Corrective Action Plans

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VIEWS OF RESPONSIBLE OFFICIALS Draft and approve eligibility criteria in accordance with federal reporting requirements. Implement monthly reconciliations between TANF and internal records. Establish a report review committee with designated personnel. It’s important to note that administrative expe...
VIEWS OF RESPONSIBLE OFFICIALS Draft and approve eligibility criteria in accordance with federal reporting requirements. Implement monthly reconciliations between TANF and internal records. Establish a report review committee with designated personnel. It’s important to note that administrative expenses are listed under Letter F of the Family Preservation program. Other expenses that could be considered administrative under different letters—such as materials, payroll, etc.—are related to direct services, since the employees being paid under these accounts are social workers and the materials are used for activities that are part of the direct service. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS ADSEF establishes eligibility criteria and guidelines for the granting of incentives and bonuses related to compensated efforts assigned to the TANF program. IMPLEMENTATION DATE Up to date RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (A...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF establishes eligibility criteria and guidelines for the granting of incentives and bonuses related to compensated efforts assigned to the TANF program. IMPLEMENTATION DATE Up to date RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym) continue
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. Anexes: • Comunicación Límite de tiempo de Beneficios Categoría C • Comunicación sobre periodo de certificación Categoría C, próximos a cumplir los 60 meses. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with ...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will assess and develop, together with program directors and program specialists, retraining sessions aimed at technical staff and supervisors. As part of its ongoing digitization efforts, ADSEF has incorporated the replacement of the Social Security number with a unique identification number. IMPLEMENTATION DATE December 2025 RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated consideri...
VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated considering both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
Finding 572058 (2023-004)
Significant Deficiency 2023
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develo...
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develop written policies requiring cash disbursements to follow a clear, tiered approval process based on the amount. For example: • Up to a set threshold: Department manager approval • Above threshold: Department manager plus finance director/CFO approval • High-value disbursements: Additional executive or board-level approval. Requiring supporting documents (invoices, contracts, purchase orders) for every disbursement. Approvers must verify accuracy and completeness before authorizing payment. If there are any questions regarding this plan, please e-mail Yumiko Molden at ymolden@waikikihealth.org. Sincerely, Yumiko Molden CFO
Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant adm...
Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant administration and compliance. The grant manager's duties will include ensuring that all reimbursement requests are substantiated by adequate documentation, such as actual invoices, payroll registers, and payment records. Key actions include:  Establishing a systematic process for the collection, organization, and retention of all requisite documents.  Implementing internal review and approval procedures to guarantee that every reimbursement request undergoes thorough vetting and receives approval prior to submission, with explicit documentation of the review process.  Instructing both existing and new personnel on these newly instituted procedures to prevent future inconsistencies. Anticipated Completion Date: December 31, 2025.
Finding 2023-002 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal a...
Finding 2023-002 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal awards, ensuring adherence to 2 CFR Part 200. The Outsourced Grant Manager will implement systems to accurately allocate salaries, wages, and other expenditures. Key actions include:  Payroll Expenditures: Establish procedures to approve payroll allocations based on actual time and effort reporting, requiring supervisor approval and periodic reviews for compliance.  Non-Payroll Expenditures: Develop approval processes for non-payroll expenses, ensuring detailed documentation and implementing checks to verify overhead allocations.  Documentation and Review: Implement a comprehensive filing system for approvals and supporting documents, with regular training for staff.  Ongoing Compliance Monitoring: Conduct periodic internal audits to ensure adherence to internal controls and federal regulations, addressing issues promptly. These measures will strengthen CDF’s internal controls, ensure compliance, and maintain the integrity of federal award management. Anticipated Completion Date: December 31, 2025.
View Audit 362526 Questioned Costs: $1
2023 – 005 - Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Recommendation: 1. Implement a Formal Expenditure Review and Approval Policy – Establish a policy requiring that all expenditures charged to grants be reviewed and approved by an appropriate...
2023 – 005 - Significant Deficiency in Internal Control Over Compliance: Allowable Costs and Activities Recommendation: 1. Implement a Formal Expenditure Review and Approval Policy – Establish a policy requiring that all expenditures charged to grants be reviewed and approved by an appropriate individual before being recorded in the system. 2. Require Documentation of Review and Approval – Ensure that invoices, payroll allocations, and other cost support documents include a signature, initials, or system-generated approval to confirm review. 3. Utilize System-Based Controls – If possible, configure the financial system to require electronic approval for all grant-related expenditures before costs are recorded. Management View: Management partially agrees with the finding. While we acknowledge that documentation of expenditure approval was not always retrievable, we believe the expenditures reviewed were all appropriate. Finding 2023-006 refers to the auditors’ assessment of expenditure review and approval processes that occurred in Calendar Year 2023. During Calendar Year 2023, Prism relied on email routing of expenditures for review and approval. As of this writing, Prism Health North Texas’ expenditure review and approval processes already meet or exceed the recommendations above. Action Taken: 1. Expenditure Review – All expenditures charged to grants are reviewed and approved by two qualified individuals. 2. Documentation of Review and Approval – a. Such review and approval for non-payroll expenditures occur in and are documented in the SAP Concur software before the costs are recorded in the accounting system (Abila). b. Such review and approval for payroll-related expenditures occur via and are documented via a combination of methods, also before they are recorded in Abila. i. Employees report their time, including how much time was devoted to grant activities, in the ExponentHR payroll system, and their supervisors approve both the time and the allocation in that system. ii. Programmatic measures that also support grant billing (“units”) are calculated from activity documented in the athenaOne electronic health record (EHR). iii. Payroll allocation is calculated by one person, based on the ExponentHR documentation and the units, then reviewed and imported into Abila by a second person. The unposted transactions are reviewed again before posting. 3. Utilize System-Based Controls – In place as above. Anticipated Completion Date: The recommendations are already in place. Responsible Contact Person(s): • Name: General Laffitte • Title: Vice President of Finance and Accounting • Phone: 214-623-6896 • Address: 3900 Junius St. Ste. 300, Dallas, Texas 75246 • Name: Jana Voege • Title: Chief Financial Officer Address: 3900 Junius St. Ste. 300, Dallas, Texas 75246 Corrective Action Plan Date: 4/28/2025 Cognizant or Oversight Agency for Audit Prism Health North Texas respectfully submits the following corrective action plan for the year ended FY2023. Name and address of independent public accounting firm: Armanino LLP 15950 Dallas Pkwy #600, Dallas, TX 75248 (972) 661 - 1843 Audit Period: The consolidated financial statements of AIDS Arms, Inc. were audited for the period of calendar year 2022 and 2023. The findings from 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.
Management agrees with the finding and has updated its internal lost revenue calculation, with cumulative amounts through Period 6 reporting. While management did attempt to update its lost revenue amounts with filing of its Period 4 reports, additional data entry errors were made. Four out of the s...
Management agrees with the finding and has updated its internal lost revenue calculation, with cumulative amounts through Period 6 reporting. While management did attempt to update its lost revenue amounts with filing of its Period 4 reports, additional data entry errors were made. Four out of the six entities that need to report on PRF funding have no further reporting periods; therefore, the Organization has no ability to make further corrections. As such, the internal records maintained by the Organization must serve as teh final reporting of the PRF funding.
Condition: The Organization could not provide one salary authorization from for sample selection of 40 employees. Corrective Action Planned: The Organization has implemented a process to ensure that all salary authorizations are properly obtained and stored. When there is any change in an employee...
Condition: The Organization could not provide one salary authorization from for sample selection of 40 employees. Corrective Action Planned: The Organization has implemented a process to ensure that all salary authorizations are properly obtained and stored. When there is any change in an employee's status or salary, an Employee Status Form is completed and signed by the employee, their supervisor, and Human Resources, and when required by the COO and CEO. Additionally, the salary authorization form is added to a secure shared file drive. The shared file drive includes a section where all salary changes are listed. Both HR and Finance initial off to confirm that each salary change is supported by the proper documentation during the payroll review process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll and finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervi...
Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll and finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors' approval to time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. The entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance intimal off on the reviewed payroll times, ensuring a traceable record of the entire payroll approval process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: The Organization did not maintain property documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting ...
Condition: The Organization did not maintain property documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties and best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review as also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in ...
Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal control and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner....
Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.
Views of responsible officials and planned corrective actions: Management acknowledges the omission of the federally contract from the auditee’s prepared SEFA. Management is committed to properly preparing the SEFA, and to address this oversight, management will identify trainings for accounting p...
Views of responsible officials and planned corrective actions: Management acknowledges the omission of the federally contract from the auditee’s prepared SEFA. Management is committed to properly preparing the SEFA, and to address this oversight, management will identify trainings for accounting personnel related to SEFA reporting and for those reviewing the schedule, to ensure its accuracy.
Finding Number: 2023-004 Condition: The County did not have controls in place during the year under audit to ensure that the required certified payrolls were received by contractors and subcontractors. Planned Corrective Action: Develop a process with Neighborhood Housing and Development Department ...
Finding Number: 2023-004 Condition: The County did not have controls in place during the year under audit to ensure that the required certified payrolls were received by contractors and subcontractors. Planned Corrective Action: Develop a process with Neighborhood Housing and Development Department ensuring all appropriate documentation has been reviewed and received. Contact person responsible for corrective action: Khadija Walker-Fobbs Anticipated Completion Date: 07/15/2024
FINDING 2023-002 Information on the federal program: Subject: Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Federal Agency: U.S. Department of Treasury Assistance Listing Number: 21 .027 Federal Award Number: CY 2021 Pass-Through Entity: Direct Grant Co...
FINDING 2023-002 Information on the federal program: Subject: Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Federal Agency: U.S. Department of Treasury Assistance Listing Number: 21 .027 Federal Award Number: CY 2021 Pass-Through Entity: Direct Grant Compliance Requirements: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Other Matters Condition: An effective internal control system was not in place at the City to ensure compliance with requirements related to the grant agreement and the respective procurement method of the Procurement and Suspension and Debarment compliance requirement. Context: Two procurements were selected for testing in the current year. For the small purchase transaction, management only provided the contract. No other procurement support showing evidence of bids was provided. Additionally, support showing that the City had performed a suspension and debarment check was not provided. For the simplified acquisition transaction, management performed procurement for similar services in 2016. The vendor selected in 2016 was used for the transaction charged to the federal grant without obtaining additional bids. Additionally, support showing that the City had performed a suspension and debarment check was not provided. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will ensure that procurement procedures are done for each contract and suspension and debarment checks are documented. Responsible Party and Timeline for Completion: The Clerk-Treasurer is the responsible party. The corrective action plan will go into effect during calendar year 2025.
Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer ...
Federal Agency Name: Department of Treasury Assistance Listing Number: 21.027 Program Name: Coronavirus State and Local Fiscal Recovery Funds Finding Summary: The Foundation did not have internal controls to ensure proper review and approval (segregation of duties) between the preparer and reviewer of the quarterly financial reports. Corrective Action Plan: Previous reports were compiled by the Foundation’s vendors and submitted by the prior CFO. Future reports will be prepared by the Accountant and reviewed by the CFO prior to submission. Responsible Individuals: Alisha Kinnison, Accountant and Matt Lazar, CFO Anticipated Completion Date: July 2025
Reporting Significant Deficiency in Internal Control over Compliance Department of Treasury Federal Assistance Listing #21.027 Coronavirus State and Loan Fiscal Recovery Funds Finding Summary: Lack of documentation of a secondary review on expense reports required to be submitted. Responsible Indivi...
Reporting Significant Deficiency in Internal Control over Compliance Department of Treasury Federal Assistance Listing #21.027 Coronavirus State and Loan Fiscal Recovery Funds Finding Summary: Lack of documentation of a secondary review on expense reports required to be submitted. Responsible Individuals: Eric Price, CFO Corrective Action Plan: Management has enhanced internal control policies and processes to ensure that a secondary review of expense report is taking place prior to submission and that those reviews are formally documented. Anticipated Completion Date: Ongoing
Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-006 Cash Management Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing we noted that cash requests did not contain evidence of required approvals. Planned Cor...
Fiscal Year 2023 Single Audit Corrective Action Plan Finding Number: 2023-006 Cash Management Condition: The CMHSP has established internal controls relating to approvals of cash requests. However, during testing we noted that cash requests did not contain evidence of required approvals. Planned Corrective Action: The CFO or Finance Manager will ensure that all cash requests are approved by the proper individuals. Contact Person: Kevin Hartley, CFO 231.633.2171 Kevin.hartley@nlcmh.org Anticipated Completion Date: 10-1-24
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