Corrective Action Plans

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Condition Summary: $85,880 of SEOG funding related to the 2024-2025 award year was applied to student accounts during fiscal year 2026, because the full amount of available SEOG funding was not initially allocated to eligible students. Management Response / Corrective Action Plan: Management concurs...
Condition Summary: $85,880 of SEOG funding related to the 2024-2025 award year was applied to student accounts during fiscal year 2026, because the full amount of available SEOG funding was not initially allocated to eligible students. Management Response / Corrective Action Plan: Management concurs with this finding. As part of the University's full review of 2025-2026 packaging activity, the engaged consulting firm has implemented a quarterly reconciliation of SEOG allocation against amounts awarded and disbursed, to ensure funds are fully awarded to eligible students within the correct award year. The University is also evaluating, in consultation with the Department of Education, the appropriate treatment of the funds identified in this finding. Staff previously responsible for SEOG packaging are no longer employed at the institution. Responsible Party - Raymond Nault, Interim Director of Student Financial Services Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
Condition Summary: 3 of 25 loans tested lacked a signed promissory note, and 24 of 25 loans lacked adequate repayment documentation. Management Response / Corrective Action Plan: Management concurs with this finding. The University has directed the engaged consulting firm to complete a full inventor...
Condition Summary: 3 of 25 loans tested lacked a signed promissory note, and 24 of 25 loans lacked adequate repayment documentation. Management Response / Corrective Action Plan: Management concurs with this finding. The University has directed the engaged consulting firm to complete a full inventory of the remaining Perkins Loan portfolio, working with the loan servicer to reconstruct or obtain missing promissory notes and repayment records wherever possible, and to document the resolution status of each loan file. Administrative staff previously responsible for maintaining this documentation are no longer employed at the institution. Because the Perkins Loan program is in wind-down status and documentation gaps largely predate the current administration, full file reconstruction may extend beyond the current award year; the University will report progress to the Department of Education as file remediation continues. Responsible Party - Ebony Martin, Associate Director of Student Accounts Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
1. Tracking Deficiencies The Housing Authority will use its ERP system, Yardi, for tracking all failed inspections. The system will have record of all relevant inspection-related information, and inspection staff will update the log on the same day that deficiencies are identified and as corrections...
1. Tracking Deficiencies The Housing Authority will use its ERP system, Yardi, for tracking all failed inspections. The system will have record of all relevant inspection-related information, and inspection staff will update the log on the same day that deficiencies are identified and as corrections and follow-up inspections are completed. Management will review the log regularly to monitor outstanding deficiencies, ensure timely corrective action, and verify compliance with required deadlines. 2. Notification Procedures For a 24-hour correctable deficiency resulting in a failed inspection, the tenant and landlord (if present) will be notified at the time of inspection, and both will receive follow up notice via email or phone immediately thereafter. Where notification is made via phone, a note will be made on the inspection booklet recording the time and details of the conversation. A letter summarizing the conversation will be sent to tenant and/or landlord as applicable. For deficiencies with longer correction times (e.g. 30 days), notification will be sent to the tenant and landlord within 5 business days of the inspection. Notification will include relevant information, including the deficiency identified, the required timeframe for correction, the party responsible for correcting the violation, and potential consequences for failure to complete the required repairs or corrections. Management will periodically review documentation to ensure notifications are completed timely and in accordance with Housing Authority policy and HUD requirements. 3. Management Oversight Management will monitor all open deficiencies to ensure that required notices are issued within required timeframes, corrections are completed and verified timely, and appropriate follow-up actions are taken when repairs or corrections are not completed as required. If deficiencies are not corrected within the required timeframe, the Housing Authority will take appropriate enforcement action in accordance with program requirements and applicable regulations, including HAP abatement and termination of tenant assistance, if required. In addition, failure by staff to complete required inspection and follow-up responsibilities will be reported to executive management for corrective action to ensure continued compliance and accountability. 4. Verification of Corrections All remediation of deficiencies must be verified before the deficiency is considered corrected and closed. Verification may include: Reinspection conducted by Housing Authority staff, with dates of correction documented; Remote video inspection, if it is feasible to discern whether the deficiency was adequately cured; or Photographs clearly documenting completed repairs or corrections 5. Staff Training Inspection and program staff will receive training on: HUD inspection requirements; Identification of life-threatening and 24-hour deficiencies; Required correction and verification timelines; and Documentation and recordkeeping procedures.
U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Early Head Start Child Care Partnership Applicable Federal Award Number and Year – 07HP000640-01-00 and 07HP000640-02-00 9/1/2024 – 8/31/2025 and 9/1/2025 – 8/31/2026 Reporting Significant De...
U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Early Head Start Child Care Partnership Applicable Federal Award Number and Year – 07HP000640-01-00 and 07HP000640-02-00 9/1/2024 – 8/31/2025 and 9/1/2025 – 8/31/2026 Reporting Significant Deficiency in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation of expenditures incurred to support the drawdown of federal awards claimed for reimbursement on an interim basis throughout the reporting period. Corrective Action Plan: At the time of the audit, the new CFO had reviewed its internal processes and has incorporated new procedures and controls over the tracking and submitting of drawdown requests for reimbursement of expenditures incurred under federal awards. All drawdown requests submitted are now reconciled and properly supported by internal records for expenditures incurred during the period being requested. Individual Responsible for Corrective Action: Milton Trabal, Chief Financial Officer Anticipated Completion Date: 2026
U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07HP000640-02-00 9/1/2025 – 8/31/2026 Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Complianc...
U.S. Department of Health and Human Services Federal Financial Assistance Listing #93.600 Head Start Cluster Applicable Federal Award Number and Year – 07HP000640-02-00 9/1/2025 – 8/31/2026 Preparation of Schedule of Expenditures of Federal Awards Material Weakness in Internal Control Over Compliance Criteria: Proper controls over financial reporting include the ability to prepare the schedule of expenditures of federal awards (Schedule) and accompanying notes to the Schedule in accordance with requirements of the Uniform Guidance. Condition: The Organization’s internal controls over the preparation of the Schedule were not operating effectively. As a result of our audit procedures, misstatements in the Schedule were identified and adjustments to the Schedule were proposed and recorded by management. Corrective Action Plan: Management is in the process of reviewing its accounting processes and procedures over the preparation of the Schedule in order to accurately report federal expenditures incurred during the reporting period. Individual Responsible for Corrective Action: Milton Trabal, Chief Financial Officer Anticipated Completion Date: 12/31/2026
Management agrees with the finding and has implemented a revised reporting checklist to ensure compliance going forward.
Management agrees with the finding and has implemented a revised reporting checklist to ensure compliance going forward.
The district continues to find solutions to help segregate duties with our minimally staffed central office (business manager, HR director & nutrition director). We modified duties of our building secretaries due to being short staffed. This eliminated an additional check & balance measure added a f...
The district continues to find solutions to help segregate duties with our minimally staffed central office (business manager, HR director & nutrition director). We modified duties of our building secretaries due to being short staffed. This eliminated an additional check & balance measure added a few years ago of the secretary entering receipts into WebLink. The building secretaries continue to write deposit slips & post payment to our student information system. The district’s business manager & HR director will work with board members on the finance & negotiations committee to develop a plan to add more checks & balances to our current operation. We will use the segregation of duties handbook to help with this process.
Management will ensure the financial statements are submitted to REAC within 90 days of year-end.
Management will ensure the financial statements are submitted to REAC within 90 days of year-end.
Management will submit the budget and a corrective action plan to HUD regarding the budget.
Management will submit the budget and a corrective action plan to HUD regarding the budget.
Management will make the delinquent deposit to the replacement reserve of $62,016 and establish transfers for the monthly deposit amount.
Management will make the delinquent deposit to the replacement reserve of $62,016 and establish transfers for the monthly deposit amount.
The hospital asked the audit team for support in filing this year. An action plan has been developed so that this is done internally in 2026.
The hospital asked the audit team for support in filing this year. An action plan has been developed so that this is done internally in 2026.
Finding Type: Immaterial Noncompliance / Significant Deficiency in Internal Control over Compliance (Reporting). Program: Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategic Fund. Audito...
Finding Type: Immaterial Noncompliance / Significant Deficiency in Internal Control over Compliance (Reporting). Program: Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategic Fund. Auditor Description of Condition and Effect: Reporting did not agree to the audited general ledger or to the schedule of expenditures of federal awards (SEFA) due to: 1) Management recording in the general ledger and reporting to the pass-through agency, amounts that were transfers to an internal program, the actual costs of which were being reported under a separate cost center. Because transfers to an internal program do not qualify as grant expenditures or, for that matter expenses in general, the amounts reported as cumulative expenditures of grant funds were reported inaccurately, and 2) Audit adjustments were necessary to adjust subrecipient expenses per the general ledger to actual costs per the subrecipient reporting and back up files. In the initial general ledger, the balance of advances from the prior year, plus advances paid to subrecipients during the year, were incorrectly recorded as grant expenses. In addition, we noted that the reports did not appear to be reviewed for accuracy or completeness. As a result of this condition, the Organization reported inaccurate amounts to the grant pass-through agency. Questioned Costs: No costs were required to be questioned as a result of this finding inasmuch as our testing did not identify any unallowed costs. Auditor Recommendation: We recommend that management continue reviewing all transfers to an internal program, refundable advances associated with revenues, and those made to subrecipients, particularly around year-end, to identify amounts that should be recorded as refundable advances and what amounts should be recorded as grant expenses. This is important because the general ledger can then be used as a base for all grant financial reporting. We further recommend that the reporting be reconciled to the schedule of expenditures of federal awards at year-end. In addition, all reports should be reviewed and approved by appropriate personnel prior to submission. Management's Acknowledgment Management acknowledges that the root cause — the general ledger not serving as a clean, reliable basis for grant financial reporting without manual correction — reflects a structural accounting setup issue compounded by insufficient oversight of the reporting workflow. The core distinction between internal transfers, subrecipient advances, and actual incurred costs must be consistently reflected in GL coding from the point of transaction entry. The SOP's reporting and reconciliation provisions are only effective if the underlying GL data is structured correctly. Corrective Action Plan (see table)
Finding Type: Immaterial Noncompliance / Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program: Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategi...
Finding Type: Immaterial Noncompliance / Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program: Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategic Fund. Auditor Description of Condition and Effect: Although there were improvements in the monitoring process from the prior year, during testing in the current year of seven subrecipients, it was determined: 1) The Assistance Listing Number (ALN) for the grant was not included in the subgrant agreement. All other applicable program information was noted, 2) Searches at www.sam.gov performed by management were not timely reviewed and no certification of eligibility was present in the subgrant agreements. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Questioned Costs: No costs were required to be questioned as a result of this finding inasmuch as our testing did not identify any unallowed costs. Auditor Recommendation: We recommend that management become familiar with the subrecipient monitoring requirements and draft policy and procedures that provide reasonable assurance that future subrecipient arrangements will be in compliance with the Uniform Guidance. Management's Acknowledgment Management acknowledges that the recurrence of this finding — albeit at a reduced severity level compared to the FY2024 material weakness designation — reflects incomplete implementation rather than absence of policy. The ALN omission in subgrant agreement templates is a straightforward technical correction that should have been applied uniformly once identified. The corrective actions below are procedural in nature and largely already embedded in the updated SOP; the remaining work is one of consistent execution and documentation. Corrective Action Plan (See CAP for Table)
Corrective Action Taken - Secured a fidelity bond effective July 1, 2026 - Maintained documentation of all efforts to obtain replacement coverage during the period coverage was unavailable. - Continued reporting insurance procurement efforts to the Board of Directors. - Will continue to pursue broad...
Corrective Action Taken - Secured a fidelity bond effective July 1, 2026 - Maintained documentation of all efforts to obtain replacement coverage during the period coverage was unavailable. - Continued reporting insurance procurement efforts to the Board of Directors. - Will continue to pursue broader fidelity coverage as market conditions permit. - Will monitor renewal date to ensure timely renewal before expiration and prevent future lapses in coverage. Responsible Persons: Executive Director, Lee Pliscou Completion Date: July 1, 2026
Corrective action planned: Complete the physical inventory of all offices; reconcile inventory results to the property subsidiary ledger; investigate any discrepancies identified, resolved and ensure all required inventory documentation is complete, including supervisory review and approvals, is mai...
Corrective action planned: Complete the physical inventory of all offices; reconcile inventory results to the property subsidiary ledger; investigate any discrepancies identified, resolved and ensure all required inventory documentation is complete, including supervisory review and approvals, is maintained. Assets determined to be missing, obsolete, or no longer in service will be processed in accordance with MLSC’s property management procedures and the Financial Guide. Anticipated completion date: August 31, 2026.
This finding is due to the district inadequately maintaining property records for assets acquired under the Education Stabilization Fund – Elementary and Secondary Education that identify all of the property records elements not per federal guidance. Additionally, there was no indication that a phys...
This finding is due to the district inadequately maintaining property records for assets acquired under the Education Stabilization Fund – Elementary and Secondary Education that identify all of the property records elements not per federal guidance. Additionally, there was no indication that a physical inventory of the property acquired under the Education Stabilization Fund – Elementary and Secondary Education had been performed within the preceding two years.
Finding Reference Number: 2025-003 Description of Finding: IYT submitted its Audited Financial Statements and Single Audit Report to the Federal Audit Clearinghouse in August 2026, approximately five months after it was due. IYT was required to submit it no later than March 31, 2026; nine months aft...
Finding Reference Number: 2025-003 Description of Finding: IYT submitted its Audited Financial Statements and Single Audit Report to the Federal Audit Clearinghouse in August 2026, approximately five months after it was due. IYT was required to submit it no later than March 31, 2026; nine months after the June 30, 2025 fiscal year-end, in accordance with 2 CFR 200.512. Federal awarding agencies may deny future federal awards or subject IYT to additional cash monitoring requirements. Statement of Concurrence or Nonconcurrence: We concur with the audit finding. Corrective Action: This finding is a repeat of prior-year finding 2024-004. IYT's prior corrective action committed to on-time submission but did not establish the controls needed to make that commitment hold: it relied on the intent to submit on time rather than on a dated, back-scheduled calendar with an owner for each step and a checkpoint to catch slippage early. When the FY24-25 audit timeline slipped, there was no interim milestone to surface the delay while it could still be recovered, and the report was again submitted late. IYT acknowledges and accepts the responsibility for late submission. Meeting the FAC deadline is IYT's responsibility and remains so even where individual steps sit with the audit firm or with governance. IYT will establish a compliance calendar built by working backward from the Federal Audit Clearinghouse (FAC) statutory deadline, with defined interim milestones and an owner assigned to each by position: engagement of the audit firm and confirmation of fieldwork dates; completion of the year-end close; delivery of the prepared-by-client (PBC) list; fieldwork; draft report; management review; Finance Committee and Board review; and final FAC submission and certification. IYT's timeline depends on inputs from the audit firm (scheduling, fieldwork and reporting turnaround, and draft-review cycles) and from governance (Audit Committee and Board review windows). IYT manages these inputs to the deadline rather than treating them as outside its control: target dates are agreed with the auditors and committee chairs in advance and confirmed in writing, and if any party is at risk of missing a date, IYT escalates and adjusts immediately rather than absorbing the delay. Progress against every milestone is monitored by management and reported to the Audit Committee as a standing agenda item, so slippage is identified and escalated early rather than discovered near the deadline. Name of Contact Person: Macarena O'Brien, Chief Financial & Administrative Officer macarena@improveyourtomorrow.org | (480) 993-4764 Projected Completion Date: March 31, 2027
Finding Reference Number: 2025-002 Description of Finding: During the single audit, IYT provided three successive versions of the Schedule of Expenditures of Federal Awards (SEFA). The initial version included only the expenditures of grant funds received through California Volunteers and reflected ...
Finding Reference Number: 2025-002 Description of Finding: During the single audit, IYT provided three successive versions of the Schedule of Expenditures of Federal Awards (SEFA). The initial version included only the expenditures of grant funds received through California Volunteers and reflected an incorrect amount. The second version corrected the California Volunteers amount but omitted the other pass-through entities. The final version included expenditures from all pass-through entities. Earlier versions did not fully reconcile to the accounting system. Because of the significance of the AmeriCorps State and National funding (Assistance Listing 94.006) passed through multiple entities, this was reported as a material weakness in internal control over compliance related to entity-wide federal award reporting under 2 CFR 200.508(b) and 2 CFR 200.510. Statement of Concurrence or Nonconcurrence: We concur with the audit finding. Corrective Action: IYT implemented a formal, documented process for preparing the Schedule of Expenditures of Federal Awards (SEFA) that addresses completeness, accuracy, and reporting of pass-through information. IYT maintains a document that identifies all federal awards received and expended, including each pass-through entity, pass through identifying number, and award period, so that every funding source is captured. Federal expenditures are reconciled to the general ledger and to each pass-through entity's reports on a scheduled basis throughout the year, and total SEFA expenditures are compared to federal revenue recognized in the financial statements. The SEFA is subject to a documented preparer-and-reviewer control, and IYT will not designate the SEFA as final until it is complete, fully reconciled to the accounting system and supporting records, and reviewed and approved by management. Finance staff received training on the SEFA preparation and reporting requirements of 2 CFR 200.508(b) and 200.510, including the identification and reporting of pass-through awards. A complete, fully reconciled, and reviewed SEFA is prepared prior to the start of the FY 2026 audit. Name of Contact Person: Macarena O'Brien, Chief Financial & Administrative Officer macarena@improveyourtomorrow.org | (480) 993-4764 Completion Date: June 30, 2026
The Executive Director and Executive Assistant will coordinate with the appropriate NRWA program manager on an ongoing basis to ensure that Montana Rural Water Systems retains copies of all Wastewater Community Assessment Reports, documentation showing implementation of recommendations, focus storie...
The Executive Director and Executive Assistant will coordinate with the appropriate NRWA program manager on an ongoing basis to ensure that Montana Rural Water Systems retains copies of all Wastewater Community Assessment Reports, documentation showing implementation of recommendations, focus stories, certification records, and other supporting program documentation. Program staff will be required to provide the MRWS office with a copy of each required submission at the time it is submitted to NRWA. These records will be maintained in a centralized program file and retained for future audits and program reviews. MRWS will also contact NRWA to request copies of, or written confirmation regarding, the five Wastewater Community Assessment Reports, documentation showing implementation of recommendations, certification records, and other supporting program documentation from the audit period. Any documentation received will be placed in the Association's program files. Completion Date: The documentation retention process and request to NRWA for prior records will be completed by August 31, 2026. Documentation retention and coordination with NRWA will continue an ongoing basis. Tanya and I will oversee this process, remain in communication with the appropriate NRWA program managers, and make sure the required documentation is retained by Montana Rural Water Systems going forward. We will also reach out to NRWA to obtain the reports and supporting documentation identified in the findings so that those records can be placed in the Association's files. Sincerely, Ben Rigby Executive Director Montana Rural Water Systems Association, Inc.
The Executive Director and Executive Assistant will coordinate with the appropriate NRWA program manager on an ongoing basis to ensure that Montana Rural Water Systems retains copies of all reports, assessments, focus stories, and other supporting documentation submitted for the Disaster Recovery Ci...
The Executive Director and Executive Assistant will coordinate with the appropriate NRWA program manager on an ongoing basis to ensure that Montana Rural Water Systems retains copies of all reports, assessments, focus stories, and other supporting documentation submitted for the Disaster Recovery Circuit Rider Program. Program staff will be required to provide the MRWS office with a copy of each required submission at the time it is submitted to NRWA. These records will be maintained in a program file and retained for future audits and program reviews. MRWS will also contact NRWA to request copies of, or written confirmation regarding, reports, assessments, and other program documentation submitted during the audit period. Any documentation received will be placed in the Association's program files. Completion Date: The documentation retention process and request to NRWA for prior records will be completed by August 31, 2026. Documentation retention and coordination with NRWA will continue an ongoing basis. Tanya and I will oversee this process, remain in communication with the appropriate NRWA program managers, and make sure the required documentation is retained by Montana Rural Water Systems going forward. We will also reach out to NRWA to obtain the reports and supporting documentation identified in the findings so that those records can be placed in the Association's files. Sincerely, Ben Rigby Executive Director Montana Rural Water Systems Association, Inc.
SAMARITAS AND SUBSIDIARIES Management’s Corrective Action Plan For the Year Ended December 31, 2025 Finding 2025-001 Contact Person(s): Bridgette Zappacosta, Chief Financial Officer Corrective Action Planned: Management concurs with the finding. During the period under review, the Finance Department...
SAMARITAS AND SUBSIDIARIES Management’s Corrective Action Plan For the Year Ended December 31, 2025 Finding 2025-001 Contact Person(s): Bridgette Zappacosta, Chief Financial Officer Corrective Action Planned: Management concurs with the finding. During the period under review, the Finance Department was transitioning to a new accounting system. The identified exceptions occurred prior to the implementation of the new system and related processes. As part of the transition to Blackbaud Financial Edge NXT, Samaritas has implemented controls designed to prevent expenditures from being charged outside of a federal award's period of performance. Grant records within the system now include defined start and end dates that prevent expenditures from being applied to awards outside the authorized grant period. In addition, Samaritas enhanced its invoice approval process by adding a required custom field to identify the service period associated with each invoice. This information is reviewed during the monthly close process to identify invoices received before or after a grant period and to ensure expenditures are recorded in the appropriate award period. The Finance Department completed training on these revised procedures in July 2026. Management will continue to monitor compliance with these controls as part of its monthly grant and financial review processes. Anticipated Completion Date: Implemented July 2026; ongoing monitoring procedures are in place.
CORRECTIVE ACTION PLAN — Finding 2025-003 Grant Accounting Reconciliation and Compliance over Allowable Costs / Reporting — Compliance Finding (Allowable Costs / Cost Principles, Reporting) and Material Weakness in Internal Control over Compliance and Financial Reporting Programs: Weatherization Ass...
CORRECTIVE ACTION PLAN — Finding 2025-003 Grant Accounting Reconciliation and Compliance over Allowable Costs / Reporting — Compliance Finding (Allowable Costs / Cost Principles, Reporting) and Material Weakness in Internal Control over Compliance and Financial Reporting Programs: Weatherization Assistance for Low-Income Persons (ALN 81.042); Low-Income Home Energy Assistance Program – LIHEAP (ALN 93.568), and related state and federal funds administered through the Weatherization program | Cognizant / Pass-Through Agencies: U.S. Department of Energy; U.S. Department of Health and Human Services; State of Vermont Department for Children and Families | Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | CAP Contact: Joshua Davis, Executive Director, JDavis@sevca.org 1. Summary of Finding Finding 2025-003 identified that Weatherization work-in-progress (WIP), grant revenue, and deferred revenue balances did not reconcile to the supporting documentation required under the related grants, resulting in significant audit adjustments; those balances were adjusted to agree with program reporting only at grant-year and fiscal-year close rather than on an ongoing basis. The finding also identified that expenditures recorded in the general ledger could not be reconciled to expenditures reported in the state reporting system (Hancock) for both the LIHEAP and Weatherization programs, and that subcontract labor and subcontract material costs were overstated and billed to both programs, requiring repayment of $133,144.05 to the State of Vermont. 2. Management’s Response Management concurs with the finding, and the $133,144.05 has been repaid. Both conditions share a common root cause: Weatherization and Finance operate on separate systems — Hancock for program job-costing, the general ledger for financial reporting — without a recurring, independently reviewed monthly reconciliation between the two. Program staff prepare both the Hancock job-closing data and the resulting Monthly Expenditure Reports (MERs), and Finance’s role has been limited to sign-off on the cash draw request and MER rather than independent verification of the underlying data. This allowed a set of jobs that were closed, reported, then inadvertently reopened, re-closed, and billed a second time to go undetected until identified by the independent audit. 3. Root Cause Gap A – Balance reconciliation (drives the WIP, revenue, and deferred revenue condition): No recurring monthly reconciliation exists between Hancock’s reported WIP activity by grant and the general ledger’s WIP asset, revenue, and deferred revenue balances. Alignment has relied on a semi-annual adjusting entry that forces the general ledger to agree with year-end or grant-end program reporting, without documenting the variance being corrected. Gap B – Source data review (drives the expenditure reporting and overbilling condition): Finance’s review of the MER and cash draw request has not included independent verification that the population of jobs and costs reported as newly closed for the month is accurate and non-duplicative, which allowed reopened-and-reclosed jobs to be billed twice without detection. Gap C – Subcontract cost validation: Subcontractor invoices and purchase orders are reviewed and approved at the point of payment. Weatherization’s existing job-closeout procedure for verifying subcontract labor and material costs on a closed job has not been reviewed for consistency with grant requirements, and is not currently integrated with Finance’s review of cash draw requests and MERs. 4. Corrective Actions The actions below establish monthly, documented, independently reviewed controls for closing Gaps A, B and C scoped to what can be reliably implemented and sustained in the near term. 1. Develop and implement a written Monthly Grant Reconciliation Procedure requiring Hancock’s month-end WIP, revenue, and deferred revenue activity by grant to be reconciled to the corresponding general ledger balances every month, rather than only at grant-year and fiscal-year close — Finance Director; within 60 days (by early October 2026). 2. Replace the semi-annual WIP adjusting entry with a monthly adjusting entry supported by a documented reconciliation identifying the variance between Hancock-reported and general-ledger balances. During the initial implementation period, Finance will develop and refine the reconciliation methodology; each variance identified will be documented, researched, and corrected once its cause is determined. A specific materiality threshold and escalation protocol for unresolved variances will be documented and adopted by January 2027, based on the pattern observed in the initial reconciliation cycles. The reconciliation and any correcting entries are subject to documented Finance Director review and sign-off, and independent review and sign-off by the Executive Director, retained for audit testing — Finance Director / Staff Accountant / Executive Director; first full month applied July 2026, ongoing thereafter; materiality threshold and escalation protocol adopted by January 2027. 3. Develop and implement a written MER Review Procedure requiring that, prior to submission, Finance compare the current month’s Hancock closed-job listing against the prior month’s listing for each grant to identify jobs appearing more than once, including jobs closed, reopened, and re-closed — Finance Director / Staff Accountant; within 60 days (by early October 2026). 4. Formalize the existing Finance review and sign-off of the MER and cash draw request to explicitly include and document this closed-job comparison, subject to independent review and sign-off by the Executive Director prior to submission, — Finance Director / Executive Director; effective with the September 2026 submission cycle. 5. Require Weatherization to flag, at the point of submission, any job reopened after an initial closing, so Finance’s review has a defined starting point — Weatherization Administration Staff; effective with the October 2026 submission cycle. 6. Train Weatherization and Finance staff on the updated procedures, including the integrated job-closeout review (Item 7), and on 2 CFR 200 Subpart E (allowable, allocable, and properly supported costs), and retain completed reconciliations and MER review documentation, including job-closeout review documentation, to support future audit testing — Finance Director / Accounting Staff; training by early November 2026, retention ongoing. 7. Review Weatherization’s current job-closeout procedure, in coordination with Weatherization Administration Staff, to confirm that subcontract labor and material costs attributed to a closed job are verified as complete, accurate, not previously billed, and correctly classified. Correct or strengthen the procedure as needed to bring it into compliance, document it, and integrate it with Finance’s review of the MER and cash draw request (Items 3–4) — Finance Director / Weatherization Administration Staff; review completed by mid-September 2026, procedure documented, corrected as needed, and integrated with Finance’s review by mid-November 2026. 8. After the monthly WIP/general ledger reconciliation (Item 2) and MER closed-job comparison (Items 3–4) have been operating for at least one full quarter, apply the same closed-job comparison methodology retrospectively to Hancock data for FY24 and FY25 to identify any additional jobs closed, reopened, and re-closed and billed more than once. Document the results, including any additional amounts potentially due to the State of Vermont or U.S. Department of Energy, and report findings to the Finance Committee and, if additional overbilling is identified, to the State of Vermont Department for Children and Families and the U.S. Department of Energy — Finance Director; lookback completed by April 2027, following at least one full quarter of the new procedures operating. 9. Establish a semiannual internal compliance review across all major federal award programs (Head Start, CSBG, LIHEAP, HWAP, and CDBG), phased in to match available capacity. The first cycle will verify that expenditures recorded in the general ledger reconcile to amounts reported to each funder; a sample-based test of cost allowability will be incorporated beginning with the second cycle. The review is performed by the Finance Director and independently reviewed by the Executive Director, with results reported to the Finance Committee — Finance Director / Executive Director; first review by June 2027, semiannual thereafter, cost-allowability testing added beginning with the review in December 2027. 5. Anticipated Completion Date Both procedures will be documented, approved, and in effect no later than October 2026, with the first full reconciliation and MER review cycle completed at October month-end close. The Weatherization job-closeout review (Item 7) will be completed, corrected as needed, and integrated with Finance’s review by mid-November 2026. Staff training will be completed by early November 2026. The materiality threshold and escalation protocol for reconciliation variances (Item 2) will be adopted by January 2027. The FY24–FY25 historical lookback (Item 8) will be completed by April 2027. The program-wide semiannual internal compliance review (Item 9) will begin no later than June 2027, with cost-allowability testing phased in by December 2027. 6. Broader Process Review – Weatherization / Finance Integration These near-term actions reduce but do not fully resolve a systemic issue: Weatherization and Finance rely on separate systems and staff, connected only by manual, summary-level data transfer. Fully closing that gap — including possible transaction-level reconciliation between Hancock and the general ledger — requires broader cross-departmental review, which management has begun, led by the Executive Director and Finance Director in consultation with Weatherization Administration Staff. The review will incorporate the results of the Weatherization job-closeout procedure review (Item 7) and will evaluate the feasibility of transaction-level reconciliation, staffing needs, and interim manual controls, and is targeted for completion by November 2026. A detailed scope, timeline, and set of deliverables is maintained as a supplementary document, available to the Finance Committee and auditors on request; a summary of findings and any resulting recommendations will be incorporated into next year’s corrective action reporting. 7. Monitoring The Finance Director will review completed monthly reconciliations and MER review documentation, and the integrated Weatherization job-closeout review (Item 7), as part of each monthly close and submission cycle; the Executive Director will independently review and sign off on this documentation on the same cycle. Unresolved reconciliation variances will be handled per the protocol adopted under Item 2. Reconciliation status and any unresolved variances will be reported to the Finance Committee monthly, together with progress on the broader Weatherization / Finance process review until that work concludes. The semiannual program-wide internal compliance review (Item 9) will be reported to the Finance Committee upon completion of each cycle. 8. Evidence of Completion Items 1–2 (Monthly WIP/GL reconciliation): Reconciliation workpapers, variance research notes, Finance Director and Executive Director sign-off, and escalation records where applicable. Items 3–4 (MER closed-job comparison): Closed-job comparison reports, and the MER and draw request with Finance Director and Executive Director sign-off. Item 5 (Weatherization reopened-job flag): Flagged job listing submitted with each MER cycle. Item 6 (Training): Training materials and sign-in sheets or completion certificates. Item 7 (Weatherization job-closeout review): Documentation of the procedure review, any corrections made, and sign-off integrating it into the MER/draw review. Item 8 (Historical lookback): Lookback workpapers, a summary of results, and related Finance Committee and funder correspondence. Item 9 (Semiannual compliance review): Review workpapers, sample testing documentation, and the Finance Committee report. All records will be retained in accordance with SEVCA’s record retention policy and 2 CFR 200.334.
CORRECTIVE ACTION PLAN — Finding 2025-002 Compliance Finding – Cash Management | Low-Income Home Energy Assistance Program (LIHEAP) (ALN 93.568) Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | Pass-Through Entity: State of Vermont Department for Children and Families | Cognizant Federa...
CORRECTIVE ACTION PLAN — Finding 2025-002 Compliance Finding – Cash Management | Low-Income Home Energy Assistance Program (LIHEAP) (ALN 93.568) Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | Pass-Through Entity: State of Vermont Department for Children and Families | Cognizant Federal Agency: U.S. Department of Health and Human Services | CAP Contact: Joshua Davis, Executive Director, JDavis@sevca.org 1. Summary of Finding Finding 2025-002 identified that SEVCA drew the maximum allowable 50% advance under the LIHEAP award at the onset of the grant period without a documented cash flow forecast or disbursement schedule demonstrating that the amount drawn was limited to actual, immediate program needs. Approximately 30 days after receipt, a significant portion of the advance remained unexpended. This is not consistent with 2 CFR 200.305(b), which requires advances to be limited to the minimum amounts needed and timed to minimize the elapsed time between receipt and disbursement of funds. 2. Management’s Response SEVCA concurs with the finding. No questioned costs were identified. Management is implementing the corrective actions below. 3. Corrective Actions 1. Develop and implement a written Cash Management Procedure requiring that each advance drawdown request be supported by a documented cash flow forecast / disbursement schedule covering the period through the next expected draw date for that award, in accordance with 2 CFR 200.305(b) — Finance Director; 9/1/26. 2. Limit advance drawdown amounts to anticipated disbursements through the next scheduled draw date, rather than defaulting to the maximum allowable advance percentage — Finance Director; 9/1/26. 3. Formalize Finance Director review and sign-off of draw requests, and require independent review and sign-off by the Executive Director prior to submission, to explicitly document verification of the supporting forecast and the next expected draw date, and the amount requested — Finance Director / Executive Director; 9/1/26. 4. Use a single recurring draw worksheet per award documenting cash on hand, anticipated disbursements through the next draw date, and the amount requested, while reconciling the prior draw’s actual disbursements against projections and flagging any idle balances — Finance Director; 9/1/26. 5. Train relevant staff on the updated procedure and 2 CFR 200.305 requirements, and retain completed draw worksheets to support future audit testing — Finance Director / Accounting Staff; 9/1/26, retention ongoing. 4. Anticipated Completion Date 9/1/26. 5. Monitoring The Finance Director will review completed draw worksheets as part of each draw cycle; the Executive Director will independently review and sign off on each draw worksheet prior to submission, and will assess quarterly whether advances are being appropriately sized and timely utilized across federal awards. Draw worksheets, supporting forecasts, and sign-offs will be retained to support future audit testing.
CORRECTIVE ACTION PLAN — Finding 2025-001 Compliance Finding – Special Tests and Provisions | Community Services Block Grant (ALN 93.569) Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | Pass-Through Entity: State of Vermont Department for Children and Families | Cognizant Federal Agenc...
CORRECTIVE ACTION PLAN — Finding 2025-001 Compliance Finding – Special Tests and Provisions | Community Services Block Grant (ALN 93.569) Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | Pass-Through Entity: State of Vermont Department for Children and Families | Cognizant Federal Agency: U.S. Department of Health and Human Services | CAP Contact: Joshua Davis, Executive Director, JDavis@sevca.org 1. Summary of Finding Finding 2025-001 identified that, as of the September 24, 2025 board meeting, SEVCA’s 13-member Board of Directors did not meet the required CSBG tripartite composition: four participant-sector members, five private-sector members, and four public-sector members, leaving neither the participant nor the public sector at one-third. SEVCA returned to compliance the following month by seating the additional members needed to restore the required composition, recruited and seated through SEVCA’s established board-selection process. No questioned costs were identified. 2. Management’s Response SEVCA concurs with the finding. The tripartite structure is fundamental to community action agency governance and to meaningful representation of low-income individuals and families, public officials, and private-sector members. Management and the Board have strengthened monitoring of Board composition and are maintaining a continuing pipeline of prospective members in each required sector. 3. Root Cause Board-member turnover created a temporary imbalance among the three required sectors. The underlying control gap was the absence of a documented composition matrix, a recurring compliance review, and a formal escalation procedure triggered when a departure caused—or was expected to cause—a sector to fall below its required representation. Because members must be seated through SEVCA’s established selection procedures, vacancies cannot always be filled immediately, making proactive succession planning and sector-specific recruitment necessary. 4. Corrective Actions 1. Provide Board training on CSBG tripartite composition requirements and each member’s role in maintaining a compliant Board — Executive Director / Board Chair; completed and incorporated into ongoing Board education. 2. Maintain a Board composition matrix identifying each member’s sector, term dates, appointing or selecting authority, applicable public-official status, and current or anticipated vacancies — Executive Director / Board Secretary; completed and maintained ongoing. 3. Review the composition matrix at each regular Executive Committee meeting, include it in the monthly Board meeting materials, and document the review in the minutes — Board Chair / Executive Director; ongoing. 4. Maintain an all-Board recruitment pipeline of qualified candidates for each required sector through public advertising, community partnerships, and direct outreach, beginning recruitment as early as possible when a departure is anticipated — Board of Directors / Executive Director; implemented and ongoing. 5. Adopt written requirements that vacancies affecting tripartite compliance be filled within 90 days where reasonably possible, with immediate escalation of any current or anticipated imbalance to the Board Chair and governance committee, together with contingency procedures for declined appointments, failed elections, or mid-year changes in Board size — Executive Committee; within 90 days of plan approval. 6. Obtain an annual certification by the Board Chair or governance committee confirming tripartite composition compliance and documentation of member-selection procedures — Board Chair / Governance Leadership; annually, beginning with the next governance review. 5. Anticipated Completion Date Restoration of tripartite compliance, Board training, and the composition matrix are complete. Written vacancy, escalation, and contingency requirements will be completed within 90 days of approval of this plan. Recruitment, succession planning, composition monitoring, and annual certification continue as ongoing governance responsibilities. 6. Monitoring The Executive Director and Board Chair will monitor the composition matrix, review it at each regular Executive Committee meeting, and include it with the monthly Board meeting materials. Progress toward filling affected seats will be reported to the full Board until compliance is restored, and the Board Chair or Executive Committee will complete the annual composition certification.
Onvida Health Management will revise/update existing procurement and/or grant policies to incorporate all Uniform Guidance requirements related to micro-purchases, small purchases, competitive proposals, and documentation of cost or price analysis. Procedures for verifying suspension and debarment s...
Onvida Health Management will revise/update existing procurement and/or grant policies to incorporate all Uniform Guidance requirements related to micro-purchases, small purchases, competitive proposals, and documentation of cost or price analysis. Procedures for verifying suspension and debarment status will also be formally addressed in these policies. Responsible Official: Dana Alexander, Controller Completion Date: Any outstanding items not already completed that are listed in the corrective action plan, will be completed by an estimation date of October 1, 2026.
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