Corrective Action Plans

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Prior to awarding contracts over $25,000, we will conduct a review of the government website (SAM) to confirm contractors have not been suspended or debarred. Documentation will be retained to provide evidence of verification. While we do have a process to select vendors who provide us with the lowe...
Prior to awarding contracts over $25,000, we will conduct a review of the government website (SAM) to confirm contractors have not been suspended or debarred. Documentation will be retained to provide evidence of verification. While we do have a process to select vendors who provide us with the lowest costs, we will update our process to document the rationale on vendor selection on purchases over $2,500. We will update our procurement policy to reflect this process enhancement.
We have established a process to calculate program income semi-annually and will keep in place until this grant is officially closed. The program income calculated will be added back to this award. We will invest those dollars back into our houses and track and report this activity as part of our se...
We have established a process to calculate program income semi-annually and will keep in place until this grant is officially closed. The program income calculated will be added back to this award. We will invest those dollars back into our houses and track and report this activity as part of our semi-annual reporting to HUD.
We have adjusted our indirect cost rate using the de minimis cost rate of 15% to the modified total direct costs under 2 CFR 200.414(f). We will adjust future reimbursement submissions to bring our indirect rate back in-line with this standard.
We have adjusted our indirect cost rate using the de minimis cost rate of 15% to the modified total direct costs under 2 CFR 200.414(f). We will adjust future reimbursement submissions to bring our indirect rate back in-line with this standard.
Issue Identified: HUD regulations require that deposits into the Replacement Reserve account be made on a monthly basis. Our agency has historically made annual lump-sum deposits, which is not in compliance with HUD guidelines. Corrective Actions 1. Change in Deposit Frequency Action: Transition fro...
Issue Identified: HUD regulations require that deposits into the Replacement Reserve account be made on a monthly basis. Our agency has historically made annual lump-sum deposits, which is not in compliance with HUD guidelines. Corrective Actions 1. Change in Deposit Frequency Action: Transition from an annual deposit schedule to a monthly deposit schedule in accordance with HUD requirements. Responsible Party: CFO and Accounting Manager Timeline: Effective July 1, 2025 monthly deposits will begin. Verification: Monthly entries and bank confirmations will be reviewed by Accounting. 2. Implementation of Automated Transfers Action: Establish and schedule automated monthly bank transfers to the Replacement Reserve account. Responsible Party: Accounting Manager in collaboration with Banking Institution Timeline: Setup completed by April 15, 2025. First automated transfer on July 1, 2025. Verification: Confirmation of automation setup from the bank and successful execution of first transfer. 3. Monthly Notifications to Fiscal Personnel Action: Create an automated monthly email notification system to alert key fiscal personnel of each deposit, including the amount and confirmation of receipt. Responsible Party: Budget & Reimbursement Manager Timeline: Notification system was remediated by July 1, 2025 Verification: Email log confirming monthly communications sent to fiscal team. Ongoing Monitoring and Compliance The Accounting Manager will review monthly bank statements to verify timely and accurate deposits. The Controller will incorporate verification into monthly closing procedures. Authorization and Approval
Finding Number: 2025-001 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cassandra Sassenberg Corrective Action Planned: At Quarter End, the Fiscal S...
Finding Number: 2025-001 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Grants to States for Medicaid Name of Contact Person Responsible for Corrective Action: Cassandra Sassenberg Corrective Action Planned: At Quarter End, the Fiscal Supervisor and/or Fiscal Coordinator will request specific employee payroll information from payroll staff. Payroll staff will provide a UKG general ledger system report showing account breakouts of the allocation, rather than solely a summary total spreadsheet to allow for review by employee, account code, and time study participation status. For employees included on the participant list, only the portion of salary charged to account 11.420 will remain on Line A1 of the DHS-2550 report. Any portion charged to accounts 11.430 or 11.440 will be removed from Line A1 and reported as an administrative cost on Line E1. If an employee is not included on the participant list, the employee’s full salary, including any amount charged to account 11.420, will be reported as an administrative cost on Line E1. This process will ensure that only eligible participant payroll remains on Line A1 and prevent payroll costs from being removed from Line A1 in excess of the amount required. Anticipated Completion Date: 12/31/2026
The County will work with Rehmann to develop policies and procedures sufficient to satisfy the rules of the uniform guidance.
The County will work with Rehmann to develop policies and procedures sufficient to satisfy the rules of the uniform guidance.
Finding 1228718 (2025-002)
Material Weakness 2025
Finding 2025-002 – Material Weakness in Internal Controls over Federal Award Compliance Criteria – 2 CFR 200.303 requires the recipient to establish, document, and maintain effective internal control over federal awards. Condition – The Organization has not established and documented internal contro...
Finding 2025-002 – Material Weakness in Internal Controls over Federal Award Compliance Criteria – 2 CFR 200.303 requires the recipient to establish, document, and maintain effective internal control over federal awards. Condition – The Organization has not established and documented internal control policies and procedures over compliance with federal award requirements other than procurement. It is also noted that the procurement policy that is documented does not conform to current federal limits. Context and Cause – The Organization’s current policies do not include a review of the fiscal policy for required changes on a scheduled basis. Effect of Condition – Incomplete documentation of policies regarding federal compliance could prevent management and the Board from providing adequate oversight over compliance activities of the Organization. Questioned Cost – None. Recommendation – We recommend the Organization develop and implement policies and procedures addressing the applicable federal compliance requirements for each federal program. Action Taken – Management concurs with the finding and has developed a corrective action plan. We understand that a material weakness is identified in internal controls over compliance. The material weakness is in internal controls over compliance, and not a compliance finding. Draft and adopt written internal control policies and procedures addressing each applicable compliance requirement, including defined roles, responsibilities, and approval processes. Update the Organization's procurement policy to conform to current Federal procurement thresholds and methods under 2 CFR §§ 200.317–200.327, including micro-purchase and simplified acquisition thresholds. Establish a recurring (at least annual) fiscal policy review cycle, with responsibility assigned to a specific role, to identify and incorporate required regulatory changes, including updates to Federal thresholds. Present the updated policies and procedures to the Board (or Finance/Audit Committee) for formal review and approval. Responsible parties: Fiscal Director. Anticipated completion date: October 31, 2026.
Views of Responsible Officials and Planned Corrective Action Management acknowledges that time and effort procedures were not consistently followed throughout FY25 and, that, as a result, invoicing was tied to the grant approved budget rather than actual time and effort. The organization has struggl...
Views of Responsible Officials and Planned Corrective Action Management acknowledges that time and effort procedures were not consistently followed throughout FY25 and, that, as a result, invoicing was tied to the grant approved budget rather than actual time and effort. The organization has struggled with time keeping because of the unique nature of immigration legal work – the fact that cases last for years at a time and that different funders require vastly different things to be tracked – even different federal streams of funding require different things to be tracked. While during FY24 we had this finding as well, because the audit for FY24 was not complete until November 2025, the fiscal year for 2025 was well underway when we started working on a new time-keeping system which is why FY25 we have the finding again. However, the organization has implemented a new system of reporting designed to capture time and effort of all employees charged to government grant and contracts, as well as other grants and contracts awarded to the agency from the philanthropic community. We have also purchased a new HRIS system which we hope will continue improve our time keeping efforts in FY27 and we have been working closely with experts from Your Part-time Controller to ensure that a new system is successfully implemented. In addition, we are implementing monthly reconciliation meetings between finance and program staff to ensure that invoicing amount are appropriately tied to actual expenditures. Corrective Action to be Taken (Estimated Completion Date) 9/30/2026 Designated Person Responsible Cathryn Miller-Wilson, Executive Director
FINDING 2025-005 TIMELY SUBMISSION OF SINGLE AUDIT REPORTING PACKAGE - NONCOMPLIANCE Management acknowledges the finding that City did not comply with established policies and procedures that requires the preparation and review of key account reconciliations and financial reporting activities and re...
FINDING 2025-005 TIMELY SUBMISSION OF SINGLE AUDIT REPORTING PACKAGE - NONCOMPLIANCE Management acknowledges the finding that City did not comply with established policies and procedures that requires the preparation and review of key account reconciliations and financial reporting activities and recognizes the importance of submitting the Single Audit reporting package and Data Collection Form within the timeframe required by 2 CFR Section 200.512(a). The delay in submitting the fiscal year 2025 Single Audit reporting package was primarily attributable to delays in completing account reconciliations and related financial reporting activities necessary to finalize the City's financial records and complete the annual audit process. As discussed in Management's responses to the related findings regarding the timeliness of reconciliations, grant revenue recognition, and annual financial report filings, the City is implementing strengthened financial reporting and grant management procedures. These corrective actions include establishing defined reconciliation procedures and completion timeframes, implementing a period-end closing checklist, strengthening grant reconciliation and reporting procedures, and providing additional oversight and training for Finance Department personnel. The new Finance Director and Comptroller will monitor the year-end closing, grant reporting, and audit preparation processes to ensure that required financial information is completed and provided to the City's independent auditors in a timely manner. Management will also monitor the submission of the Single Audit reporting package and Data Collection Form to ensure compliance with the applicable federal filing deadline. The City is committed to implementing these corrective actions to ensure that future Single Audit reporting packages are submitted to the Federal Audit Clearinghouse within the timeframe required by the Uniform Guidance.
FINDING 2025-004 EQUIPMENT AND REAL PROPERTY MANAGEMENT - SIGNIFICANT DEFICIENCY Management agrees with the finding that the fixed asset listing maintained by the City for assets acquired with federal and state funds did not contain all required elements and further recognizes the importance of main...
FINDING 2025-004 EQUIPMENT AND REAL PROPERTY MANAGEMENT - SIGNIFICANT DEFICIENCY Management agrees with the finding that the fixed asset listing maintained by the City for assets acquired with federal and state funds did not contain all required elements and further recognizes the importance of maintaining complete and accurate property records for assets acquired with federal and state financial assistance. The City will update its existing fixed assets and grant administration policies to establish specific requirements for identifying and tracking property acquired with federal and state funds in accordance with applicable federal and state regulations. The updated procedures will require the fixed asset records to include, as applicable, the property description, serial number or other identification number, funding source and applicable award identification number, title holder, acquisition date, acquisition cost, percentage of federal or state participation, location, use and condition, and disposition information. As part of the corrective action, the Finance Department will review the existing fixed asset records for federally and state-funded assets and update the records to include the required information. Procedures will also be established to ensure that applicable information is captured when assets are acquired and maintained throughout the asset's useful life, including when assets are transferred, disposed of, or otherwise removed from service. The new Finance Director and Comptroller will oversee implementation of the updated procedures and provide appropriate guidance to personnel responsible for purchasing, grant administration, and fixed asset management. These measures will strengthen the City's internal controls and ensure that property acquired with federal and state financial assistance is consistently identified, tracked, and reported in accordance with applicable requirements.
The Utility will work on a formal process for tracking all federal grants so that the reported federal expenditures are accurate.
The Utility will work on a formal process for tracking all federal grants so that the reported federal expenditures are accurate.
The Utility is working through a process to ensure all contractors are not on the debarred list. The Utility will check the contractor is not on the SAM Exclusion list reported on the SAM.gov website.
The Utility is working through a process to ensure all contractors are not on the debarred list. The Utility will check the contractor is not on the SAM Exclusion list reported on the SAM.gov website.
2025-004: Significant Deficiency/Non-Compliance - Audit Completion and Submission to the Federal Governmental Compliance Area: Reporting (L) Views of Responsible Officials and Planned Corrective Actions: The Campbell County Board of Commissioners (Board) concurs with this finding and the auditor's r...
2025-004: Significant Deficiency/Non-Compliance - Audit Completion and Submission to the Federal Governmental Compliance Area: Reporting (L) Views of Responsible Officials and Planned Corrective Actions: The Campbell County Board of Commissioners (Board) concurs with this finding and the auditor's recommendation to submit the required information in a timely manner in order to meet the nine-month submission deadline to the Federal Clearinghouse. The Board recognizes that failing to submit the audit to the Federal Clearinghouse violates federal grant terms, which may result in the withholdings of funds or the termination of awards, and will prioritize submitting the audit by the deadline to ensure compliance. Following the Fiscal Year Ended June 30, 2023, the following changes have been made to address factors that have contributed to the delays in audit submissions and improve operational efficiency: - The responsibility for coordinating audits has been assigned to the Office of the Commissioners to ensure that the audit remains on schedule. - The Chief Finance Executive position has been reinstated in the Office of Commissioners to provide guidance and support to department heads and financial personnel, ensuring the effective administration and implementation of fiscal policies, plans, and programs. - Training sessions are being offered to staff to improve their skills with the county's financial system. Training will enable them to use the system effectively and generate better reports for the audit process. - Implementation of cross-training for staff involved in the audit process to minimize the loss of institutional knowledge. The audit for the Fiscal Year Ended June 30, 2026, will be submitted prior to the federal deadline of March 31, 2027. The following individuals can be contacted for further information on the status of this corrective action: Clerk's Office: Cindy Lovelace, County Clerk Treasurer's Office: Rachael Knust, County Treasurer Commissioner's Office: Juli Pierce, Chief Finance Executive
Recommendation: The auditor recommends the District implement controls to ensure that the applications used to determine eligibility for participation within the program be retained for three years as required by the relevant grant requirements. Action Taken: The District will strengthen internal co...
Recommendation: The auditor recommends the District implement controls to ensure that the applications used to determine eligibility for participation within the program be retained for three years as required by the relevant grant requirements. Action Taken: The District will strengthen internal controls by implementing procedures, training and monitoring to ensure all eligibility applications and supporting documentation are properly maintained and retained for a minimum of three years in accordance with grant requirements and are available for audit review. Responsible Person: Madalyn Templeton, Student Nutrition Supervisor Anticipated Completion Date: June 30, 2026
Recommendation: The auditor recommends the District implement controls to ensure student files are complete and accurate and conduct training for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Action Taken: The District will ...
Recommendation: The auditor recommends the District implement controls to ensure student files are complete and accurate and conduct training for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Action Taken: The District will implement controls to ensure student files are complete and accurate and conduct training for Title I personnel and school sites over the appropriate level of written documentation required for different situations. Responsible Person: Michelle Hill, Student Information Coordinator Anticipated Completion Date: June 30, 2026
Segregation of Duties - Auditor’s recommendation: We recognize the Borough has attempted to segregate duties to the best of its ability. The Borough should continue to seek opportunities to segregate duties including involvement from Council Members. Borough’s Response: Because of the limited number...
Segregation of Duties - Auditor’s recommendation: We recognize the Borough has attempted to segregate duties to the best of its ability. The Borough should continue to seek opportunities to segregate duties including involvement from Council Members. Borough’s Response: Because of the limited number of personnel in the office, the Borough recognizes the limitations with regards to segregation of duties and therefore will consider mitigating controls. The Borough will continue to seek involvement from the Borough Council in terms of reviewing financial information.
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Borough should continue to review and accept both proposed adjusting journal en...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and, in the future, under the pronouncement, the Borough should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. Borough’s Response: The Borough has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the Borough believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the Borough considers such assistance provided by the auditors to be the most cost-effective manner to prepare such information. The Borough will also ensure that in the future all transactions will be properly reflected in the accounting software.
2025-001 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.517 Recommendation: The auditor recommends that the Company continues to work with HUD to obtain access to the REAC system so that its annual filings can be submitted. Explanation of disagreement with audit finding: ...
2025-001 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.517 Recommendation: The auditor recommends that the Company continues to work with HUD to obtain access to the REAC system so that its annual filings can be submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Company is continuing its efforts to gain access to the REAC system. Name(s) of the contact person(s) responsible for corrective action: Ryan Santarella If the United States Department of Housing and Urban Development has questions regarding this plan, please call Ryan Santarella at 518-567-5053.
2025-001 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.517 Recommendation: The auditor recommends that the Company continues to work with HUD to obtain access to the REAC system so that its annual filings can be submitted. Explanation of disagreement with audit finding: ...
2025-001 Section 202 Supportive Housing for the Elderly – Assistance Listing No. 14.517 Recommendation: The auditor recommends that the Company continues to work with HUD to obtain access to the REAC system so that its annual filings can be submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Company is continuing its efforts to gain access to the REAC system. Name(s) of the contact person(s) responsible for corrective action: Ryan Santarella If the United States Department of Housing and Urban Development has questions regarding this plan, please call Ryan Santarella at 518-567-5053.
Corrective Action Plan - Finding 2025-01: Non-Compliance with Federal Filing Deadlines To prevent a recurrence, Saints Joachim & Anne Nursing & Rehabilitation Center has updated its internal financial reporting calendar to include a "Hard Close" date for all audit activities. Effective immediately, ...
Corrective Action Plan - Finding 2025-01: Non-Compliance with Federal Filing Deadlines To prevent a recurrence, Saints Joachim & Anne Nursing & Rehabilitation Center has updated its internal financial reporting calendar to include a "Hard Close" date for all audit activities. Effective immediately, the Controller is required to initiate the upload of the Data Collection Form and all related financial statements to the Federal Audit Clearinghouse no later than September 15th of each year. This 15-day buffer will ensure that any technical difficulties with the FAC portal or administrative delays do not impact our compliance with federal reporting deadlines. Contact: Christine D'Ottavio, CFO Saints Joachim & Anne Nursing and Rehabilitation Center, 2720 Surf Avenue, Brooklyn, New York 11224 Date: April 28, 2026
Finding 2025-006: Reporting and Expenditure Cutoff - Material Weakness Corrective Action Plan: A Federal grant spreadsheet for each grant year is completed for each award. In addition, the following policies will be implemented. • Implement a Grant Reporting and Period-of-Performance Review Procedur...
Finding 2025-006: Reporting and Expenditure Cutoff - Material Weakness Corrective Action Plan: A Federal grant spreadsheet for each grant year is completed for each award. In addition, the following policies will be implemented. • Implement a Grant Reporting and Period-of-Performance Review Procedure. • Maintain a reporting calendar for each Federal and State award. • Before submission, confirm the grant reporting period, reconcile expenditures to the general ledger, verify transaction dates and period of performance, review receipts/reimbursement activity, and remove subsequent-period activity. • Require documented supervisory review and approval before submission. • Set internal report preparation deadlines at least 10 business days before the external due date whenever possible. Responsible Official: Chief Executive Officer, Chief Financial Officer, Financial Coordinator, Grant Program Director and Grant Administrative Support Anticipated Completion Date: 09/25/2026
Finding 2025-005: Inadequate Controls Over Federal Reimbursement Draw Requests - Significant Deficiency Corrective Action Plan: For each SAMHSA draw request, budget, general ledger and payroll expenditures are reviewed prior to PMS funding requests and approved by CEO. To further document this proce...
Finding 2025-005: Inadequate Controls Over Federal Reimbursement Draw Requests - Significant Deficiency Corrective Action Plan: For each SAMHSA draw request, budget, general ledger and payroll expenditures are reviewed prior to PMS funding requests and approved by CEO. To further document this process, below actions will be implemented. • Implement a detailed Federal Reimbursement Draw Request Procedure. • Require a detailed expenditure schedule showing vendor/payee, invoice or payroll reference, expenditure date, payment date, amount, grant/program, general ledger account, and grant period. • Include only incurred, paid, allowable, and allocable expenditures in reimbursement requests. • Retain invoices, payroll records, proof of payment, general ledger support, and other documentation with each draw package. • Require preparer certification and an independent documented review before submission. • Verify payment status, allowability, grant coding, period of performance, and reconciliation to the accounting system before submission. Responsible Official: Chief Executive Officer, Chief Financial Officer, Financial Coordinator, Grant Program Director and Grant Administrative Support Anticipated Completion Date: 09/25/2026
Finding 2025-004: Inadequate Supporting Documentation and Review Controls Over Federal Expenditures and Payroll - Material Weakness Corrective Action Plan: • Require complete supporting documentation for federally funded expenditures, including invoices/receipts, authorization, contracts when applic...
Finding 2025-004: Inadequate Supporting Documentation and Review Controls Over Federal Expenditures and Payroll - Material Weakness Corrective Action Plan: • Require complete supporting documentation for federally funded expenditures, including invoices/receipts, authorization, contracts when applicable, proof of payment, grant and general ledger coding, allocation support, and supervisory approval. • Do not charge unsupported expenditures to Federal awards. • Require supervisor review of employee time records and grant payroll allocations. • Require CFO review of the payroll register and documented CEO approval of the final payroll summary when required by policy. • Designate an authorized alternate approver in writing when the CEO is unavailable, consistent with organizational policy. • Maintain centralized electronic records by fiscal year, funding source, grant, and transaction type. Responsible Official: Chief Executive Officer, Chief Financial Officer, Grant Program Director, HR Manager and Supervisors Anticipated Completion Date: 09/25/2026
Finding 2025-003: Matching Requirement Not Monitored - Material Weakness Coffective Action Plan: Grant matching requirements were reviewed; however, adequate documentation was not presented. A Federal grant spreadsheet for each grant year is completed for each award. Match details will be included i...
Finding 2025-003: Matching Requirement Not Monitored - Material Weakness Coffective Action Plan: Grant matching requirements were reviewed; however, adequate documentation was not presented. A Federal grant spreadsheet for each grant year is completed for each award. Match details will be included in this spreadsheet with necessary documentation. Responsible Official: Chief Financial Officer Anticipated Completion Date: 08/24/2026
The reports have been changed and filed accordingly reflecting that the funds are being used for the municipal office renovation project.
The reports have been changed and filed accordingly reflecting that the funds are being used for the municipal office renovation project.
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