Corrective Action Plans

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In Finding 2025-008, it was reported that the Organization did not properly apply sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. In response to Finding 2025-008, Management recognizes the importance of complying with sliding fee gu...
In Finding 2025-008, it was reported that the Organization did not properly apply sliding fee discounts for certain patients with visits to the Organization during the year ended December 31, 2025. In response to Finding 2025-008, Management recognizes the importance of complying with sliding fee guidelines. The Patient Services Manager has trained all Patient Services Representatives on the sliding fee; performance improvement plans have been developed on employees with errors. Currently the manager has assigned a team to review all sliding fee applications with the goal of 100% reviewed by the end of 2026. Sliding fee applications with errors are returned for correction and communication to the patient. The manager will continue reviewing the sliding fee process in the team's monthly meeting.
In Finding 2025-007, a condition was noted in which the Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In response to Finding 2025-007, Management r...
In Finding 2025-007, a condition was noted in which the Organization did not verify that employees and certain vendors were not suspended, debarred, or otherwise excluded from participating in federal programs before entering into transactions with them. In response to Finding 2025-007, Management recognizes the importance of complying with the Organization’s procurement policy. FHC has ensured the proper team members conduct checks and reviewed the policy with appropriate team members..
In Finding 2025-006, a condition was noted that during the year, the Organization failed to reconcile expenditures prior to drawing federal grant funds. In response to Finding 2025-006, Management recognizes the importance of the requirements to draw federal grant funds only after making qualifying ...
In Finding 2025-006, a condition was noted that during the year, the Organization failed to reconcile expenditures prior to drawing federal grant funds. In response to Finding 2025-006, Management recognizes the importance of the requirements to draw federal grant funds only after making qualifying expenditures. Additionally the policy has been reviewed and FHC has implemented an approval process for grant draw which include: • Ongoing reconciliation spreadsheets are monitored and balanced to Payment Management System monthly. • Draw request is prepared by Interim Chief Financial Officer and approved by the Chief Executive Officer before the draw is implemented. The CEO verifies documentation for the draw prior to approval. • Documentation is maintained that supports the draw and all expenditures.
In Finding 2025-005, a finding reported that the Organization did not submit timely or accurate FFR filings. In response to Finding 2025-005, Management recognizes the importance of complying with federal reporting guidelines and has filed timely and corrected previous FFRs starting in 2026.
In Finding 2025-005, a finding reported that the Organization did not submit timely or accurate FFR filings. In response to Finding 2025-005, Management recognizes the importance of complying with federal reporting guidelines and has filed timely and corrected previous FFRs starting in 2026.
Management will reconfigure the system to require after-the-fact entry of actual hours worked and to restrict advance entry and approval, reinforce supervisory review procedures to ensure timely and accurate approval of timecards, and provide training to employees and supervisors on federal timekeep...
Management will reconfigure the system to require after-the-fact entry of actual hours worked and to restrict advance entry and approval, reinforce supervisory review procedures to ensure timely and accurate approval of timecards, and provide training to employees and supervisors on federal timekeeping requirements under 2 CFR 200.430. These actions will strengthen internal controls and ensure payroll costs charged to federal awards accurately reflect work performed going forward.
Views of Responsible Officials: Management acknowledges this deficiency. The delay traces to a multi-year audit backlog inherited by the current VP of Finance in 2026: the fiscal year 2023 audit was not completed on time, which pushed fiscal year 2024 fieldwork past the September 30, 2025 filing dea...
Views of Responsible Officials: Management acknowledges this deficiency. The delay traces to a multi-year audit backlog inherited by the current VP of Finance in 2026: the fiscal year 2023 audit was not completed on time, which pushed fiscal year 2024 fieldwork past the September 30, 2025 filing deadline and resulted in the late DCF submission. Since then, management has restored the organization's relationship with its prior audit firm, enabling more efficient execution and communication. The fiscal year 2023 and 2024 audits were both completed and closed out in 2026, resolving the backlog. The fiscal year 2025 audit is on track for completion by September 30, 2026, positioning RoboNation to submit the related DCF within the required Federal deadline. Management has also implemented standardized monthly reconciliation procedures, formalized close processes, and enhanced reporting capabilities to sustain timely audits going forward. The fiscal year 2026 audit is targeted for fieldwork completion in April 2027 and full completion by end of May 2027, establishing a predictable cadence well ahead of deadlines.
Views of Responsible Officials: Management acknowledges the finding and agrees with the recommendation. RoboNation recognizes the importance of maintaining complete procurement records for federally funded transactions, including documentation of vendor selection, procurement method, basis for price...
Views of Responsible Officials: Management acknowledges the finding and agrees with the recommendation. RoboNation recognizes the importance of maintaining complete procurement records for federally funded transactions, including documentation of vendor selection, procurement method, basis for price, sole-source justification when applicable, and suspension/debarment verification. Once RoboNation was made aware of the deficiency during the 2023 audit, action was immediately taken and SAM.gov checks were completed in 2025 for all applicable vendors, not only new vendors. Management will further strengthen its procurement and suspension/debarment procedures by implementing a formal checklist requiring documentation of vendor selection, procurement method, basis for price, sole-source justification when applicable, and SAM.gov screening prior to contract execution or payment. Management will also ensure that supporting documentation is retained in the applicable procurement files and will provide comprehensive training and continued guidance to staff involved in Federally funded procurement to support consistent application of these procedures.
Finding 2025-002 Reporting Corrective Action: The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected with 2025 and 2026 reporting.
Finding 2025-002 Reporting Corrective Action: The City discovered and corrected the error during 2024, at which time additional reviews were implemented over report submission. The error has been corrected with 2025 and 2026 reporting.
Finding Type: Internal Control. Name of Contact Person: Mr. Ryan Essex, Executive Director, (573) 651-3747. Recommendation: The Organization should establish internal control procedures to ensure that the Quarterly Reports and Annual Reports are reviewed by the YHDP Grant Coordinator to ensure accur...
Finding Type: Internal Control. Name of Contact Person: Mr. Ryan Essex, Executive Director, (573) 651-3747. Recommendation: The Organization should establish internal control procedures to ensure that the Quarterly Reports and Annual Reports are reviewed by the YHDP Grant Coordinator to ensure accuracy before submission. This review should be documented. Corrective Action: We will ensure the reports are being reviewed and the review is being documented going forward. Proposed Completion Date: Immediately.
Finding Type: Noncompliance and Internal Control. Name of Contact Person: Mr. Ryan Essex, Executive Director, (573) 650-3747. Recommendation: The Organization should establish internal control procedures to ensure that all proper documentation to support eligibility for participation in the program ...
Finding Type: Noncompliance and Internal Control. Name of Contact Person: Mr. Ryan Essex, Executive Director, (573) 650-3747. Recommendation: The Organization should establish internal control procedures to ensure that all proper documentation to support eligibility for participation in the program is maintained and readily available in the participant file. Corrective Action: The Organization has established better internal controls with new program directors in place. Additionally, determination is made within the Organization along with files being maintained onsite. Proposed Completion Date: Immediately.
Finding Type: Noncompliance. Contact Person: Mr. Ryan Essex, Executive Director, (573) 651-3747. Recommendation: The Organization should follow their established internal control procedures to identify and track interest earned on federal program funds, determine the amount required to be remitted i...
Finding Type: Noncompliance. Contact Person: Mr. Ryan Essex, Executive Director, (573) 651-3747. Recommendation: The Organization should follow their established internal control procedures to identify and track interest earned on federal program funds, determine the amount required to be remitted in accordance with applicable federal regulations and award terms, and remit such amounts timely to the appropriate federal agency or pass-through agency. Corrective Action: The Organization has implemented procedures to request funds on a reimbursement basis. This should minimize federal funds earning interest. We will work to ensure that our established procedures to identify and track interest earned on federal program funds are followed and remit the funds accordingly, if necessary. Proposed Completion Date: Immediately.
Finding Type: Noncompliance. Contact Person: Mr. Ryan Essex, Executive Director, (573) 651-3747. Recommendation: We recommend that all required filings be submitted timely according to the Single Audit Act of 1984 and Title 2 U.S. Code of Federal Regulations Guidelines. Corrective Action: We have hi...
Finding Type: Noncompliance. Contact Person: Mr. Ryan Essex, Executive Director, (573) 651-3747. Recommendation: We recommend that all required filings be submitted timely according to the Single Audit Act of 1984 and Title 2 U.S. Code of Federal Regulations Guidelines. Corrective Action: We have hired a new Director and Finance Director and will ensure the Data Collection Form is submitted timely going forward. Proposed Completion Date: Fiscal year 2027.
2025-002 Coronavirus State and Local Fiscal Recovery Fund, ALN #21.027 Condition: During our audit, we noted the Organization had not adopted formal written procurement policies and procedures governing purchases made with Federal award funds. Specifically, the Organization had not documented procur...
2025-002 Coronavirus State and Local Fiscal Recovery Fund, ALN #21.027 Condition: During our audit, we noted the Organization had not adopted formal written procurement policies and procedures governing purchases made with Federal award funds. Specifically, the Organization had not documented procurement methods, purchasing thresholds, quotation requirements, sole-source procurement requirements, or procedures for ensuring compliance with applicable Federal procurement standards. Although testing of procurement transactions selected for examination did not identify instances of noncompliance with Uniform Guidance procurement requirements, the Organization's procurement practices were based on informal procedures. Auditor's Recommendation: We recommend that management develop and formally adopt written procurement policies consistent with Uniform Guidance. At a minimum, such policies should address procurement methods and thresholds, competitive bidding and quotation requirements, sole-source procurement documentation, conflict-of-interest standards, contractor responsibility determinations, suspension and debarment considerations, and procurement record retention requirements. Action Taken: We have documented and adopted our Procurement Policy in accordance with Uniform Guidance. A copy of this policy will be provided upon request. Anticipated Completion Date: December 31, 2026
Managementconcurswiththefindingandwilllimitaccesstotheschoolfoodservicebankaccounttodesignatedpersonnel,requiredualauthorizationforallwithdrawals,andreconciletheaccountmonthly.Anyfundswithdrawnforpurposesunrelatedtothefoodservicewill be returned to the account.
Managementconcurswiththefindingandwilllimitaccesstotheschoolfoodservicebankaccounttodesignatedpersonnel,requiredualauthorizationforallwithdrawals,andreconciletheaccountmonthly.Anyfundswithdrawnforpurposesunrelatedtothefoodservicewill be returned to the account.
Managementconcurswiththefindingandwillrequirestaffwhosepayrollischargedtotheprogramtocompletecontemporaneoustimeandeffortrecords,reviewed and approved by a supervisor before each payroll charge is submitted for reimbursement.
Managementconcurswiththefindingandwillrequirestaffwhosepayrollischargedtotheprogramtocompletecontemporaneoustimeandeffortrecords,reviewed and approved by a supervisor before each payroll charge is submitted for reimbursement.
Managementconcurswiththefindingandwillimplementadailypoint-of-servicemealcountlogforeachmealservice,reconciledtoclaimsbeforesubmissionfor reimbursement. A designated staff member will maintain and retain these records for at least three years.
Managementconcurswiththefindingandwillimplementadailypoint-of-servicemealcountlogforeachmealservice,reconciledtoclaimsbeforesubmissionfor reimbursement. A designated staff member will maintain and retain these records for at least three years.
Finding Number: 2025-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Britt See-Benes, City Administrator and Maegen Hunt Bothwell, Finance Director Corrective Action Planned The City Administrator and Finance Director will attempt to monitor transact...
Finding Number: 2025-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Britt See-Benes, City Administrator and Maegen Hunt Bothwell, Finance Director Corrective Action Planned The City Administrator and Finance Director will attempt to monitor transactions and restructure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffing limitations and funding constraints. Anticipated Completion Date Ongoing.
Responsible Official’s Response and Corrective Action Planned: Management has implemented a new process to include financial oversight and review of all documents prior to submission to FEMA for reimbursement going forward. Since the Finding last year, we have not had the opportunity to utilize this...
Responsible Official’s Response and Corrective Action Planned: Management has implemented a new process to include financial oversight and review of all documents prior to submission to FEMA for reimbursement going forward. Since the Finding last year, we have not had the opportunity to utilize this new process as the FEMA expenditures in question were prior to last year’s Finding. We will continue to meet with all leadership staff to discuss documentation requirements necessary for FEMA reimbursements. Lastly, Management will only sign off on reimbursed costs after all changes to FEMA requests have been adequately documented.
2025-002 Finding – Material Weakness in Internal Controls over Allowable Costs and Non-Compliance Responsible official: Patti Lawrence, Accounting Manager Context and Cause: A material amount of funding for the program was initially used for an unallowable activity. Funding for construction was used...
2025-002 Finding – Material Weakness in Internal Controls over Allowable Costs and Non-Compliance Responsible official: Patti Lawrence, Accounting Manager Context and Cause: A material amount of funding for the program was initially used for an unallowable activity. Funding for construction was used for down payment assistance. It was also noted that the program requires a separate bank account for the funds, yet the funds were not segregated. The organization experienced turnover at the executive level. Management did not communicate with the funder in order to gain an understanding of allowable costs, and other program requirements. The organization subsequently met with the funder and re-submitted allowable invoices for the federal funding. The organization experienced turnover in executive management during the year, and organizational knowledge of the funding purpose was lost in that transition. Recommendation: It was recommended the Organization should communicate with funders in order to understand the purpose of the funding and other program requirements, and develop an internal control system that ensures only allowable costs are charged to the grants. Corrective Action Planned: The Organization has engaged a CPA firm as a 3rd party CFO service and accounting department. The firm has experience in single audits, and ensure funding is utilized per the terms of the grant. Implementation date: October 31, 2026
2025-003 Finding – Material Weakness in Internal Controls over Compliance Responsible official: Patti Lawrence, Accounting Manager Context and Cause: The Organization has a documented fiscal policy; however the policy does not include procedures that cover specific compliance attributes associated w...
2025-003 Finding – Material Weakness in Internal Controls over Compliance Responsible official: Patti Lawrence, Accounting Manager Context and Cause: The Organization has a documented fiscal policy; however the policy does not include procedures that cover specific compliance attributes associated with federal award requirements. 2 CFR 200.303 requires the recipient to establish, document, and maintain effective internal control over federal awards. Recommendation: It was recommended the Organization develop, document, and implement policies and procedures that address the recent guidance regarding applicable federal compliance requirements. Corrective Action Planned: The Organization has engaged a CPA firm as a 3rd party CFO service and accounting department. The firm is helping develop written policies over federal award attributes. Implementation date: October 31, 2026
Type of Finding: Significant deficiency in compliance and internal control over compliance over invoice requests for reimbursement. View of Responsible Officials: Management accepts this finding. Review and approval of reimbursement requests is a significant internal control to ensure the agency is ...
Type of Finding: Significant deficiency in compliance and internal control over compliance over invoice requests for reimbursement. View of Responsible Officials: Management accepts this finding. Review and approval of reimbursement requests is a significant internal control to ensure the agency is requesting appropriate reimbursement from our funders. Corrective Action: Management is now requiring all invoice requests to have a cover sheet that will show proof of review. This process will be implemented across all divisions.
Significant deficiency in compliance and internal control over compliance relating to approval of timecards. View of Responsible Officials: Management accepts this finding. Approval of timecards by employees and supervisor is required based on agency policies. This issue was due to a supervisor not ...
Significant deficiency in compliance and internal control over compliance relating to approval of timecards. View of Responsible Officials: Management accepts this finding. Approval of timecards by employees and supervisor is required based on agency policies. This issue was due to a supervisor not being available for approval and no delegate was assigned. Corrective Action: Management will require all approvers of payroll to assign delegates to approve timecards in their absence. Exceptions will be documented.
Type of Finding: Material weakness in internal controls over compliance relating to suspension and debarment checks and maintenance of documentation puts CCS at risk of noncompliance with the standards of Procurement. Views of Responsible Officials: Management accepts this finding. Performing timely...
Type of Finding: Material weakness in internal controls over compliance relating to suspension and debarment checks and maintenance of documentation puts CCS at risk of noncompliance with the standards of Procurement. Views of Responsible Officials: Management accepts this finding. Performing timely suspension and debarment checks avoids any potential issues with using federal funds for unallowable vendors. Maintaining documentation and performing proper procurement steps is vital to ensure compliance with agency policy. Corrective Action: Management is in the process of setting agency-wide procurement procedures that will align with our current policy. This includes completing a suspension and debarment check on all new vendors. Management is in the process of finding a third-party vendor to assist with annual suspension and debarment checks.
Views of Responsible Officials and Planned Corrective Actions Management concurs with the above unallowable expenses finding. The Organization has discussed this finding with the California Governor’s Office of Emergency Services (Cal OES) Auditor and has agreed upon the corrective action necessary ...
Views of Responsible Officials and Planned Corrective Actions Management concurs with the above unallowable expenses finding. The Organization has discussed this finding with the California Governor’s Office of Emergency Services (Cal OES) Auditor and has agreed upon the corrective action necessary to address the identified unallowable costs. The Organization will remove the related-party rent expenses from the affected grant awards through the abatement process approved by Cal OES. Upon completion of the abatement process, any required adjustments or reimbursements will be made in accordance with Cal OES guidance to ensure that only allowable costs are charged to the federal awards. As part of its corrective action, the Organization is strengthening its grant management and financial review processes. The Controller has been designated as the primary reviewer and approver of all grant cost allocations and will ensure grant budgets are reviewed for allowability before they are established within the accounting system. Finance staff will perform documented reviews of grant expenditures to verify compliance with Uniform Guidance (2 CFR Part 200), including the identification of related-party transactions and other potentially unallowable costs prior to charging expenses to federal awards. In addition, the Vice President of Finance will perform a secondary review of grant expenditures involving higher-risk transactions to provide additional oversight. The Organization will also implement formal written policies and procedures governing allowable costs under 2 CFR Part 200, including specific guidance for identifying, reviewing, and documenting related-party transactions. Annual training on federal grant compliance and allowable costs will be provided to both finance and program staff to reinforce these requirements and promote consistent application across the Organization. In collaboration with Cal OES and legal counsel, the Organization will evaluate and implement an appropriate long-term governance and leasing structure that complies with federal cost principles and addresses related-party considerations. This evaluation will ensure future lease arrangements and related-party transactions are structured and documented in accordance with applicable federal requirements. These enhanced controls will be implemented within 30 days. Together with centralized grant accounting procedures and strengthened financial oversight, these corrective actions are intended to ensure that only allowable costs are charged to federal awards and to prevent recurrence of this finding.
Views of Responsible Officials and Planned Corrective Actions San Diego Youth Services (SDYS) concurs with this finding. During the audit period, the Organization experienced significant turnover in both accounting and program leadership positions, which impacted the tracking and timely submission o...
Views of Responsible Officials and Planned Corrective Actions San Diego Youth Services (SDYS) concurs with this finding. During the audit period, the Organization experienced significant turnover in both accounting and program leadership positions, which impacted the tracking and timely submission of required grant and contract reports. To address this issue, SDYS has implemented enhanced internal controls to strengthen grant reporting oversight and ensure compliance with all reporting requirements. These corrective actions include: • The development and maintenance of a centralized grant reporting calendar that identifies all reporting requirements, responsible staff, and submission deadlines for each grant and contract. • Assignment of clear reporting responsibilities to designated program and fiscal staff, with established internal due dates that preceded funder deadlines to allow adequate time for review. • Monthly monitoring of reporting deadlines by program leadership and the Finance Department to ensure timely completion and submission of required reports. • Increased executive oversight by the Chief Operating Officer (COO), who will review grant reporting compliance on a regular basis. Any report anticipated to be submitted after its required deadline must be communicated to and approved by the COO in advance whenever practicable. The reason for the delay, corrective actions, and revised submission timeline will be documented and monitored to prevent recurrence. • Cross-training of program and fiscal staff to ensure continuity of reporting responsibilities during periods of staff turnover or vacancies. Management believes these enhanced procedures will strengthen accountability, improve communication between program and fiscal teams, and ensure accurate and timely submission of all grant and contract reporting requirements going forward.
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