026
Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of the Treasury Award Number and Year: 2021 Compliance Requirement: Procurement and Suspension and Debarment Management’s Response: We concur. Vi...
Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Financial Assistance Listing Number: 21.027 Federal Grantor: U.S. Department of the Treasury Award Number and Year: 2021 Compliance Requirement: Procurement and Suspension and Debarment Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The program managers lacked a complete understanding of federal grant requirements and overlooked this procedure. To resolve the matter, the City Manager and department leaders convened and suggested that staff receive proper training. They will continue to review the training schedule, factoring in staff availability, venue options, and budget limits. All current non-Federal entities have been verified. Name of Responsible Person: City of Merced’s Leadership and Grant Program Managers Projected Implementation Date: June 30, 2027
Program: HOME Investment Partnerships Program Federal Financial Assistance Listing Number: 14.239 Federal Grantor: U.S. Department of Housing and Urban Development Award Number and Year: M16-MC060227; M17-MC060227; M20-MC060227; M21-MC060227; M23- MC060227; M24-MC060227 Compliance Requirement: Speci...
Program: HOME Investment Partnerships Program Federal Financial Assistance Listing Number: 14.239 Federal Grantor: U.S. Department of Housing and Urban Development Award Number and Year: M16-MC060227; M17-MC060227; M20-MC060227; M21-MC060227; M23- MC060227; M24-MC060227 Compliance Requirement: Special Tests and Provisions – Wage Rate Requirements Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The City Engineering Department is the lead for all city capital projects and monitors prevailing wage requirements. The Housing Division is responsible for compliance with HUD specific requirements. This shared responsibility requires a high level of coordination and information sharing. The Housing Division does have draft of HOME Policies &Procedures which were prepared by a consulting firm contracted for the Five-year Consolidated Plan. These policies and procedures include Davis-Bacon and other related federal prevailing wage laws. Name of Responsible Person: Director of Development Services – currently vacant City Engineer - Daryl Jordan Housing Program Supervisor - Kimberly Nutt Projected Implementation Date: The consultant assisting the City has prepared a Draft of Policies and Procedures which are currently being reviewed. We anticipate final approval and implementation by end of January 2027.
Program: HOME Investment Partnerships Program Federal Financial Assistance Listing Number: 14.239 Federal Grantor: U.S. Department of Housing and Urban Development Award Number and Year: M16-MC060227; M17-MC060227; M20-MC060227; M21-MC060227; M23- MC060227; M24-MC060227 Compliance Requirement: Speci...
Program: HOME Investment Partnerships Program Federal Financial Assistance Listing Number: 14.239 Federal Grantor: U.S. Department of Housing and Urban Development Award Number and Year: M16-MC060227; M17-MC060227; M20-MC060227; M21-MC060227; M23- MC060227; M24-MC060227 Compliance Requirement: Special Tests and Provisions – HQS Enforcement Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The City’s Housing Division are aware of HUD’s requirement to have written policies and procedures in place for each HUD formula grant funding source (CDBG & HOME), including environmental reviews, financial management, uniform relocation assistance, and lead paint abatement. The barriers to carrying out rental housing monitoring activities have largely been centered around: 1) lack of sufficient number of staff to perform all job tasks, including training and monitoring and, 2) insufficient training information and opportunities on the subject of rental housing monitoring, including how to properly calculate restricted rent amounts and tenant income. As part of the Five-Year Consolidated Plan implementation creation and adoption of Policies and Procedures to perform this work was identified. Name of Responsible Person: Director of Development Services – currently vacant Housing Program Supervisor - Kimberly Nutt Projected Implementation Date: The consultant assisting the City has prepared a Draft of the Policies and Procedures which are currently being reviewed. We anticipate final approval and implementation by end of January 2027.
2025-101 Lack of Effective Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization’s current review process related to the sliding fee scale t...
2025-101 Lack of Effective Internal Controls over the Application of the Sliding Fee Scale Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization’s current review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner does not always detect all errors. We also noted: • Sliding fee scales were not used for the agreement that the Organization has in place with the local school district in which they provide services to students. The agreement specifically does not allow the Organization to obtain information related to household size and income as needed to appropriately place the family on the sliding fee scale. The agreement also indicates no amounts can be collected from the students, except when that student has insurance which allows the Organization to bill the insurance company for a portion of the fees. • Sliding fee scales are not used in the disaster recovery bus program that does not charge the patients for services. Corrective Action Planned: The Organization has hired a new Chief Financial Officer and a new Revenue Cycle Manager. Sliding fee discount program training has been incorporated into onboarding for all new front desk employees. The billing department is adding a Patient Accounts Specialist who will monitor and review individual sliding fee determinations for accuracy and completeness and will conduct ongoing training with front desk staff as needed. Additionally, management will perform quarterly random sample testing of sliding fee determinations to verify that household size, income documentation, and discount tier were applied in accordance with the Organization's sliding fee discount policy. With respect to the school district agreement and the bus program, management will contact HRSA to request written guidance or a waiver confirming that the sliding fee discount schedule is not required to be applied to these programs. Management will also amend the Organization's sliding fee discount policies and procedures accordingly and will remove the word "disaster" from references to the bus program, as the program is not limited to disaster-related services. Person Responsible for Corrective Action: Tonya Nicholson, Chief Financial Officer Anticipated Completion Date: October 2026
Corrective Action Planned: The Department of Administration is implementing a policy requiring city departments to file FFATA reports when contracting with subrecipients using federal grant funds in amounts of $30,000 or more. This policy will be distributed to all city departments along with instru...
Corrective Action Planned: The Department of Administration is implementing a policy requiring city departments to file FFATA reports when contracting with subrecipients using federal grant funds in amounts of $30,000 or more. This policy will be distributed to all city departments along with instructions on how to file the reports. Name(s) of Contact Person(s) Responsible for Corrective Action: Kimberly Kujoth, Grant Compliance Manager Anticipated Completion Date: September 30, 2026
AUDIT FINDING REFERENCE NUMBER: 2025-003 FEDERAL AGENCY: Department of Education FEDERAL PROGRAM: Student Financial Assistance Cluster - NSLDS reporting AWARD YEAR: 2024-2025 CONDITION: {REFER TO AUDIT REPORT EXPLANATION) CORRECTIVE ACTION PLAN: The College experienced turnover and process change in...
AUDIT FINDING REFERENCE NUMBER: 2025-003 FEDERAL AGENCY: Department of Education FEDERAL PROGRAM: Student Financial Assistance Cluster - NSLDS reporting AWARD YEAR: 2024-2025 CONDITION: {REFER TO AUDIT REPORT EXPLANATION) CORRECTIVE ACTION PLAN: The College experienced turnover and process change in the Registrar area during the audited year. The Registrar's office has formalized processes and enhanced communication with other departments since the year in question. The procedures currently being followed should prevent enrollment status change reporting from being out of compliance. ANTICIPATED COMPLETION DATE: Immediately CONTACT PERSON: Aimee Murch MurchA@villa.edu
AUDIT FINDING REFERENCE NUMBER: 2025-002 FEDERAL AGENCY: Department of Education FEDERAL PROGRAM: Student Financial Assistance Cluster - Gramm Leach Bliley Act AWARD YEAR: 2024-2025 CONDITION: {REFER TO AUDIT REPORT EXPLANATION) CORRECTIVE ACTION PLAN: The College has identified the reasons for its ...
AUDIT FINDING REFERENCE NUMBER: 2025-002 FEDERAL AGENCY: Department of Education FEDERAL PROGRAM: Student Financial Assistance Cluster - Gramm Leach Bliley Act AWARD YEAR: 2024-2025 CONDITION: {REFER TO AUDIT REPORT EXPLANATION) CORRECTIVE ACTION PLAN: The College has identified the reasons for its shortcomings in compliance with GLBA and is investing in IT services and infrastructure that ensures compliance for current and future years. We are already underway with moving to meet these requirements. ANTICIPATED COMPLETION DATE: Fall 2026 CONTACT PERSON: Brian Emerson bemerson@villa.edu
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