Corrective Action Plans

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SAOP shall implement a policy to secure approvals for charges related to the federal program.
SAOP shall implement a policy to secure approvals for charges related to the federal program.
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do n...
Corrective Action Plan: The Utility Commission General Manager or Communications System Supervisor will review the quarterly progress reports prepared by someone else. Section II of the Project Status Report instructions states “Answer each question to the best of your ability.” The work orders do not include all costs related to labor benefits and taxes, and also the electronics and customer premise equipment associated with the projects. These costs are calculated and added in when the project is completed and is being closed out. Estimating these items for the quarterly Project Status Report is providing the project costs spent through the respective quarter to the best of our ability due to the limitations of the work order reporting process. Planned Completion Date for the Corrective Action: On-going Contact Persons Responsible for the Corrective Action Plan: The following Reedsburg Utility staff members are responsible for items outlined above in the Corrective Action Plan: • Brett Schuppner, Reedsburg Utility General Manager • Ken Las, Communications System Supervisor
2023-007 Internal Controls over Systems for Award Management (SAM Debarment) (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to suspe...
2023-007 Internal Controls over Systems for Award Management (SAM Debarment) (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to suspension and debarment are consistently implemented. Corrective Action: 1. SAM Debarment Registration: Under new leadership, we became compliant with SAM Debarment Registration in March 2025. 2. Compliance Tracking: We have implemented systems to ensure that registration will be completed annually and on time, supported by a robust compliance tracking system. 3. Vendor Vetting: 1. All new vendors will be vetted through the SAM (System for Award Management) Department prior to the initiation of services. 2. Continuous service providers will undergo an annual vetting process to ensure ongoing compliance and quality. Responsible Parties: Sandra Robicheaux – ED Madelyn Wages – Director of Operation Date to be Corrected: March 2025
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that ...
2023-006 Internal Controls and Compliance over Special Tests and Provisions – Reasonable Rental Rates (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to special tests and provisions – reasonable rental rates are consistently implemented including maintaining documentation of the verification of rental reasonableness in the program participant's file. Corrective Action: In response to the findings from the 2023 audit regarding the annual requirement for rent reasonableness, we developed the following action plan to ensure compliance with HUD regulations: 1. Annual Schedule: We established that annual rent reasonableness assessments for Temenos TCDC would be conducted each January, as required by HUD. This included comprehensive assessments for all scatter site properties. 2. Staff Reminders: A systematic reminder protocol was implemented for all staff involved in the rent reasonableness process. This included: 1. Calendar alerts 2. Email notifications 3. Regular team meetings to discuss timelines and responsibilities 3. Monitoring and Compliance: The Executive Director (ED) and Director of Operations closely monitored the compliance process to ensure assessments were completed accurately and on time. By implementing this action plan, Temenos TCDC aimed to address the 2023 audit findings effectively and ensure compliance with HUD's annual rent reasonableness requirements, including assessments for all TCDC site properties. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Implemented in January of 2025
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are c...
2023-005 Compliance and Internal Controls over Program Income (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to program income are consistently implemented. In addition, documentation should be included in each participant's files to support income calculations and the participant's share of rent payable to the program. Corrective Action: We would like to clarify our approach to income documentation within client files: 1. Income Documentation: While not all clients have income, we will ensure that clients without income provide a zero-income affidavit (also known as a non-income affidavit) to document their status. 2. Stabilized Case Management: Our current case managers have been with Temenos CDC (TCDC) for over a year, providing stability and experience in verifying client income. 3. Policy and Procedure Updates: Recent updates to our policies and procedures have introduced standardized forms that clearly differentiate between households with income and those without. 1. Households with income will include the mandatory TCDC income calculation sheet. 2. Households without income will be required to submit the zero-income affidavit. 4. File Checklists: We have created file checklists to ensure uniformity across all client files, enhancing our documentation process. 5. Annual Audits: All client files will be audited by a supervisor at least once a year to ensure compliance with our policies. 6. HMIS Training: Case managers are required to complete mandatory HMIS training, which supports effective compliance in file management and income verification. These measures are designed to strengthen our documentation practices and ensure compliance with audit requirements. Responsible Parties: Sandra Robicheaux – ED Ramona Edwards – Property Manager Wanda Williams – Case Manager Damita Gardner – Case Manager Terence Gomes – Case Manager Date to be Corrected: Mandatory Training Implemented 01/2025 Updated Document Requirements 11/2025
2023-004 Compliance and Internal Controls over Earmarking (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program Contract No. TX0425L6E002106 Recommendation: The Organization should establish procedures to ensure that controls related to earmarki...
2023-004 Compliance and Internal Controls over Earmarking (Significant Deficiency) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program Contract No. TX0425L6E002106 Recommendation: The Organization should establish procedures to ensure that controls related to earmarking are consistently implemented which should include reconciling the administrative costs to all drawn funds on individual grants. Corrective Action: In response to the findings from the 2023 audit, we are implementing several corrective actions to enhance our financial management processes, ensuring compliance and preventing future discrepancies. 1. Monthly Reporting: The Director of Operations is required to send monthly ELLOC (HUD account balances) reports to both Your Part Time Controller (YPTC) and the Executive Director (ED). This ensures transparent tracking of funds. 2. Expenditure Budgets: Monthly expenditure budgets have been established for each grant to maximize the use of grant funds and prevent shortages in administrative expenditures. 3. Regular Reviews: Balances are reviewed monthly in conjunction with drawdown preparations. YPTC will provide recommendations for any necessary adjustments to expenditures, which will be communicated to the ED during monthly drawdown closeouts. 4. Budget Adjustments: For the 2025 NOFO budgets, adjustments will be made to align with the grant history from the past three years. This historical analysis highlights areas of both funding shortages and overages, allowing for more accurate future budgeting. 5. HUD Notification: Notifications for adjustments to the 2024 NOFO will be sent to HUD to prevent the recurrence of findings in the upcoming 2024 audit. Through these measures, we aim to strengthen our financial oversight and ensure compliance with HUD requirements. Responsible Parties: Sandra Robicheaux – ED Madelyn Wages – Director of Operations Tyler Starkel - YPTC Date to be Corrected: 1. Implementation of drawdown process began 06/01/2024 2. HUD budget adjustment to be submitted by 01/31/2026
2023-003 Compliance and Internal Controls over Matching (Material Weakness) Internal Controls over Period of Performance and Earmarking (Material Weakness) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: We recommend that part of the r...
2023-003 Compliance and Internal Controls over Matching (Material Weakness) Internal Controls over Period of Performance and Earmarking (Material Weakness) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: We recommend that part of the review process for payroll include verification that the cost charged to the grant does not exceed the grant hours reported on employee timesheet. Corrective Action: In response to the first finding, we have implemented a comprehensive payroll review process that addresses both the initial concern and the subsequent finding. The new payroll process that has been established will ensure that costs charged to the grant do not exceed the hours reported on employee timesheets, effectively eliminating both issues: Responsible Parties: Sandra Robicheaux – Executive Director Claudia Dixon – CFO Tyler Starkel - YPTC Date to be Corrected: Implementation for above changes went into effect 6/01/2024
2023-002 Compliance and Internal Controls over Procurement (Material Weakness and Noncompliance) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to procuremen...
2023-002 Compliance and Internal Controls over Procurement (Material Weakness and Noncompliance) U.S. Department of Housing and Urban Development 14.267 – Continuum of Care Program 2023 Funding Recommendation: The Organization should establish procedures to ensure that controls related to procurement are consistently implemented and that all written records are maintained to support that the compliance requirement is met. Corrective Action: In alignment with the recent leadership transition, a comprehensive policy and procedure manual has been established to ensure our procurement practices meet HUD guidelines. The following outlines our updated procurement policy: 1. Compliance with Standards: All procurement of property (goods, supplies, or equipment) and services must adhere to the standards of conduct and conflict-of-interest requirements outlined in 2 CFR 200.317 and 200.318. 2. Micro Purchases (Under $9,999): Temenos CDC (TCDC) will document the reasonableness of costs for all micro purchases to ensure appropriate spending practices. 3. Small Purchases ($10,000 and above): For small purchases exceeding $10,000, TCDC will solicit a minimum of three bids for services to promote competitive pricing. 4. Vendor Vetting: 1. All new vendors will be vetted through the SAM (System for Award Management) Department prior to the initiation of services. 2. Continuous service providers will be subject to an annual vetting process to ensure ongoing compliance and quality. These measures are designed to reinforce our commitment to transparency, accountability, and compliance with HUD requirements. Responsible Parties: Sandra Robicheaux - Executive Director Madelyn Wages – Director of Supportive Services Ramona Edwards – Property Manager Date to be Corrected: Implementation for above changes went into effect 6/01/2024
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
Management will review Uniform Guidance 2 CFR sections 200.318 through 200.327 to ensure the Organization’s procurement policy fully incorporates all federal compliance requirements. Management will develop and implement a formal, written procurement policy.
2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District shoul...
2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District should review their record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. Action: The District will ensure that all payroll timecards are approved and signed by the appropriate supervisor before being processed for payment. The payroll clerk will not process the timecard unless it is signed and approved. Additionally, we will review the District’s record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. The District will thoroughly review timecards to avoid clerical errors in the future. Date for Completion: These steps have already been put into place and will continue to be built upon.
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or d...
Thomas Swabb, Tribal Chairman Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition During testing we noted the following:For 1 of 1 vendors tested, the Tribe did not maintain documentation demonstrating that the vendor was verified as not federally suspended or debarred prior to entering into the contract. Corrective Action: Effective January 1, 2026, every proposal or contract that goes out will require all vendors to be active in SAMS.gov for all federal grants. This will be a requirement during the biddingprocess. Anticipated date of completion: January 30, 2026.
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully subm...
Mount Sinai Foundation, Incorporated 703 Blue Street Fayetteville, North Carolina 28301 CORRECTIVE ACTION PLAN December 3, 2025 U.S. Department of Housing and Urban Development Five Points Plaza Building 40 Marietta Street Atlanta, Georgia 30303 Mount Sinai Foundation, Incorporated respectfully submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings for the year ended December 31, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - Financial Statement Audit and Federal Award Program Audits Finding 2023-001 - U.S. Department of Housing and Urban Development, Mortgage Insurance Rental and Cooperative Housing for Moderate Income Families and Elderly, Market Interest Rate (Sections 221d(3) and (4) Multifamily - Market Rate Housing), CFDA #14.135 Recommendation: That management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2023-001 and the recommendation described in the accompanying schedule of findings and questioned costs. The Corporation has executed a new management agreement with Remnant Management Inc. effective October 1, 2024. Remnant Management Inc. will ensure that all transactions are properly recorded and that key accounts are reconciled and reviewed on a periodic basis beginning October 1, 2024 and going forward. Sincerely yours, Shannon Pow President Remnant Management, Inc. Managing Agent effective October 1, 2024
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or impleme...
2023-001 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Community Development Block Grant/Entitlement Grant ALN 14.218; passed through the County of Berks Emergency Rental Assistance ALN 21.023; passed through the County of Berks Condition/Cause The auditee did not have any documented or implemented internal controls over the review of federal program reporting requirements. Reports were prepared and submitted without documentation of supervisory review or verification of accuracy and completeness. Management did not design or implement procedures to review reports prior to submission, relying solely on the preparer's knowledge without formal oversight. Recommendation We recommend that all grant reports are reviewed by a person independent of the preparer who has knowledge of the grant requirements. This review should include comparing the amounts reported to detailed support for accuracy. We also recommend the Authority review its recordkeeping procedures for documentation related to grant reporting. There should be a process in place to ensure all required documentation is maintained and filed in an orderly system that allows the Authority to locate and provide documentation when required. Management Response In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Repo11 CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. Written policies and procedures have been developed.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
Views of Responsible Officials and Planned Corrective Actions: PRIDE agrees with the finding and recommended procedures will be implemented.
The County will implement procedures to ensure the review and approval of the monthly report is documented.
The County will implement procedures to ensure the review and approval of the monthly report is documented.
The County will implement procedures to ensure the approval process is documented.
The County will implement procedures to ensure the approval process is documented.
The County will implement a new policy to ensure all subrecipients that are given federal funds of $25,000 or more are properly monitored.
The County will implement a new policy to ensure all subrecipients that are given federal funds of $25,000 or more are properly monitored.
The County will implement a new policy to verify vendors are not suspended or debarred.
The County will implement a new policy to verify vendors are not suspended or debarred.
Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to sta...
Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Borough’s Response: Eldred Borough has board oversight and will continue to do so. The Borough employees do cover duties of the other employee when necessary and will continue to do so. Bank Reconciliations will be signed by Council. Pay Requisitions are signed by Council and will continue to do so.
2023-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all empl...
2023-002 Activities Allowed and Allowable Costs To address the finding regarding missing backup documentation for cash disbursements, the Biddeford-Saco-Old Orchard Beach Transit Committee has implemented new workflow controls in our new integrated accounting software. Starting July 1, 2025 all employees are now required to create a purchase order (PO) and obtain approvals before payments can be made. This process controlled by the finance manager creates a complete audit trail for every transaction, ensuring that all disbursements are properly documented.
U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit...
U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.
U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to suppo...
U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.
View Audit 372833 Questioned Costs: $1
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