Corrective Action Plans

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Corrective Action Plan
Corrective Action Plan
1. Monthly allocation to GL is to be reconciled based on the PG&M stated in the grant agreement.
1. Monthly allocation to GL is to be reconciled based on the PG&M stated in the grant agreement.
2. Implement a two-level review prior to submitting and filing CDFI reports and the SEFA.
2. Implement a two-level review prior to submitting and filing CDFI reports and the SEFA.
3. Provide training to our accounting and finance staff on the CDFI allocation definition and the reconciliation protocol to be established.
3. Provide training to our accounting and finance staff on the CDFI allocation definition and the reconciliation protocol to be established.
4. This plan is to be completed by October 15, 2025, and the first reconciliation is scheduled to begin for the month of October 2025.
4. This plan is to be completed by October 15, 2025, and the first reconciliation is scheduled to begin for the month of October 2025.
To: Boyer & Ritter From: Stephanie Phillips, Senior Financial Manager RE: Corrective Action Plan for 2024-001 Date: September 23, 2025 Finding 2024-001: Compliance Finding Finding Title: Reporting Anticipated Completion Date: Already Implemented Name of Agency Responsible for carrying out the correc...
To: Boyer & Ritter From: Stephanie Phillips, Senior Financial Manager RE: Corrective Action Plan for 2024-001 Date: September 23, 2025 Finding 2024-001: Compliance Finding Finding Title: Reporting Anticipated Completion Date: Already Implemented Name of Agency Responsible for carrying out the corrective action plan: Finance Person in the agency (name & title): Stephanie Phillips, Senior Financial Manager County Management acknowledges the importance of timely and accurate submission of Cash on Hand Quarterly Reports in accordance with PA Department of Housing and Urban Development requirements. Accordingly, the Finance department will work collaboratively with the Housing and Redevelopment Authority to strengthen oversight, encourage timely reporting and promote compliance. The county has taken the following steps to address this compliance finding – established a reporting calendar that outlines submission deadlines and responsible parties clearly identified, a verification process through which the Finance department confirms timely electronic filing via IDIS, enhanced internal compliance monitoring checklist used by Finance, and formalizing a review process to ensure that any issues identified during monitoring are promptly communicated to the Housing and Redevelopment Authority along with a timeline for submitting corrective action plans.
Corrective Action Plan September 26th , 2025 Health Resources and Services Administration Delaware Valley Community Health, Inc. and Delaware Valley Community Support Network Trust respectfully submit the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Ave...
Corrective Action Plan September 26th , 2025 Health Resources and Services Administration Delaware Valley Community Health, Inc. and Delaware Valley Community Support Network Trust respectfully submit the following corrective action plan for the year ended December 31, 2024. CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2024 The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. FINDINGS – FEDERAL AWARDS PROGRAM AUDIT U.S. Department of Health and Human Services, COVID‐19 Health Centers Program Cluster (Assistance Listing Number 93.224/93.527) Finding 2024‐001 – Special Tests and Provisions SIGNIFICANT DEFICIENCY Recommendation We recommend that proper training be given to employees at registration to ensure that the sliding fee discounts are being properly calculated. Supervisors should monitor and review the sliding fee calculations on a periodic basis to ensure compliance with the sliding fee scale. In addition, management should conduct internal audits to ensure the sliding fee is calculated properly. Action Taken Employees received training in January 2025 to ensure the sliding fee discounts are correctly applied. Additionally, DVCH is planning an annual refresher training for staff for the first quarter of 2026. The Patient Account Counselor Team Leader conducts a monthly internal audit, which began in the first quarter of 2025, of sliding fee discount. In September of 2025, the audit was adjusted to collect additional actionable information. The findings from the internal audit are reviewed with staff, the Director of Revenue Cycle Management, and the Director of Operations. The audit samples each site and department to ensure accuracy across the organization. DVCH is exploring the possibility of engineering a change in our electronic practice management system to facilitate and remind the registration and revenue cycle staff to complete the sliding fee calculations when needed. This discovery process began in September 2025. If the Health Resources and Services Administration has questions regarding this plan, please call Ryan Taylor, Chief Financial Officer at 267-240-2578.
September 25, 2025 Management's Planned Corrective Action Plan For the Year Ended December 31, 2024 Names of contact person(s) responsible for corrective action: Georgina Acevedo, Chair and Kevin McAllister, Treasurer Federal Award Finding and Questioned Costs Finding Number: 2024-001 – Supportive H...
September 25, 2025 Management's Planned Corrective Action Plan For the Year Ended December 31, 2024 Names of contact person(s) responsible for corrective action: Georgina Acevedo, Chair and Kevin McAllister, Treasurer Federal Award Finding and Questioned Costs Finding Number: 2024-001 – Supportive Housing for the Elderly (Section 202) – CFDA # 14.157 Planned Corrective Action: The Board of Directors acknowledges the required deposits to the replacement reserve account were not made. The Project is applying for a rent increase and deposits will be made as soon as the cash position is available to make the required deposits. Anticipated Completion Date: Upon approval of the rent increase.
View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authoriz...
View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authorized Representative
View of Responsible Official: The timesheet implemented in July 2024 properly reflects the actual vs budgeted hours for employees with multiple funding sources. We will continue to analyze discrepancies to determine if budget revisions are necessary. Finding resolved timeline: October 2025 Designate...
View of Responsible Official: The timesheet implemented in July 2024 properly reflects the actual vs budgeted hours for employees with multiple funding sources. We will continue to analyze discrepancies to determine if budget revisions are necessary. Finding resolved timeline: October 2025 Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President; Ricardo Colon Padilla, financial officer.
Finding: The Organization erroneously identified certain federal grants as state funded grants on the Schedules. Additionally, certain grant funding was omitted from the Schedules that was identified through the audit that had various federal/state grant requirements applicable to them. Contact Pers...
Finding: The Organization erroneously identified certain federal grants as state funded grants on the Schedules. Additionally, certain grant funding was omitted from the Schedules that was identified through the audit that had various federal/state grant requirements applicable to them. Contact Person Responsible for Corrective Action: Sean Jackson, Chief Executive Officer Corrective Action Planned: Isles operation, service delivery and finance staff are dedicated to ensuring that funding is used appropriately and in accordance with any restrictions set forth by the funder. The following procedures have been refined to ensure all funding sources are reflected accurately going forward. 1. When grant funding is received, the staff person who receives the award notice will request a new revenue code specific to the new grant award from the Finance Department. In order for Finance Department to generate that code, the staff person must provide the following information: a. Funder (either federal, state, county, city, or private entity) b. Grant number c. Amount d. Grant period e. Department f. Initiative code - internal code for specific areas of work g. Revenue code h. Revenue GL Code (4017 – Federal // 4016 – State // 4015 – City etc.) i. Reporting Requirements - Monthly, Quarterly, progress reports, etc. j. Include attachment of actual grant 2. Appropriate finance staff reviews provided contract along with the information outlined in item 1, confirms accuracy of the information, and then creates the appropriate codes in accounting software. 3. Appropriate finance staff creates and reviews the Schedules and Director of Finance reviews report before the Schedules are prepared annually. 4. GN-06 report requested by Finance in advance to closing the books to reconcile funding source to grants each year. Anticipated Completion Date: December 31, 2025.
With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance wit...
With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance with federal grant matching requirements. The new policy and procedures are attached.
FINDING 2024-002 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Federal Agency: Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Number and Year(o...
FINDING 2024-002 Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Federal Agency: Department of the Treasury Federal Program: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Number and Year(or Other Identifying Numbers): FY2021 Pass-Through Entity: Direct Grant Compliance Requirement: Procurement and Suspension and Debarment Audit Findings: Material Weakness, Other Matters Condition Prior to entering into subawards and covered transactions with State and Local Fiscal Recovery Funds (SLFRF) award funds, recipients are required to verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded. "Covered transactions" include, but are not limited to, contracts for goods and services awarded under a non-procurement transaction (i.e., grant agreement) that are expected to equal or exceed $25,000. The verification is to be done by checking the Excluded Parties List System (EPLS), collecting a certification from that person, or adding a clause or condition to the covered transaction with the executives of a prospective vendor. A sample of five covered transactions, totaling $667,753, that equaled or exceeded $25,000 paid from SLFRF funds was selected for testing. For one of the transactions tested in the amount of $98,583, the City did not retain documentation showing that they verified that the vendor was not suspended or debarred from receiving federal funds prior to issuing the payment. Context The City had not designed or implemented effective policies and procedures to verify that contractors were not suspended or debarred, or otherwise excluded from participating in federal programs prior to entering into covered transactions using SLFRF funds. While a control process was in place, it did not ensure that all vendors were not suspended or debarred from receipt of federal grant funds for goods and services. Contact Person Responsible for Corrective Action: Tracy McGinnis - Controller Contact Phone Number and Email Address: 765-983-7222; tmcginnis@richmondindiana.gov Views of Responsible Officials: We concur with the finding. INDIANA STATE BOARD OF ACCOUNTS 24 Description of Corrective Action Plan: The City will include a suspension and debarment clause into our federal contracts with vendors receiving federal funds going forward. Responsible Party and Timeline for Completion: The Controller, Deputy Controller and the Director of Strategic Initiatives will collaborate on a process for the Corrective Action to be implemented in January 2026 for the next fiscal year.
AACF concurs with this finding. AACF submitted a corrective action plan to AmeriCorps and on January 31, 2025 AmeriCorps accepted their corrective action plan and closed the finding. AACF will ensure all requirements under 2 CFR 200.403 and 45 CFR 2540.200-207 are met moving forward.
AACF concurs with this finding. AACF submitted a corrective action plan to AmeriCorps and on January 31, 2025 AmeriCorps accepted their corrective action plan and closed the finding. AACF will ensure all requirements under 2 CFR 200.403 and 45 CFR 2540.200-207 are met moving forward.
View Audit 368447 Questioned Costs: $1
AACF concurs with this finding. AACF leadership, including its Board and Executive Director, will review and update the organization’s fiscal policies and procedures within 90 days to ensure compliance with Uniform Guidance requirements. All contractors will be required to certify that neither their...
AACF concurs with this finding. AACF leadership, including its Board and Executive Director, will review and update the organization’s fiscal policies and procedures within 90 days to ensure compliance with Uniform Guidance requirements. All contractors will be required to certify that neither their agency nor any of their principals are debarred or suspended from doing business with the federal government. The Executive Director, Elizabeth Chung, will be responsible for ensuring this documentation is obtained prior to executing any contractual agreements moving forward. In addition, the Director of Operations, TJ Sydykov, will conduct debarment checks for all applicable vendors through SAM.gov in 2024 and 2025 and will provide the results to the Executive Director, Elizabeth Chung, for review within 30 days.
Contact Person – Brenda Klein, Finance Director Corrective Action Plan – With our online time entry portal, we have approval steps in place for department head to approve all time entered for payroll. All full-time employees are now using the online portal. Payroll detail registers are reviewed by t...
Contact Person – Brenda Klein, Finance Director Corrective Action Plan – With our online time entry portal, we have approval steps in place for department head to approve all time entered for payroll. All full-time employees are now using the online portal. Payroll detail registers are reviewed by the Finance Director after every payroll to ensure accuracy. Completion Date – January 1, 2025
Federal Program: Community Development Block Grant – Disaster Recovery (CDBG-DR) (ALN 14.228) Condition: Untimely submission of monthly progress reports. Planned Corrective Action: Management acknowledges the finding related to the timeliness of monthly report submissions. Although reports were prep...
Federal Program: Community Development Block Grant – Disaster Recovery (CDBG-DR) (ALN 14.228) Condition: Untimely submission of monthly progress reports. Planned Corrective Action: Management acknowledges the finding related to the timeliness of monthly report submissions. Although reports were prepared internally by the required due date, submission to the PRDOH reporting system was delayed pending review and approval of the prior month’s report by PRDOH . To strengthen compliance with reporting requirements, the Organization will implement the following corrective actions: • Internal documentation: Maintain dated copies of all monthly reports prepared by the 5th day following the reporting period to demonstrate timely preparation. • Communication with PRDOH: Retain written communications with PRDOH when reports cannot be submitted due to pending approvals, documenting the cause of delay. • Formal request: Submit a written request to PRDOH seeking clarification of reporting requirements and advocating for a process that permits timely submission regardless of system approval delays. • Monitoring: assign responsibility to the Finance and Compliance Officer to track reporting deadlines and ensure documentation of both preparation and submission efforts. Responsible Official: Thomas P. King Anticipated Completion Date: Ongoing – procedures to be implemented beginning with reports due for October 2025.
The City takes its responsibility to safeguard public funds seriously and is committed to improving internal controls over grant management that affect the City’s ability to comply with federal regulations. The City’s decentralized model for procurement and grant management has created challenges to...
The City takes its responsibility to safeguard public funds seriously and is committed to improving internal controls over grant management that affect the City’s ability to comply with federal regulations. The City’s decentralized model for procurement and grant management has created challenges to meet federal compliance requirements. The City is committed to safeguarding public funds while meeting the needs of residents. A full-time analyst has already been hired to oversee SLFRF funds and assist staff with meeting compliance requirements. A full-time Contracts and Procurement Officer has also been hired to train staff and update the City’s procurement policies and procedures. Improving federal compliance will be a primary function of this role. Additional training is being created to educate City staff on federal compliance requirements. The City is currently working with our legal team on options to include suspension and debarment language in contracts, reducing administrative burden on City staff while ensuring compliance. These improvements reflect the City’s commitment to improving internal controls and ensuring that federal funds are managed with the highest level of compliance and accountability.
The Town will provide additional training for all employees involved.
The Town will provide additional training for all employees involved.
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the find...
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Below is the process for submitting required grant reporting. 3. The Director will input the required information 4. Prior to submission of the report, the Director will have the Deputy Director verify the information that has been entered against the supporting documentation. 5. The Deputy Director will let the Director know if it is ok to submit the report. 6. The Director will submit and print a completed submission document that the Deputy Director will verify again. 7. The Deputy Director and Director will both sign and date the completed report. 8. This will be filed for audit purposes. Anticipated Completion Date: This is already taking place. The 2025 filing in April followed this process.
Finding 2024-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Descri...
Finding 2024-002 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Town will begin checking the EPLS system for all vendors receiving federal dollars. This will be part of the new purchasing policy that is being created for the Town. The Finance and Records Dept. will work with the Department Head receiving federal dollars to check the chosen vendor’s suspension and debarment status prior to proceeding with the project. Documentation verifying the check will be saved for audit purposes. Anticipated Completion Date: We will immediately begin checking the EPLS system for vendors receiving federal dollars. The new purchasing policy should be completed by September 2025.
DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will d...
DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will develop a match policy to include documented review and signed document retention for matching contributions, ensuring compliance with CFR §200.306. a. We will then follow this policy and retain signed documentation of matching contributions. Proposed Completion Date – October 31, 2025
Corrective Action Plan: Management will formalize a procurement policy in line with federal guidelines. Anticipated Completion date: 10/31/2025 Responsible Person: Rebecca Solow, Co-Founder and Executive Director
Corrective Action Plan: Management will formalize a procurement policy in line with federal guidelines. Anticipated Completion date: 10/31/2025 Responsible Person: Rebecca Solow, Co-Founder and Executive Director
Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: During our testing of the Schedule of Expenditures of Federal Awards (SEFA) and the SESA, we noted that the expenditures were not reported in accordance with GAAP. An adjustment of $268,000 was recorded to pro...
Finding #2024-003 – Significant Deficiency and Other Noncompliance. Condition and context: During our testing of the Schedule of Expenditures of Federal Awards (SEFA) and the SESA, we noted that the expenditures were not reported in accordance with GAAP. An adjustment of $268,000 was recorded to properly state the expenditures. Recommendation: Implement policies and procedures to ensure that all expenditures have been properly recorded in accordance with GAAP in the SEFA and SESA. Corrective action plan: Management agrees with the finding. Beginning in fiscal year 2025, a detailed reconciliation process will be implemented to ensure that all expenditures are properly accrued and reported at the grant level in the SEFA and SESA, aligned with the appropriate reporting period, and the general ledger. Responsible officer: Gouri Kulkarni, Vice President of Finance. Estimated completion date: December 31, 2025.
Finding #2024-002 – Material Weakness and Other Noncompliance. Condition and context: During testing of a sample of 5 transactions requiring procurement, we identified that simplified acquisition procedures of obtaining and documenting bids were not performed for a vendor with expenditures greater t...
Finding #2024-002 – Material Weakness and Other Noncompliance. Condition and context: During testing of a sample of 5 transactions requiring procurement, we identified that simplified acquisition procedures of obtaining and documenting bids were not performed for a vendor with expenditures greater than $10,000 but less than $250,000 and competitive procurement procedures were not performed for 2 vendors with expenditures greater than $250,000. Brighter Bites’ rational for the selection of the vendor and approval was documented, however the procurement file did not include bids from other vendors under the simplified acquisition procedures and did not include a request for proposal, vendor responses, and an evaluation of the proposals to support Brighter Bites’ procurement rationale. Recommendation: Provide additional training to employees responsible for procurement on Brighter Bites’ procurement policy. Corrective action plan: Management agrees with the finding. Brighter Bites will enhance procurement compliance by providing additional targeted training to all staff involved in procurement activities. The organization will also revise its procurement checklist to ensure full documentation, including bids or proposals, vendor evaluations, and justification for selection. Internal audits will be conducted periodically to assess adherence to policy. Responsible officer: Amy Priebe, Vice President of Operations. Estimated completion date: December 31, 2025.
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