Corrective Action Plans

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Funds will not be drawn down until an invoice or proper pay request is received, and purchase order or contract are in hand, and payment is made promptly within no more than three business days. The Schedule of Expenditures of Federal Awards will be reviewed by Management that all funding received a...
Funds will not be drawn down until an invoice or proper pay request is received, and purchase order or contract are in hand, and payment is made promptly within no more than three business days. The Schedule of Expenditures of Federal Awards will be reviewed by Management that all funding received and reported has be fully expensed by the Authority prior to submission on the Hinkle system for audit.
Historic South acknowledges this finding is the same as reported in 2024. Although the corrective actions identified in the prior year’s audit were implemented, they were not fully in place during most of the period covered by the current audit. As a result, the transactions tested during the 2025 a...
Historic South acknowledges this finding is the same as reported in 2024. Although the corrective actions identified in the prior year’s audit were implemented, they were not fully in place during most of the period covered by the current audit. As a result, the transactions tested during the 2025 audit occurred before the corrective measures became effective. Corrective measures implemented include policies and procedures designed to strengthen its procurement and contracting processes. These include: 1. Requiring the solicitation of multiple bids for all construction work in excess of $10,000 2. Establishing criteria for awarding all construction work 3. Implementing formal contracting processes for all construction work Management believes these corrective actions address the deficiencies identified and expects them to be fully effective for construction activities occurring after implementation.
CITY OF GOSHEN CORRECTIVE ACTION PLAN FINDING 2025-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (SLRF) – Suspension and Debarment Contact Person Responsible for Corrective Action: Goshen Clerk-Treasurer Richard R. Aguirre Contact Phone Number and Email address: 5...
CITY OF GOSHEN CORRECTIVE ACTION PLAN FINDING 2025-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (SLRF) – Suspension and Debarment Contact Person Responsible for Corrective Action: Goshen Clerk-Treasurer Richard R. Aguirre Contact Phone Number and Email address: 574-533-8623; richardaguirre@goshencity.com Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: For future expenditures involving federal programs, and prior to entering into covered transactions, the City of Goshen will verify that all contractors and subrecipients are not suspended or debarred or otherwise excluded by using one or more of the following procedures: (a) incorporating the required suspension and debarment language into fully executed agreements, (b) obtaining written or emailed certification from vendors confirming they are neither suspended nor debarred, (c) verifying vendor status through the applicable federal suspension and debarment database (Excluded Parties List System, EPLS). The City has included suspension and debarment clauses in many contracts involving the use of federal and state monies since 2023. However, due to an internal misunderstanding within another City Department, the agreement at issue was not identified as being subject to the federal suspension and debarment requirement. That is because, in April 2024, the City awarded a contract to a local contractor for the Steury Avenue and Lincoln Avenue Reconstruction and Drainage Improvement project and the Goshen Common Council did not approve using $5,086,932.81 in American Rescue Plan funds (SLRF) for that project until Dec. 16, 2024. So, there was no verification before the expenditure of $1,875,887 of SLRF funds for the contractor in 2025. As of the date of this corrective action plan, the Clerk-Treasurer’s Office has verified that contractors and vendors paid with federal funds in 2025 and 2026 (including the contractor identified in Finding 2025-002) are not suspended or debarred or otherwise excluded. Going forward, the Clerk-Treasurer’s Office and the Grant Coordinator will coordinate more closely with all City departments to improve awareness of the suspension and debarment compliance requirements associated with federal awards. This enhanced communication and oversight is intended to prevent similar instances of noncompliance in the future. Anticipated Completion Date: City officials and key staff members have been reminded of these verification procedures through verbal communication, email, or both. By Dec. 31, 2026, City staff will receive additional guidance from Clerk- Treasurer’s staff on identifying when suspension and debarment requirements apply to vendor contracts and on following the City's established verification procedures before contract approval and execution. – Completed and resubmitted to the State Board of Accounts, August 10, 2026
Beginning with FY2026, a new Federal Programs Supervisor/Director was hired by the Board, and a Fiscal Administrator was appointed on August 27, 2025. These new designees will ensure that all federal programs operate within their allowable costs, activities, procurement, suspension and debarment gui...
Beginning with FY2026, a new Federal Programs Supervisor/Director was hired by the Board, and a Fiscal Administrator was appointed on August 27, 2025. These new designees will ensure that all federal programs operate within their allowable costs, activities, procurement, suspension and debarment guidelines. Approved budgets will be reviewed and complied with as purchases are made and reviewed monthly thereafter.
Beginning with FY2026, a new Federal Programs Supervisor/Director was hired by the Board, and a Fiscal Administrator was appointed on August 27, 2025. These new designees will ensure that all federal programs operate within their allowable costs, activities, procurement, suspension and debarment gui...
Beginning with FY2026, a new Federal Programs Supervisor/Director was hired by the Board, and a Fiscal Administrator was appointed on August 27, 2025. These new designees will ensure that all federal programs operate within their allowable costs, activities, procurement, suspension and debarment guidelines. Approved budgets will be reviewed and complied with as purchases are made and reviewed monthly thereafter.
Beginning with FY2026, a new Federal Programs Supervisor/Director was hired by the Board, and a Fiscal Administrator was appointed on August 27, 2025. These new designees will ensure that all federal programs operate within their allowable costs, activities, procurement, suspension and debarment gui...
Beginning with FY2026, a new Federal Programs Supervisor/Director was hired by the Board, and a Fiscal Administrator was appointed on August 27, 2025. These new designees will ensure that all federal programs operate within their allowable costs, activities, procurement, suspension and debarment guidelines. Approved budgets will be reviewed and complied with as purchases are made and reviewed monthly thereafter.
Prior to purchases being made, the Child Nutrition Program Supervisor will check for suspension and debarment of vendors. The accounts payable accountant will also review for suspension and debarment prior to payment being made. Evidence of review will be maintained in an appropriately labeled file ...
Prior to purchases being made, the Child Nutrition Program Supervisor will check for suspension and debarment of vendors. The accounts payable accountant will also review for suspension and debarment prior to payment being made. Evidence of review will be maintained in an appropriately labeled file each year.
Prior to purchases being made, the Child Nutrition Program Supervisor will check for suspension and debarment of vendors. The accounts payable accountant will also review for suspension and debarment prior to the payment being made. Evidence of review will be maintained in an appropriately labeled f...
Prior to purchases being made, the Child Nutrition Program Supervisor will check for suspension and debarment of vendors. The accounts payable accountant will also review for suspension and debarment prior to the payment being made. Evidence of review will be maintained in an appropriately labeled file each year. See response to finding 2025-018 above.
Name of auditee: Fiesta House Senior Housing, Inc. HUD auditee identification number: 122-EE166-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Curren...
Name of auditee: Fiesta House Senior Housing, Inc. HUD auditee identification number: 122-EE166-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-003: The Corporation's accounting books and records as submitted for audit included certain accounts which were not presented in accordance with accounting standards generally accepted in the United States of America ("GAAP"). As a result, audit adjustments provided by management were required to present the December 31, 2025 financial statements in accordance with GAAP. Comments on the Finding and Each Recommendation: Management should review the internal controls to ensure that the accounting software allows for timely recording of information and that a timely review of the reconciliations is completed by another accountant not responsible for the month end close. Action(s) taken or planned on the finding: The accounting software provider was changed and a new system to indicate review and approval of the month end closing process is being implemented.
Name of auditee: Fiesta House Senior Housing, Inc. HUD auditee identification number: 122-EE166-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Curren...
Name of auditee: Fiesta House Senior Housing, Inc. HUD auditee identification number: 122-EE166-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-002: During the year ended December 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included 16 of the same invoices as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdrawal. In addition, management submitted and received approval for two proposals for work that was not completed. Comments on the Finding and Each Recommendation: Management should transfer $62,856 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management will deposit the $62,856 during 2026.
Name of auditee: Fiesta House Senior Housing, Inc. HUD auditee identification number: 122-EE166-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Curren...
Name of auditee: Fiesta House Senior Housing, Inc. HUD auditee identification number: 122-EE166-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition 2025-001: The Corporation paid entity costs of $6,950 from operating cash. Comments on the Finding and Each Recommendation: The Sponsor should reimburse the Corporation $6,950 or management should request HUD approval for funds to be reimbursed from the reserve for replacement. Action(s) taken or planned on the finding: Management plans to request reimbursement from the reserve for replacement in 2026.
Condition Caminar Latino, Inc. issued a subaward on December 3, 2024, with a reporting deadline of January 31, 2025. The subaward was not reported through the applicable FFATA subaward reporting system until June 8, 2026. We tested the complete population of two applicable subawards associated with ...
Condition Caminar Latino, Inc. issued a subaward on December 3, 2024, with a reporting deadline of January 31, 2025. The subaward was not reported through the applicable FFATA subaward reporting system until June 8, 2026. We tested the complete population of two applicable subawards associated with the program during the audit period and identified one instance of untimely reporting. The other subaward was reported by the applicable deadline. Correction action FFATA reports will continue to be submitted in the timeframe required, with target submission within one week of the execution of the contract. Screenshots of submitted FFATA reports will be saved to the file. Responsible Person Co-CEOs Anticipated completion date The instruction to save screenshots was added to the standard operation procedure for sub-awards in August 2026 and all other current subawards have been submitted in the required timeframe.
Programs: ALN 66.458 Clean Water State Revolving Fund and ALN 66.468 Drinking Water State Revolving Fund Condition: The City's procurement procedures do not conform to Uniform Guidance requirements. Actions Planned in Response to Finding: The City will update procurement procedures to conform with M...
Programs: ALN 66.458 Clean Water State Revolving Fund and ALN 66.468 Drinking Water State Revolving Fund Condition: The City's procurement procedures do not conform to Uniform Guidance requirements. Actions Planned in Response to Finding: The City will update procurement procedures to conform with Minnesota statutes and Uniform Guidance. Officer Responsible for Ensuring CAP: Kimberly Block, Clerk/Treasurer Planned Completion Date: 12/31/2026
Condition: During our audit, we proposed numerous adjustments that resulted in significant changes to the City's financial statements. Actions Planned in Response to Finding: The City will continue to review internal controls and work to design modifications that will increase internal control and t...
Condition: During our audit, we proposed numerous adjustments that resulted in significant changes to the City's financial statements. Actions Planned in Response to Finding: The City will continue to review internal controls and work to design modifications that will increase internal control and the ability to detect material misstatements. Officer Responsible for Ensuring CAP: Kimberly Block, Clerk/Treasurer Planned Completion Date: Not Applicable
Condition: The City relies upon the auditor to prepare the financial statements an related disclosures in accordance with GAAP. Actions Planned in Response to Finding: The City will continue to review auditor prepared financial statements with the intention of understanding and accepting responsibil...
Condition: The City relies upon the auditor to prepare the financial statements an related disclosures in accordance with GAAP. Actions Planned in Response to Finding: The City will continue to review auditor prepared financial statements with the intention of understanding and accepting responsibility for reporting under GAAP. Officer Responsible for Ensuring CAP: Kimberly Block, Clerk/Treasurer Planned Completion Date: Not Applicable
Condition: Due to the limited size of the City's staff, the City has limited segregation of duties. Actions Planned in Response to Finding: The City reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the ...
Condition: Due to the limited size of the City's staff, the City has limited segregation of duties. Actions Planned in Response to Finding: The City reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Officer Responsible for Ensuring CAP: Mayor and Council Planned Completion Date: Not Applicable
Finding 1229057 (2025-001)
Material Weakness 2025
Avivo
MN
Emergency Solutions Grant – Assistance Listing No. 14.231 Recommendation: We recommend that management implement formal procurement policies requiring periodic reassessment of vendors used in federally funded programs, particularly when new grant awards are received or grant periods change. This sho...
Emergency Solutions Grant – Assistance Listing No. 14.231 Recommendation: We recommend that management implement formal procurement policies requiring periodic reassessment of vendors used in federally funded programs, particularly when new grant awards are received or grant periods change. This should include evaluating whether the original procurement method remains appropriate, performing updated cost or price analyses as necessary, and conducting and documenting periodic suspension and debarment checks (e.g., SAM verification). Additionally, management should establish oversight controls to ensure procurement compliance and vendor eligibility are maintained throughout the lifecycle of vendor relationships in accordance with 2 CFR §200.318–200.320 and §200.214. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Avivo is in the process of updating its procurement policy and processes to include annual reviews of ongoing vendor contracts that will assess the appropriateness of the original procurement conditions and determine if updates or new analyses are required. Reviews will be signed off by the staff with contracting authority at the time of review; and if warranted, the appropriate staff will undertake new cost analyses, complete the documentation, and save in a shared repository that relevant departments will have access to. Program leadership is working with the appropriate administrative departments to develop the necessary processes for periodic review and the collection/storage of documentation around the periodic review process. The Accounting department has added a system-wide debarment check of all active vendors in the 3rd quarter of each year and will add any new vendors to this schedule regardless of when they were originally added to the vendor payment system. This ensures that all vendors are re-checked for debarment and suspension at minimum of one time annually. Name(s) of the contact person(s) responsible for corrective action: Kelly Matter Planned completion date for corrective action plan: 12/31/2026
Finding Reference Number: 2025-003 – Internal Control over Compliance in Relation to Procurement Suspension and Debarment Description of Finding: This is a new finding. Upon review of the town’s Bid Ordinance and Charter, a policy could not be found that determines whether a vendor for goods and ser...
Finding Reference Number: 2025-003 – Internal Control over Compliance in Relation to Procurement Suspension and Debarment Description of Finding: This is a new finding. Upon review of the town’s Bid Ordinance and Charter, a policy could not be found that determines whether a vendor for goods and services was either suspended or debarred from receiving or participating in federal awards, which is required as part of the 2025 Uniform Guidance related to Federal Programs. Additionally, it could not be determined whether any suspension or debarment review had been made and documented. Statement of Concurrence or Nonconcurrence: Concur. Corrective Action: The town will update the Town Bid Ordinance to include the policy that mandates that before any contract or purchase order is awarded using federal funds, staff must verify the vendor’s eligibility status via the federal System for Award Management (SAM.gov). The Town will also update its Policy and Procedures manual to require a printed or digital SAM.gov search certificate to be attached to the procurement file as auditable evidence of the verification. Projected Completion Date: December 31, 2026
Finding Reference Number: 2025-002 – Internal Control over Compliance in Relation to Period of Performance Requirements Description of Finding: This is a new finding. For four of the seven projects reported under the Federal Program COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (SLFRF...
Finding Reference Number: 2025-002 – Internal Control over Compliance in Relation to Period of Performance Requirements Description of Finding: This is a new finding. For four of the seven projects reported under the Federal Program COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (SLFRF), totaling $204,862, documentation that the signed and accepted quote was sent back to the vendor by the program obligation deadline of December 31,2024 could not be located. Statement of Concurrence or Nonconcurrence: Nonconcur. Corrective Action: For each of these projects, fully detailed quotes incorporating specific scopes of work, pricing, and binding terms and conditions were executed (signed) by authorized Town officials on or before the December 31, 2024 obligation deadline. Additionally, work or deliverables were performed in accordance with these signed terms without dispute from either party, further proving mutual intent and the existence of a binding agreement. the existence of a binding agreement.
Finding Reference Number: 2025-001 – Internal Control over Compliance in Relation to Reporting Requirements Description of Finding: This is a new finding. For one of the seven projects reported under the Federal Program COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (SLFRF), the total ...
Finding Reference Number: 2025-001 – Internal Control over Compliance in Relation to Reporting Requirements Description of Finding: This is a new finding. For one of the seven projects reported under the Federal Program COVID-19 – Coronavirus State and Local Fiscal Recovery Funds (SLFRF), the total cumulative expenditures did not match the current period expenditures. The total cumulative expenditures reported were $295,205, but the current period expenditures reported were $264,767, a difference of $30,438 Statement of Concurrence or Nonconcurrence: Partially Concur. Corrective Action: Our preliminary review indicates the discrepancy stems from the prior administration’s specific methodology and interpretation of reporting requirements, rather than a substantive reporting error. The report in question covered the period of January 2025-March 2025. The expenditures totaling $30,438 were related to Q4 2024, and documentation indicates it was the previous administration’s intention to capture the current period expenditures (Q1 2025) versus the full fiscal year. To eliminate confusion, the Finance Department is establishing a formalized Standard Operating Procedure (SOP) that outlines the reporting requirements for these projects. Projected Completion Date: December 31, 2026
Inadequate Grant Recordkeeping The County will work to improve grant documentation and will consider having someone review grant reports prior to their submission. In the absence of necessary knowledge and expertise, the County will continue to rely on the auditors to assist with prepration of the S...
Inadequate Grant Recordkeeping The County will work to improve grant documentation and will consider having someone review grant reports prior to their submission. In the absence of necessary knowledge and expertise, the County will continue to rely on the auditors to assist with prepration of the Schedule of Expenditures of Federal Awards and reconciling the financial records to the Consolidated Year-End Financial Report.
Lack of Appropriate Personnel In the absence of necessary knowledge and expertise, the County will continue to rely on the auditors to ensure the notes to the financial statements are properly presented.
Lack of Appropriate Personnel In the absence of necessary knowledge and expertise, the County will continue to rely on the auditors to ensure the notes to the financial statements are properly presented.
Insufficient Grant Monitoring The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to the grant reports that are filed.
Insufficient Grant Monitoring The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to the grant reports that are filed.
Corrective Action Plan: To address the documentation deficiency related to the application of internal controls for sliding fee scale eligibility determinations, Partnership Community Health Center will reinforce and monitor the following ongoing practices: 1. Staff Training: Ongoing and refresher t...
Corrective Action Plan: To address the documentation deficiency related to the application of internal controls for sliding fee scale eligibility determinations, Partnership Community Health Center will reinforce and monitor the following ongoing practices: 1. Staff Training: Ongoing and refresher training is provided to all staff responsible for processing sliding fee scale applications. Training emphasizes the importance of documenting each step in the eligibility review and approval process. 2. Checklist Utilization: Staff continue to use the established checklist for each sliding fee scale application, ensuring all required steps in the eligibility review and approval process are documented, initialed, and dated. 3. Weekly Audits: Patient Services and Outreach Managers conduct regular weekly audits of a sample of sliding fee scale applications to verify that documentation of internal control procedures is consistently maintained. Any identified issues are addressed promptly with targeted corrective actions as needed. 4. Ongoing Monitoring: Results of the weekly audits are reviewed during monthly compliance meetings to ensure that corrective actions are implemented and sustained. Additional Context: This was an isolated case involving a staff member who was in training at the time of the incident and is no longer with the organization. All current staff have completed required training, and ongoing refresher sessions are in place to prevent recurrence. Person(s) Responsible: • Patient Services and Outreach Managers (for weekly checklist oversight, audits, and corrective actions) • Compliance Officer • CFO and PCHC Billing Timing for Implementation: • These practices are ongoing. Continued monitoring and reinforcement will ensure sustained compliance.
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