Corrective Action Plans

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Finding 1159888 (2024-003)
Material Weakness 2024
FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Fund – Reporting Contact Person Responsible for Corrective Action: Annette Phillippo Contact Phone Number and Email Address: 765-472-3901, ext. 1240 and aphillippo@miamicountyin.gov Views of Responsible Official...
FINDING 2024-003 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Fund – Reporting Contact Person Responsible for Corrective Action: Annette Phillippo Contact Phone Number and Email Address: 765-472-3901, ext. 1240 and aphillippo@miamicountyin.gov Views of Responsible Officials: We concur with the findings. Description of Corrective Action Plan: Verify by a second person in Auditors that reports are accurate and sent to treasury quarterly. Anticipated Completion Date: Completed before 09/22/2025 Submitted by: Annette Phillippo Miami County
All subrecipient risk assessments will be assigned a level of risk and review process will be documented with any audit findings investigated. All expenditures submitted for reimbursement will be reviewed for compliance and approved.
All subrecipient risk assessments will be assigned a level of risk and review process will be documented with any audit findings investigated. All expenditures submitted for reimbursement will be reviewed for compliance and approved.
For all grant reimbursement requests we will now have an addtional person to review and sign off on the reimbursement request.
For all grant reimbursement requests we will now have an addtional person to review and sign off on the reimbursement request.
The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.
The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.
The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.
The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.
Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creati...
Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.
AOOS will work with its fiscal agent to strengthen oversight and establish compensating controls during staff vacancies to ensure proper review of reports. In addition, AOOS will re-establish and implement policies that require management review and documentation of all reports prior to submission t...
AOOS will work with its fiscal agent to strengthen oversight and establish compensating controls during staff vacancies to ensure proper review of reports. In addition, AOOS will re-establish and implement policies that require management review and documentation of all reports prior to submission to granting agencies, thereby ensuring accuracy, accountability, and compliance with federal requirements. Completion Date: September 30, 2026 Responsible Person: Sheyna Wisdom, Executive Director, AOOS
To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness...
To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness and consistency of information. In addition, SAAMS will update its policies to clearly describe the review objectives and responsibilities of staff conducting payroll reviews. Training will be provided to relevant staff to ensure proper understanding and execution of the updated procedures. These measures will ensure payroll reviews are accurate, effective, and aligned with best practices. Completion Date: September 30, 2026 Responsible Person: Dr. Wei Ying Wong, CEO, SAAMS
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
Chaffee County will establish internal controls over grants management and SEFA preparation processes during the year to make sure the Federal expenditures are properly reflected on the information used to prepare the SEFA and match the accounting records.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
The County will re-evaluate the design of internal controls over suspension and debarment to be in compliance with the Federal requirements and the County's procurement policy/procedures.
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice...
Finding Reference Number: 2024-001 Identification of the Federal Program: Grantor: United States Department of Health and Human Services Program Name: Health Centers Cluster Assistance Listing No.: 93.224, 93.527 Name of responsible official: James Geraghty Associate Vice President, Faculty Practice Group Phone: (718) 430-3255 Email: james.geraghty@einsteinmed.edu Projected completion date: October 1, 2025 Condition In accordance with Title 2 U.S. Code of Federal Regulations, Part 200.303, Internal controls, “Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award.” The Health System was unable to demonstrate that internal controls were operating effectively to ensure proper application of the Health System’s policy relating to the sliding fee discount schedule (SFDS). Specifically, documentation supporting the application of the SFDS was not obtained within a year of the visit in line with the Health System’s policy. Views of responsible officials and planned corrective actions Management concurred with the audit finding and implemented standardized procedures to enhance screening and enrollment of patients. Additional controls are in place to ensure timely documentation of income and family size. In order to ensure compliance with the SFDS policy including documentation and retention, a policy was adopted requiring reviews on the day before visit, during visit and day after visit, as well as periodic retrospective reviews. There will be regular staff training on eligibility, determination and documentation requirements.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
View Audit 370140 Questioned Costs: $1
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
It should be noted that distribution of funds under this program terminated on December 31, 2024; no new loans will be originated. The Foundation will implement the recommended actions as appropriate in future programs that may be similar to this one.
View Audit 370140 Questioned Costs: $1
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Clus...
To: FY2024 Uniform Guidance Reporting Package From: David Noble, Director, Grant Administration RE: 2024 Uniform Guidance Audit Corrective Action Plan Date: September 25, 2025 Finding: 2024-001 Activities Allowed or Unallowed/Allowable Costs Federal Program: Medicaid Assistance Program/Medicaid Cluster ALN: 93.778 Grady Memorial Hospital Corporation’s CFO and VP of Fiscal Services/Controller have reviewed the reporting from KPMG relating to the Uniform Guidance. We understand the recommendation set forth by KPMG and will update our controls and processes to include additional review of expenses incurred during the relevant audit period. Grady’s corrective action plan: During the FY 2024 single audit, one unallowable payroll disbursement totaling $1,988 was reimbursed by the federal agency. The disbursement was associated with a rarely used payroll code that is routinely excluded from reimbursement requests. Internal controls over the review process for payroll charges exist and will be strengthened to ensure only allowable charges are charged to the grant. Contact person/s responsible for the corrective action: David Noble, Director, Grant Administration Anticipated Completion Date: Consistent with 2025 Financial Audit Reporting
Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely subm...
Management acknowledges the audit finding regarding timely submission of reports and retaining documentation of submissions. We will implement a new combined monitoring and record retention internal control process for financial, performance, and special reporting requirements, to ensure timely submission and retention of supporting documentation for required sponsor reporting. This process will be implemented by December 31, 2025.
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evol...
Management concurs with KPMG’s assessment that the risk assessment and monitoring control activities were not sufficiently designed to ensure adequate segregation of duties or to provide evidence of control operation. These gaps were primarily due to limited staffing and processes that have not evolved to meet all compliance requirements. Management will implement new control policies and procedures that ensure proper segregation of duties and introduce review mechanisms at a sufficient level of precision to detect and prevent noncompliance. These policies and procedures will be implemented by December 31, 2025.
Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to b...
Planned Corrective Action: We have implemented a process to monitor cost cash match including obtaining, reviewing, and retaining support for reported cost match amounts. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: In Process at 12/31/2024 with Remainder to be Completed by October 1, 2025
Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of nonc...
Planned Corrective Action: We have implemented a cloud‐based platform that automates the AP process. All invoices are submitted to this platform and given to individuals for dual review and approval before being paid. This system was put in place in July 2024, there have been no noted issues of noncompliance since using this platform. Name of Contact Person: Rhonda Conn, Associate Director Anticipated Completion Date: Done ‐ July 31, 2024
Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance...
Auditor’s Recommendation: “We recommend management ensure sufficient staffing and oversight to abide by internal processes and procedures which require prior approval of expenditures and reports prior to drawdown or submission.” Management response: The Family Place has reviewed its award compliance procedures and concurs with the finding. During the period, responsible departments—including the finance and accounting and human resources teams—experienced unexpected turnover, a significant shortage of staffing, and a time reporting system conversion. As a result, certain compliance procedures were not performed consistently and timely, resulting in unintentional noncompliance with respect to allowable costs, cash management, and reporting controls. Corrective actions: The Executive Leadership Team reviewed the staffing needs of the finance and accounting and human resources teams in 2024. Hiring and training staff to achieve a full team was established as key objectives for the Executive Leadership Team in early 2025. As of September 2025, all vacant positions in both teams have either been filled or have been posted and are in active hiring process. The Chief Financial Officer and Chief of Human Resources have reviewed all internal procedures related to award compliance and will ensure that compliance is timely and well documented going forward. Specifically, the Chief Financial Officer will ensure that purchase orders, invoices, financial reports, and performance reports are completed, reviewed, and approved prior to submission and funding. These processes will have additional oversight by the Chief Executive Officer, with assistance from the newly established Compliance Department, and the Board of Trustees. Responsible parties for corrective actions: The Chief Financial Officer will have direct responsibility for award compliance and will be supported by Chief of Human Resources. The Chief Executive Officer, Tiffany A. Tate, with assistance from the newly established Compliance Department, will confirm that compliance occurs on a timely basis and prior to submission and funding. Separately, the Chief Financial Officer will report on progress to the Audit & Finance Committee of the Board of Trustees. The Executive Leadership Team will be responsible for ensuring the finance and accounting and human resources teams achieve and maintain full staffing levels. Anticipated completion date: The organization is actively implementing the corrective actions by ensuring sufficient staffing as mentioned above and training to ensure prior approval of all grant reports and drawdown requests. As of October 1, 2025, all grant reports will be appropriately approved and documented as such.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT sys...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will ensure that all GLBA requirements over the Information Security Program are both documented completely and inclusive in scope of both general CMHA IT systems as well as IT systems specific to the SFA program. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are ma...
Corrective Action Plan: Atrium Health CMHA management, as part of the 2025 process and procedure consulting engagement, will develop a plan to ensure that the IT systems are changed such that notification letters can be retained, or a control exists whereby hard-copies of notification letters are maintained. Proposed Completion Date: By December of 2025, Atrium Health CMHA management will complete the corrective action.
Corrective Action Plan for Finding 2024-002 Finding 2024-002 – Allowable Costs - Assistance Listing: 14.251 – Economic Development Initiative, Community Project Funding and Miscellaneous Grants Federal Agency: U.S. Department of Housing and Urban Development (HUD) Views of Responsible Officials: The...
Corrective Action Plan for Finding 2024-002 Finding 2024-002 – Allowable Costs - Assistance Listing: 14.251 – Economic Development Initiative, Community Project Funding and Miscellaneous Grants Federal Agency: U.S. Department of Housing and Urban Development (HUD) Views of Responsible Officials: The Organization concurs with the auditor’s finding and appreciates the feedback provided. We acknowledge that documentation submitted in support of draw requests did not always align precisely with the accounting records, specifically the profit and loss by class. Although there were sufficient allowable costs incurred during the audit period to support the drawdowns, we understand that consistency between supporting documentation and accounting system records is essential for compliance with Federal requirements. Corrective Action Plan: We are in the process of developing formal written procedures for managing draw requests under federal awards. These procedures will include verifying that all draw requests are supported by invoices or expenditure documentation that is properly coded in the accounting system. Ensuring that supporting documentation submitted for reimbursement exactly matches the accounting entries, both in amount and coding (by class/funding source). Because the Organization is relatively new to managing federal awards, we will provide targeted training to accounting and program staff on draw request preparation and review. Responsible Official: Bev Kurokawa, treasurer Email: bevk2323@gmail.com Phone: 808 281-3586 Expected Completion Date: December 31, 2025
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