Corrective Action Plans

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Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies to retain proof of amounts requested for reimbursement. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
Finding Number: 2025-007 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...
Finding Number: 2025-007 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Northeast Florida Community Action Agency, Inc. agrees with the findings. Our organization will take action to correct the composition of the tripartite board by appointing the required representatives as soon as possible. The Executive Director is responsible for ensuring the agency remains in comp...
Northeast Florida Community Action Agency, Inc. agrees with the findings. Our organization will take action to correct the composition of the tripartite board by appointing the required representatives as soon as possible. The Executive Director is responsible for ensuring the agency remains in compliance. Moving forward, the Executive Director will review the board composition quarterly to ensure that all vacant positions are filled. This will help maintain the integrity of the agency’s Board of Directors at all times.
The Authority agrees with the finding and is in the process of corrective the issue. The PHA will review CFP grants quarterly to ensure proper and timely reporting on all CFP activities and will work the CFO, Tessa Fitzgerald, to ensure all CFP reporting is timely and in compliance with HUD CFP repo...
The Authority agrees with the finding and is in the process of corrective the issue. The PHA will review CFP grants quarterly to ensure proper and timely reporting on all CFP activities and will work the CFO, Tessa Fitzgerald, to ensure all CFP reporting is timely and in compliance with HUD CFP reporting regulations. Kim Byrd, Executive Director, will be responsible for implementing this corrective action by December 31, 2026.
2025-004 Per 2 CFR §200.510(b), the SEFA must include: - A list of individual federal programs by agency, including the Assistance Listing number. - The total federal awards expended for each program, including capital projects funded by federal grants. - Amounts passed through to subrecipients. - O...
2025-004 Per 2 CFR §200.510(b), the SEFA must include: - A list of individual federal programs by agency, including the Assistance Listing number. - The total federal awards expended for each program, including capital projects funded by federal grants. - Amounts passed through to subrecipients. - Outstanding balances for loan or loan guarantee programs. - Significant accounting policies used in preparing the SEFA. Recommendation: We recommend that management: - Implement a reconciliation process to ensure that all federal expenditures are accurately captured in the SEFA. - Provide additional training for accounting personnel on federal reporting requirements. - Review all local government awards to determine whether Federal funds are a component of the contracts. - Review SEFA data for completeness and accuracy before submission. Management’s Response: Management concurs with the recommendation. HTM recognizes that accurate SEFA preparation begins with identification of federal funding when an award is received and cannot depend solely on a year-end exercise performed after transactions have already been recorded. Management will establish a federal award identification and reconciliation process connecting contract administration, accounting records, federal award information, and the final SEFA. Corrective Action Status and Plan: Management is reviewing the FY 2025 SEFA and related award information and plans to formalize an enhanced SEFA preparation and review process by December 31, 2026. Finance/Accounting will maintain a centralized award inventory identifying the awarding agency and pass-through entity, Assistance Listing number, period of performance, federal and nonfederal funding components, amounts passed through to subrecipients, outstanding loan or loan-guarantee balances when applicable, and the accounting policies used to prepare the SEFA. At least quarterly, Accounting will reconcile the inventory and cumulative federal expenditures to the general ledger, grant billing records, award agreements, and supporting schedules; differences will be investigated, resolved, and documented. Management also plans to complete a preliminary year-to-date SEFA review before year-end. As part of the immediate FY 2025 remediation, management will document the bridge from the prior SEFA to the final revised schedule; retain support for the funding classification of County Operating and Measure H amounts; reconcile the final SEFA to the general ledger and project schedules; and ensure related amounts and disclosures in the audit report are updated consistently. The additional implementation activities are described below. • Reviewing all new grant agreements and contracts to identify funding sources and determine the appropriate federal participation percentage. • Providing targeted training to accounting personnel regarding federal reporting requirements and awards with blended funding sources. • Establishing a secondary management review of the SEFA, including reconciliation of expenditures to underlying award agreements and supporting schedules. The Mission's procedures for preparing the Schedule of Expenditures of Federal Awards (SEFA) did not adequately address contracts containing multiple funding sources. In certain instances, awards administered through local government entities contained both federal and state funding components; however, the agreements were initially classified as fully federal for SEFA reporting purposes. In addition, no formal process existed to systematically review funding agreements and document the federal funding portion of each award prior to SEFA preparation. The enhanced review and monitoring procedures will improve the accuracy and completeness of SEFA reporting, ensure that expenditures are properly classified between federal and non-federal funding sources, and reduce the risk of future reporting errors and noncompliance with Uniform Guidance requirements. Name of responsible person: Tisha Lazare, Chief Financial Officer Anticipated completion date: December 31, 2026
2025-002- Suspension and Debarment Award Information Cluster: N/A Federal Granting Agency: U.S. Department of Energy Award Name: Preventing Outages and Enhancing the Resilience of the Electric Grid Formula Grants to States and Indian Tribes Award Number: DE-GD0000041 Award Years: 2025 Assistance Lis...
2025-002- Suspension and Debarment Award Information Cluster: N/A Federal Granting Agency: U.S. Department of Energy Award Name: Preventing Outages and Enhancing the Resilience of the Electric Grid Formula Grants to States and Indian Tribes Award Number: DE-GD0000041 Award Years: 2025 Assistance Listing #: 81.254 Assistance Listing Title: Grid Resilience Grant Program 40101 (d) Pass-through Entity: N/A Management acknowledges the audit finding related to the performance and documentation of suspension and debarment verification for vendors participating in federally funded projects. Santee Cooper is prohibited from entering into applicable covered transactions with parties that are suspended, debarred, or otherwise excluded from participation in Federal programs and is required to verify a party's eligibility prior to entering into a covered transaction. In accordance with 2 CFR § 180.300, verification may be accomplished by checking the System for Award Management (SAM.gov) Exclusions, collecting a certification from the party, or adding an appropriate clause or condition to the covered transaction. Santee Cooper had an established Supplier Performance Policy and vendor monitoring process during 2025; however, management acknowledges that the process did not sufficiently require and document the applicable Federal suspension and debarment verification. Specifically, for the transactions identified through the audit, Santee Cooper was unable to provide documentation demonstrating that the vendors' suspension and debarment status had been verified through SAM.gov or another permissible verification method prior to entering into the covered transactions. Management has taken and will continue to take the following actions to address the audit finding and strengthen the suspension and debarment verification process: 1. For suppliers not already established in Santee Cooper's supplier system that are being considered for use for the first time on federally funded projects, Procurement will verify the supplier's eligibility through SAM.gov prior to entering into the applicable covered transaction. Evidence of the verification, including the date performed and results obtained, will be retained in the applicable Purchase Order file. 2. Management will perform periodic monitoring of applicable vendors participating in federally funded projects through SAM.gov to confirm that the vendors have not become suspended, debarred, or otherwise excluded from participation in Federal programs. Evidence of the monitoring performed will be retained. 3. Procurement will retain the SAM.gov verification and other applicable supporting documentation in the Purchase Order file to provide an auditable record that the required suspension and debarment procedures were performed. 4. If a supplier is identified as suspended, debarred, or otherwise ineligible to participate in Federal programs, Procurement will notify the requisitioning area and the supplier will not be used for the applicable federally funded purchase. Leadership Responsible: Suzanne Ritter, Treasurer & Senior Director Treasury & Accounting and Interim Controller Completion Date: 9/30/2026 Leadership Signature(s) Suzanne Ritter Treasurer & Senior Director Treasury & Accounting and Interim Controller
2025-001 – Timeliness of Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting Award Information Cluster: N/A Federal Granting Agency: U.S. Department of Energy Award Name: Preventing Outages and Enhancing the Resilience of the Electric Grid Formula Grants to States and Indi...
2025-001 – Timeliness of Federal Funding Accountability and Transparency Act (FFATA) Subaward Reporting Award Information Cluster: N/A Federal Granting Agency: U.S. Department of Energy Award Name: Preventing Outages and Enhancing the Resilience of the Electric Grid Formula Grants to States and Indian Tribes Award Number: DE-GD0000041 Award Year: 2025 Assistance Listing #: 81.254 Assistance Listing Title: Grid Resilience Grant Program 40101 (d) Pass-through Entity: N/A Management acknowledges that its historical processes did not sufficiently identify first-tier subawards subject to Federal Funding Accountability and Transparency Act (FFATA) reporting requirements under 2 CFR Part 170, nor ensure that required subaward information was reported in the applicable federal reporting system within the required statutory timeframe. Upon identification of the issue, Management took immediate corrective action to identify all active and prior subawards under the Federal award subject to FFATA requirements. Management conducted a comprehensive retrospective review and has already completed and submitted reporting for the thirty-one identified applicable subawards through SAM.gov. To ensure ongoing and future compliance, Management has established and is implementing standard operating procedures to govern FFATA reporting. These procedures include: 1. Identification & Threshold Tracking: Establishing a systematic review mechanism at the time of subaward execution and subsequent modification to promptly identify first-tier subawards meeting or exceeding the $30,000 reporting threshold. 2. Timely Submission Workflow: Designating responsible personnel to compile, review, and report all required subaward data elements through SAM.gov no later than the end of the month following the month in which the subaward or qualifying modification was issued. 3. Documentation & Retention: Maintaining central repositories of reporting confirmation records, date stamps, and supporting documentation evidencing the completion, accuracy, and timeliness of each submission. Management will continue to apply these enhanced monitoring and reporting procedures across all current and future applicable federal awards. Leadership Responsible: Suzanne Ritter, Treasurer & Senior Director Treasury & Accounting and Interim Controller Completion Date: 9/29/2026 Leadership Signature(s) Suzanne Ritter Treasurer & Senior Director Treasury & Accounting and Interim Controller
Finding No. 2025-002 — Cash Management — Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services Federal Program Name and Assistance Listing Number: Low-Income Home Energy Assistance 93.568 Federal Award Identification Number and Years: 23DSS4301 EW 9/25 and 9/26 ...
Finding No. 2025-002 — Cash Management — Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services Federal Program Name and Assistance Listing Number: Low-Income Home Energy Assistance 93.568 Federal Award Identification Number and Years: 23DSS4301 EW 9/25 and 9/26 Name of Passthrough Entity: Connecticut Department of Social Services Planned Corrective Action: Management will continue to identify opportunities to streamline invoice processing along with conducting periodic reviews of processed invoices to ensure payment was made within the 10 day payment period. Management will also maximize recruitment efforts to fill vacant staffing positions. Name of Contact Person: Tiffany Bell, Director of Energy Services, anticipated completion date — December 31, 2026.
Finding No. 2025-001 — Reporting — Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services Federal Program Name and Assistance Listing Number: Low-Income Home Energy Assistance 93.568 Federal Award Identification Number and Years: 23D554301 EW 9/25 and 9/26 Name o...
Finding No. 2025-001 — Reporting — Significant Deficiency Name of Federal Agency: U.S. Department of Health and Human Services Federal Program Name and Assistance Listing Number: Low-Income Home Energy Assistance 93.568 Federal Award Identification Number and Years: 23D554301 EW 9/25 and 9/26 Name of Passthrough Entity: Connecticut Department of Social Services Planned Corrective Action: CRT is actively recruiting to fill a vacant position at this time whose responsibilities will include ensuring financial reporting to funders is completed timely. Management will also ensure that the schedule of report due dates is provided to all applicable finance staff to ensure reports are submitted timely. Name of Contact Person: Jeffrey Walsh, Chief Financial Officer, anticipated completion date — December 31 , 2026.
Finding 1239655 (2025-004)
Material Weakness 2025
Federal Agency Name: Corporation for National and Community Service Federal Financial Assistance Listing #94.012 Program Name: September 11th National Day of Service and Remembrance Grants Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance Findin...
Federal Agency Name: Corporation for National and Community Service Federal Financial Assistance Listing #94.012 Program Name: September 11th National Day of Service and Remembrance Grants Subrecipient Monitoring Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Subawards did not contain minimum required elements in accordance with 2 CFR 200.332. The organization did not consider all suggested elements when evaluating subgrantee’s fraud risk and risk of noncompliance with subaward in accordance with 2 CFR 200.332(c). Documentation couldn’t be provided to substantiate whether suspension and debarment was considered prior to awarding subgrant. The organization required the subgrantee to complete performance reports, however, did not require completion of a financial report in accordance with 2 CFR 200.332(e)(1). The organization did not consider whether subgrantee was required to be audited and therefore did not review whether subgrantee had deficiencies. Corrective Action Plan: Management agrees with the finding and has begun implementing enhanced subrecipient monitoring procedures designed to address each of the identified compliance requirements. Subaward agreements will be revised to include the applicable information and terms required by 2 CFR §200.332. Prior to issuing subawards, management will verify and retain documentation of each prospective subrecipient's suspension and debarment status and will determine whether the subrecipient is subject to Single Audit requirements. Management will review available audit information, including identified findings or deficiencies, when applicable. Management is also enhancing its pre-award risk assessment process to evaluate each prospective subrecipient's risk of noncompliance with the federal subaward. The revised process will incorporate documented risk factors, including prior experience with the same or similar subawards, results of previous audits or other available financial oversight information, personnel and systems used to administer federal awards, and other factors relevant to the subrecipient's ability to comply with federal requirements. The results of the risk assessment will be documented and used to determine the appropriate level and nature of subrecipient monitoring. Subrecipients will be required to submit both programmatic and financial reports during the period of performance. Management will document its review of required reports and will perform additional monitoring, including desk reviews or other procedures, as appropriate based on assessed risk and performance. These procedures will be incorporated into the organization's documented subrecipient monitoring process and retained with the applicable grant records. Responsible Individuals: David Paine - President, Dominique Carver – Operations Director, Miranda Cirtwell – Controller Anticipated Completion Date: February 15, 2026
Finding 1239654 (2025-003)
Material Weakness 2025
Federal Agency Name: Corporation for National and Community Service Federal Financial Assistance Listing #94.012 Program Name: September 11th National Day of Service and Remembrance Grants Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Rep...
Federal Agency Name: Corporation for National and Community Service Federal Financial Assistance Listing #94.012 Program Name: September 11th National Day of Service and Remembrance Grants Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Reporting of information on subawards as required by the Federal Funding Accountability and Transparency Act of 2006 (FFATA) was not completed for each of the four subrecipients in which pass through funds exceeded $30,000. Corrective Action Plan: Management agrees with the finding and has implemented procedures to ensure that applicable subawards are identified and reported in accordance with Federal Funding Accountability and Transparency Act (FFATA) requirements. Management will review subawards at the time of award to determine whether federal reporting requirements apply, complete required reporting within the applicable reporting period, and retain documentation supporting completion of the reporting. Responsibility for monitoring and completing required FFATA reporting has been incorporated into the organization's federal grant administration procedures. Responsible Individuals: David Paine - President, Dominique Carver – Operations Director, Miranda Cirtwell – Controller Anticipated Completion Date: December 15, 2025
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task ...
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task ...
The Agency agrees with this finding. As part of the subaward review process, the Chief Financial Officer will ensure that first tier subawards are checked to see if FFATA reporting is needed based on the award amount. If FFATA reporting is required, the Chief Financial Officer will assign this task to the Assistant Director for Financial Compliance to ensure that reporting is completed to the FFATA Reporting System FSRS.
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2025 Financial Statement Findings: Finding 2025-001 During the audit, we identified deficiencies in internal control over financial reporting related to the Foundation's accounting for its Recovery Housing Programs funding. Specifically, the Fou...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED DECEMBER 31, 2025 Financial Statement Findings: Finding 2025-001 During the audit, we identified deficiencies in internal control over financial reporting related to the Foundation's accounting for its Recovery Housing Programs funding. Specifically, the Foundation initially recorded federal funding from housing grants received in FY24 and FY25 as revenue rather than as forgivable mortgage liabilities in accordance with the terms of the grant agreements. The Foundation also did not record federal grants receivable for allowable expenditures incurred before year-end that had not yet been requested for reimbursement. Material audit adjustments (proposed by the auditor) were required to reclassify federal funding from revenue to liabilities and to properly record grants receivables. The total proposed/adjustment related to these errors was approximately $1.234 million. Corrective Action Plan: Upon review of the grant amendments and contracts for 29 E. Mill Rd and 1207 McClellan residences, specified federal funding agency of Department of Housing and Urban Development was represented. The amendment identifies the New Jersey Department of Community Affairs as the administering agency, alongside the HUD federal program. This was the first year in which a Single Audit was performed, where the organization had spent $1 million or more in funding for the purpose of establishing new sober living for those dealing with addiction. Going forward, we will work with our Director of Housing to ensure appropriate involvement and communication up front between state representatives of DCA and our internal finance leadership. The goal will be to ensure the organization fully understands its obligations, requirements, and commitments under contract.This will help ensure that the appropriate financial oversight and compliance considerations are addressed throughout the term of the agreement. Finding 2025-002 During the audit, it was noted that the Foundation does not maintain documentary evidence of the review and approval of adjusting and other journal entries. The Foundation's process provides that entries are recorded by the Staff Accountant or Accounting Manager and reviewed by the Controller and/or Chief Financial Officer. While this review is performed, evidence identifying the reviewer, the date of review, and the scope of the review was not retained. Corrective Action Plan: Please be aware that the Hansen Foundation accounting team will create and adopt a journal entry log sheet with corresponding NetSuite Journal Entry audit reports. The log sheet will show who initially reviewed the reports and on what date this was performed. The Accounting Manager and/or Controller will perform initial monthly review and forward to myself for final review. The journal entry log and NetSuite backup reports can then be provided to the Armanino team as part of the year end analysis moving forward. Name of person responsible: Michael Hansen, CFO & Treasurer Anticipated Completion Date: September 30, 2026 DATE: 9/24/2026
Finding 2025-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, C. Cash Management, I. Procurement, Suspension and Debarment, N. Special Tests and Provisions Identification of the federal program: Research and Development Cluster Federal Agency: U.S. Department of Health a...
Finding 2025-001 – A. Activities Allowed or Unallowed, B. Allowable Costs/Cost Principles, C. Cash Management, I. Procurement, Suspension and Debarment, N. Special Tests and Provisions Identification of the federal program: Research and Development Cluster Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.273, Alcohol Research Programs Pass-Through Grantors: University of Louisville Research Foundation; Vanderbilt University Medical Center; Brown University Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.399, Cancer Control Pass-Through Grantor: NRG Oncology Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.846, Arthritis, Musculoskeletal, and Skin Diseases Research Pass-Through Grantor: Regents of the University of Michigan Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.853, Extramural Research Programs in the Neurosciences and Neurological Disorders Pass-Through Grantor: Regents of the University of Michigan Federal Agency: U.S. Department of Agriculture Assistance Listing No: 10.557, WIC Special Supplemental Nutrition Program for Women, Infants, and Children Pass-Through Grantor: Kentucky Cabinet for Health and Family Services – Department of Public Health Division of Adult & Child Health Award Period: January 1, 2025 through December 31, 2025 Summary of finding: A material weakness in internal control over compliance was issued related for the noted findings on the identified programs of Norton Healthcare, Inc. and Affiliates (the Corporation). While the Corporation has procedures in place to process and record transactions, the Corporation did not retain documentation to sufficiently support the design and operation of internal controls over the applicable compliance requirements for the listed federal programs. Furthermore, internal controls over management’s accumulation and review of such expenses for allowability were not suitably designed as it pertained to final approval of expenses incurred. Furthermore, the Corporation’s payroll department did not retain documentation to evidence the review of unapproved timesheets. Planned corrective action: Research Awards - Norton Healthcare has created Uniform Guidance-compliant policies regarding research expenditures using federal funds; those policies will be implemented. Additionally, standard work instructions regarding the documentation to be completed and retained have been created and will be implemented. A process to review vendors for suspension or debarment prior to engaging with them will be implemented. Additionally, all staff involved in the process of procuring goods and services using federal funds in the research department will receive training on the Uniform Guidance and the allowable cost and procurement principles therein. Anticipated completion date: December 31, 2026 Responsible contact person: Matthew Hawthorne Foundation Awards – Norton Healthcare will develop, document, approve and implement comprehensive policies and standard work instructions addressing applicable Uniform Guidance requirements for foundation expenditures. The policies will establish requirements and internal controls for the administration, financial management, monitoring and close out of federal awards. Standard work instructions will also be created and implemented that provide detailed procedures to consistently execute and document the requirements. Anticipated completion date: December 31, 2027 Responsible contact person: Jane Brooks
Responsible contact(s): Steve, Staff Accountant - AR, for financial reports; Program Directors/Managers for performance reports; Agnes, Controller, for financial review; Laura, CFO, for oversight. Participating staff: Program reporting staff and designated backups; Steve, with support from Sharon, f...
Responsible contact(s): Steve, Staff Accountant - AR, for financial reports; Program Directors/Managers for performance reports; Agnes, Controller, for financial review; Laura, CFO, for oversight. Participating staff: Program reporting staff and designated backups; Steve, with support from Sharon, for calendar/evidence support; Trina and AP staff for underlying reconciliations. During part of 2026, AEA did not submit the reports as required by the award on a timely manner, this was corrected for the August 2026 submissions. 1. Create a complete award-reporting calendar. Steve and each Program Manager will inventory executed agreements, amendments, and reporting instructions. The register will show award, report type, reporting period, actual contractual due date, submission method, preparer, reviewer, submitter, backup, and evidence link. Agnes will validate requirements and updates; an organization-wide assumed due date will not replace award terms. 2. Build in lead time. Using the external due date as D, AEA will target source data by D minus 10 business days, drafts by D minus 7, review by D minus 5, and submission by D minus 2. Where the reporting window is shorter, Agnes and the Program Director will set feasible earlier internal milestones without changing the external deadline. 3. Assign substantive review. Steve will prepare and reconcile financial reports to the ledger, approved payroll/allocations, prior cumulative reports, budget categories, and claim adjustments. Agnes will independently approve financial accuracy. Program staff will prepare performance results and explanations, and the Program Director will approve them. Finance and Programs will reconcile financial and performance data where related; authorized certifications will be obtained. 4. Retain proof and escalate risk. The designated submitter, program staff, will send a copy of the submitted report to Steve. Steve will save the email, copy of the submitted report, retain the final approved report, dated review, submission timestamp, portal receipt or transmission evidence, funder acknowledgment when available. Steve will index evidence and follow up on rejections. Missed internal milestones or threatened deadlines will be escalated to Laura within two business days. 5. Resolve prior reporting exceptions. Steve and Program Managers will review 2026, submit any outstanding reports promptly (where applicable), and document unresolved evidence gaps. Late reports will remain classified as late; later submission will not erase the original exception. Anticipated completion Validated complete registers and procedures: October 30, 2026. Historical reporting review: November 30, 2026. Anticipated completion after effectiveness review: January 29, 2027.
Management did not fully document the level of effort for key personnel identified as Project Directors who were providing in-kind support to the grant program. Although this grant has ended, management recognizes the importance of maintaining adequate documentation and monitoring procedures for fut...
Management did not fully document the level of effort for key personnel identified as Project Directors who were providing in-kind support to the grant program. Although this grant has ended, management recognizes the importance of maintaining adequate documentation and monitoring procedures for future grants. Management will update its grant policies and procedures to include specific requirements for tracking and documenting in-kind personnel time, as well as an approval and review process to ensure compliance with grant requirements. Contact Person: Kris Sanders, SVP Network Development and Digital Care Delivery Krishandra.Sanders@childrens.com Expected Completion Date: December 31, 2026
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records ar...
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records are reviewed and supported by appropriate documentation. Management should also implement monitoring procedures to verify that participant counts and listings are complete, accurate, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: Sound Generations is updating procedures to strengthen controls over recording participant information, including participant profiles and meal services. Administrative staff will conduct regular site visits to train and monitor site staff and volunteers on these procedures. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2027.
Finding 1239546 (2025-003)
Material Weakness 2025
Upmc
PA
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Rya...
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Ryan White, Part D) Condition: Ryan White, Part C and Part D require the use of program income under the additive method, which requires program income earned from a federally funded program is added to the federal award amount and used to further program objectives. Under the method, allowable expenditures of program income are included on the SEFA. UPMC’s SEFA did not include expenditures related to program income, which were allowable. UPMC’s preliminary SEFA did not include these expenditures, which resulted in the incorrect identification of major programs. The SEFA was subsequently corrected. Corrective action plan: UPMC has remediated the control deficiency as of the period ending December 31, 2025, and has appropriately revised its processes and internal controls to expenditures of program income in the SEFA for impacted programs. Completion: September 2026
Finding 1239536 (2025-002)
Material Weakness 2025
Upmc
PA
Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance Condition: UPMC did not report three Federal Funding Accountability and Transparency Act (FFATA) to the Federal Fundi...
Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance Condition: UPMC did not report three Federal Funding Accountability and Transparency Act (FFATA) to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Corrective Action Plan: UPMC will track FFATA reporting at the System level to ensure overall compliance. Expected Timeline to Completion: December 31, 2026 Responsible Party: UPMC Financial Integrity
Finding 1239535 (2025-001)
Material Weakness 2025
Upmc
PA
Federal Grantor: U.S. Department of Health and Human Services Assistance Listing No.: 93.912, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Condition: UPMC did not timely submit two Federal Funding Accountability and Transpar...
Federal Grantor: U.S. Department of Health and Human Services Assistance Listing No.: 93.912, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Condition: UPMC did not timely submit two Federal Funding Accountability and Transparency Act (FFATA) reports to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) within the timeframe designated by 2 CFR 170 Appendix A. Furthermore, evidence of review and approval of the FFATA reports and Federal Financial Reports required to be reported under were not maintained. Corrective Action Plan: UPMC will track FFATA reporting at the System level to ensure overall compliance. Expected Timeline to Completion: December 31, 2026 Responsible Party: UPMC Financial Integrity
CORRECTIVE ACTION PLAN September 17, 2026 Boys and Girls Club of Hawaii (BGCH) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: N&K CPAs, 999 Bishop Street, Suite 2200, Honolulu, HI 96813 Audit Per...
CORRECTIVE ACTION PLAN September 17, 2026 Boys and Girls Club of Hawaii (BGCH) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: N&K CPAs, 999 Bishop Street, Suite 2200, Honolulu, HI 96813 Audit Period: The calendar year ended December 31, 2025. Addressee: State of Hawaii, Department of Human Services Benefit, Employment and Support Services Division 1010 Richards Street, Suite 512 Honolulu, HI 96813 Primary Contact Person: Paddy Kauhane, President & CEO Contact Person Responsible: Florrie Charnaw, CFO Finding: The finding from the December 31, 2025 Schedule of Findings and Questioned Costs - #2025-001: Noncompliance with Grant Award Terms – Significant Deficiency Federal agency: Department of Health and Human Services Program: ALN No. 93.558 Temporary Assistance for Needy Families Pass-through entity: State Department of Human Services Award number and award year: DHS-24-TANF-0116, June 3, 2024 to August 2, 2025. Criteria: The DHS-24-TANF-0116 award specifically prohibits BGCH from charging youths or their families for programs or services provided under the award without prior approval from the State. Condition: While BGCH fully complied with providing the required services at the locations included in the Contract, BGCH did charge Summer Intersession fees to some youth at all nine BGCH Clubhouses without seeking prior approval of the STATE. Completion Date: September 30, 2026 Corrective Action Plan BGCH has made full refunds of the summer 2025 fees, provided all supporting documentation to DHS for them, and provided the Grant Policy and Grant Management Procedures by the required March 31, 2026 deadline. We remain compliant with this contract and will continue to fully comply with the DHS CAP executed in March 2026.
As of December 31, 2025, management has not fully funded the tenant security deposits cash account. The tenant security deposits cash account was underfunded by $7,581. a. Comments on the Finding and Each Recommendation Management agrees with the finding and recommendation. Due to a formula error, t...
As of December 31, 2025, management has not fully funded the tenant security deposits cash account. The tenant security deposits cash account was underfunded by $7,581. a. Comments on the Finding and Each Recommendation Management agrees with the finding and recommendation. Due to a formula error, the transfer amount was understated, resulting in the tenant security deposit account being underfunded by $7,581. b. Action(s) Taken or Planned on the Finding Management corrected the deficiency by transferring $7,581 from the operating account to fully fund the tenant security deposit account on January 14, 2026. Management has implemented enhanced reconciliations of tenant security deposits to ensure the security deposit account remains fully funded and accurate
Project paid expenses on behalf of an affiliate in the amount of $384.00 from Project funds without prior HUD approval. As of December 31, 2025, the affiliate owed the Project $384.00. a. Comments on the Finding and Each Recommendation Management agrees with the findings and recommendation. The paym...
Project paid expenses on behalf of an affiliate in the amount of $384.00 from Project funds without prior HUD approval. As of December 31, 2025, the affiliate owed the Project $384.00. a. Comments on the Finding and Each Recommendation Management agrees with the findings and recommendation. The payment was made in error due to an oversight into the invoice approval process. b. Action(s) Taken or Planned on the Finding The affiliate reimbursed the Project for the full amount of $384.00 on 04/29/2026.Management implemented an additional approval control in RealPage requiring review and approval by the Housing Director and/or the Property Manager prior to payment processing. This control helps ensure invoices are charged to the correct property and prevents one project from paying expenses on behalf of another project or affiliate. Management will continue to monitor compliance with these procedures.
Management acknowledges the delays identified in the submission of certain monthly progress reports corresponding to the 2025 reporting period. However, management respectfully notes that the dates reflected in PRDOH's reporting records should be considered in the context of PRDOH's established sequ...
Management acknowledges the delays identified in the submission of certain monthly progress reports corresponding to the 2025 reporting period. However, management respectfully notes that the dates reflected in PRDOH's reporting records should be considered in the context of PRDOH's established sequential reporting and approval process. Under the Puerto Rico Department of Housing's CDBG-DR/MIT Grant Compliance Portal (GCP) procedures, a subrecipient cannot submit a monthly report while a preceding report remains open and pending approval. Specifically, the PRDOH CDBG-DR/MIT Grant Compliance Portal (GCP) Manual, Version 5, dated April 4, 2024, page 35, states: “You cannot submit a report while there is an open past Report” and further provides that, “Once the open report is approved, you can submit the next monthly report.” Accordingly, delays in PRDOH's review, return, resubmission, and approval of one monthly report necessarily affect CRH's ability to submit the following month's report, even when CRH is otherwise prepared to proceed with the subsequent submission. Management therefore reviewed the complete submission and approval history for all twelvemonthly reports corresponding to 2025 in order to distinguish between reports that appear late based solely on the dates reflected in PRDOH's records and reports that were submitted late due to circumstances attributable to CRH. Out of the 12 months of 2025, five reports were submitted late. Of the five late submissions, three of which were due to the PRDOH’s delayed approval of the previous month’s report. Reporting Period Original CRH Submission PRDOH Approval Status January 3/26/25 4/3/25 Submitted late, in order to incorporate new PRDOH data and inventory requirements. February 4/23/25 5/26/25 Submitted late, in order to incorporate new PRDOH data and inventory requirements. March 5/28/25 5/28/25 Submitted late due to PRDOH approval date of previous report April 5/28/25 5/28/25 Submitted late due to PRDOH approval date of previous report. May 6/2/25 6/5/25 Submitted within term. June 7/1/25 7/9/25 Submitted within term. July 8/1/25 8/6/25 Submitted within term. August 9/2/25___ 9/19/25_ Submitted within term. September 10/2/25 10/17/25 Submitted within term. October 11/5/25 12/10/25 Submitted within term. November 12/15/25 12/23/25 Submitted late due to PRDOH approval date of previous report. December 1/5/26 2/4/26 Submitted within term. After considering the original submission dates, PRDOH approval dates, subsequent resubmissions, and the sequential reporting requirement established by PRDOH, only two reports were actually submitted late due to circumstances attributable to CRH. With respect to those reports that were actually submitted late by CRH, the delays occurred principally during a period in which PRDOH was establishing new requirements concerning the information, supporting documentation, classifications, and formatting required for inventory and data, which required overhauls of the CRH’s internal methodologies. In several instances, these requirements were communicated through comments and instructions associated with PRDOH's review of preceding reports, and in others, from e-mail requests establishing new inventory criteria. CRH has since incorporated PRDOH's data and inventory format requirements into its regular procedures, completed the necessary personnel transition and training, and strengthened its internal monitoring of monthly reporting deadlines. As of 2026, CRH's monthly reports have been submitted without a sinlge late submission. Management will continue documenting both CRH submission dates and PRDOH approval dates so that delays resulting from PRDOH's sequential review and approval process can be appropriately distinguished from delays attributable to CRH.
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