Corrective Action Plans

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This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, ...
This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding in conjunction with Finding 2024-005 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. The new Finance Team leadership have reinstated use of the class system in our general ledger to allocate direct costs to specific programs and clearly separate non-reimbursable expenses. Monthly reconciliations will be performed to ensure qualifying costs align with cash draw requests. Accounting staff have or will receive targeted training on cost allocation principles and documentation standards to support this effort.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Cayuga Centers has also begun the process of working with its main federal funder regarding this item and will coordinate closely with that funder in res...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Cayuga Centers has also begun the process of working with its main federal funder regarding this item and will coordinate closely with that funder in resolving it. As an immediate action step, Cayuga Centers is reinforcing training for all grant management personnel, emphasizing the distinction between allowable and unallowable costs. The Training Department is developing a virtual curriculum to issue to all required staff. A pre-approval process was introduced for all grant-funded expenditures, and program managers will be required to certify compliance before expenses are submitted for reimbursement.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Evaluation of this finding and Cayuga Centers’ procurement policies will be completed no later than November 2025 and any improvements needed for complia...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Evaluation of this finding and Cayuga Centers’ procurement policies will be completed no later than November 2025 and any improvements needed for compliance or recommended as best practice will be adopted. As an initial action step, Cayuga Centers has developed a compliance checklist for all significant and recurring purchases. This checklist requires evidence of competitive bidding, vendor selection, and justification for sole-source procurement. Staff involved in purchasing have received, or will receive, training on federal and organizational procurement policies. The Compliance Department will conduct quarterly reviews of procurement records to ensure adherence to established procedures.
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management overrid...
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management override, Cayuga Centers has implemented standardized procedures to ensure grant expenditures are properly classified in our financial system. Each transaction are supported by detailed documentation, including invoices, receipts, and grant-specific identifiers. Individuals responsible for grant oversight will undergo mandatory training to deepen their understanding of grant requirements, allowable costs, and reporting obligations. Additionally, Cayuga Centers is working to ensure open communication between staff and the Board. Under new leadership, the agency continues to enforce its Non-Retaliation Policy (Whistleblower). The Acting President’s office is establishing quarterly “Grant Compliance Forums” for employees to raise concerns related to grant administration.
Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts tha...
Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts that exceed $2,000. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the future all construction contracts will be reviewed on an monthly basis to determine what contracts total $2,000.00 or over to make sure we have a certified payroll for these contracts. Name(s) of the contact person(s) responsible for corrective action: Jamie Navenma, Executive Director and Cheryl Mullins, Controller Planned completion date for corrective action plan: December 1, 2025
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-011: Reporting - Insufficient Policies to Ensure Completeness and Accuracy of Reports (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-011: Reporting - Insufficient Policies to Ensure Completeness and Accuracy of Reports (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will implement a standardized reporting checklist and will ensure that all reports undergo supervisory review and sign-off prior to submission Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct quarterly reviews of submitted reports and related documentation.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-010: Cash Management - Inadequate Policies for Drawdowns, Program Income, and Reconciliations (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: The...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-010: Cash Management - Inadequate Policies for Drawdowns, Program Income, and Reconciliations (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will draft and approve comprehensive written procedures, and will ensure that staff are trained on the standardized drawdown and reconciliation processes. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct annual reviews of drawdown and reconciliation policies with documented compliance checks.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There ...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-008: Cash Management - Inadequate Authorization and Supporting Documentation for Reimbursement Requests (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Fin...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-008: Cash Management - Inadequate Authorization and Supporting Documentation for Reimbursement Requests (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: A standardized reimbursement packet and formal approval workflow will be created. All reimbursement requests will be routed for required approvals. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The Finance Department will conduct monthly reconciliations and reviews of reimbursement submissions.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: Th...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: A monthly review checklist and variance analysis template will be adopted. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The internal audit function will conduct semiannual reviews to confirm adherence to established review procedures.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-006: Activities Allowed or Unallowed / Allowable Costs - Inadequate Chart of Accounts Segregation for Unallowable Costs (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreemen...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-006: Activities Allowed or Unallowed / Allowable Costs - Inadequate Chart of Accounts Segregation for Unallowable Costs (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will implement a comprehensive redesign of the chart of accounts, including the creation of new account codes and subaccounts to clearly identify unallowable costs. In addition, management will ensure that staff receive training on the revised coding structure. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The Finance Department will conduct quarterly internal reviews to ensure the proper use of the revised account codes and to verify the accuracy of cost classifications.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future timesheets and paystubs are reconciled and will ensure control policies are in place.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future timesheets and paystubs are reconciled and will ensure control policies are in place.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future payroll disbursements are supported by a timesheet and approved by a manager.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future payroll disbursements are supported by a timesheet and approved by a manager.
Management agrees controls over cash disbursements should be complied with and will be more meticulous in maintaining documentation that approval be granted before payment is made.
Management agrees controls over cash disbursements should be complied with and will be more meticulous in maintaining documentation that approval be granted before payment is made.
Finding 1166725 (2024-001)
Material Weakness 2024
Finding ref number: 2024-001 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of the County contact person: Leo Kim, CPA CFO, Mason County Auditor’s Office, Financial Service, PO Bo...
Finding ref number: 2024-001 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of the County contact person: Leo Kim, CPA CFO, Mason County Auditor’s Office, Financial Service, PO Box 400, Shelton, WA 98584 360-429-9670 Ext 472 Corrective action the auditee plans to take in response to the finding: Mason County is committed to maintaining strong internal controls and ensuring compliance with all federal procurement requirements. While County policy already requires suspension and debarment checks, staff training and documentation practices need improvement. Corrective Action: • In 2025, the County revised its purchasing policy to include an attestation form allowing vendors to certify that they are not suspended or debarred. • Staff will be trained on how to perform and document suspension and debarment checks in SAM.gov. • The County is developing a process to conduct suspension and debarment checks when a vendor is first created and annually thereafter for all active vendors. • Compliance with these procedures will be a joint effort between the Budget Office, Auditor’s Financial Services Office, and responsible offices and departments. Mason County believes that enhanced training, consistent documentation, and proactive vendor verification will prevent recurrence of this issue and strengthen accountability across all departments. Anticipated date to complete the corrective action: December 31, 2025
Finding Number: 2024-003 Planned Corrective Action: The Grants Department Manager and Chief Financial Administrator will ensure the County submits quarterly OCJS amounts that match County accounting records each quarter. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Rob ...
Finding Number: 2024-003 Planned Corrective Action: The Grants Department Manager and Chief Financial Administrator will ensure the County submits quarterly OCJS amounts that match County accounting records each quarter. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Rob Grant, Grants Department Manager and Ben Cowdery, Chief Financial Administrator
Finding Number: 2024-006 Planned Corrective Action: The Special Projects Manager will ensure the County establishes policies/procedures related to Section 3 and includes Section 3 accomplishments in semi-annual performance reports submitted in Disaster Recovery Grant Reporting System. Anticipated Co...
Finding Number: 2024-006 Planned Corrective Action: The Special Projects Manager will ensure the County establishes policies/procedures related to Section 3 and includes Section 3 accomplishments in semi-annual performance reports submitted in Disaster Recovery Grant Reporting System. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: P Philip Schaffer, Special Projects Manager
Finding Number: 2024-005 Planned Corrective Action: The Special Projects Manager will ensure the County does not charge Indirect Costs in excess of the de minimis rate of 10 percent of modified total direct costs. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Philip Scha...
Finding Number: 2024-005 Planned Corrective Action: The Special Projects Manager will ensure the County does not charge Indirect Costs in excess of the de minimis rate of 10 percent of modified total direct costs. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Philip Schaffer, Special Projects Manager
Finding Number: 2024-004 Planned Corrective Action: The Special Projects Manager and Chief Financial Administrator will ensure the County submits Semi-Annual Performance Reports with expenditures that match County accounting records each semi-annual period. Anticipated Completion Date: December 31, ...
Finding Number: 2024-004 Planned Corrective Action: The Special Projects Manager and Chief Financial Administrator will ensure the County submits Semi-Annual Performance Reports with expenditures that match County accounting records each semi-annual period. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Philip Schaffer, Special Projects Manager and Ben Cowdery, Chief Financial Administrator
#2024-004 - Single Audit Reporting - Organization management concurs with the recommendation and will continue to monitor grants and ensure timely reporting in the future. Responsible Official – Nicole Matson, Interim Executive Director Anticipated Completion Date – This finding will be resolved as ...
#2024-004 - Single Audit Reporting - Organization management concurs with the recommendation and will continue to monitor grants and ensure timely reporting in the future. Responsible Official – Nicole Matson, Interim Executive Director Anticipated Completion Date – This finding will be resolved as the Organization will not need a single audit going forward.
Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within...
Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within the accounting and finance department are able to complete their tasks in a more timely manner.
Assistance Listing 14.231 Emergency Solutions Grants Program Assistance Listing 93.224 & 93.527 Health Center Program & Grants for New and Expanded Services under the Health Center Program Assistance Listing 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Publi...
Assistance Listing 14.231 Emergency Solutions Grants Program Assistance Listing 93.224 & 93.527 Health Center Program & Grants for New and Expanded Services under the Health Center Program Assistance Listing 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Assistance Listing 93.667 Social Services Block Grant Assistance Listing 93.914 HIV Emergency Relief Project Grants Views of the Responsible Officials and Corrective Action Plan: Although we acknowledge that certain prior-year expenditures were recorded in the FY24 SEFA, we do not believe these errors were material to the basic financial statements. In addition, we do not believe that including these expenditures affected the determination of major programs or our compliance with any federal grant requirements. We confirm that our financial statements are prepared in accordance with Generally Accepted Accounting Principles and that, as presented, they are materially accurate. For FY 2025, we expanded our search for unrecorded liabilities to include activity through seven months after year-end. Because the risk of unrecorded liabilities declines as we move further from fiscal year-end, we focused our review on transactions that could reasonably have a material impact on the financial statements. We will work closely with all departments to ensure that any outstanding obligations that have not yet been vouchered are identified and addressed. Contact Person: Shantae Thorpe, Accounting Manager, Finance, 215-686-5629
Assistance Listing 93.914 HIV Emergency Relief Project Grants Views of the Responsible Officials and Corrective Action Plan: HHS acknowledges the Controller’s finding that management decision letters were not issued for specific subrecipient audit findings under ALN 93.914, as required under 2 CFR 2...
Assistance Listing 93.914 HIV Emergency Relief Project Grants Views of the Responsible Officials and Corrective Action Plan: HHS acknowledges the Controller’s finding that management decision letters were not issued for specific subrecipient audit findings under ALN 93.914, as required under 2 CFR 200.332(e) and 200.521. While the formal letters were not issued, HHS did review the audit findings, obtained and evaluated the subrecipients’ corrective action plans and confirmed that no questioned costs or additional risks remained. These steps ensured that the underlying corrective actions were completed. To strengthen documentation and ensure consistency across all federal programs, HHS will adopt the following corrective measures: 1.Standard management Decision Template •HHS will adopt a simple, uniform management decision template and clear steps for documenting decisions within the required federal timelines. 2.Central Location for Documentation •HHS will store all management decision letters and related materials in one designated shared location to ensure accessibility and consistent record-keeping. 3.Brief Staff Guidance •HHS will provide concise written guidance to staff outlining: oWhen a management decision is required, oHow to complete it using the template, and oWhat documentation must be retained? These corrective actions will ensure consistent compliance with federal requirements while supporting the City’s long-term goal of standardizing financial processes across departments. Contact Person: Landuleni Shipanga, Controller, City of Philadelphia Office of Children and Families, 215-683-6366
Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the Office of the City Controller’s finding. PDPH maintains a process to iden...
Assistance Listing 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases Program Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the Office of the City Controller’s finding. PDPH maintains a process to identify subrecipients during the contracting process. Contracts with subrecipients include federal compliance language. The three entities identified in this finding, including Concilio, Urban Affairs Coalition (UAC), and Public Health Management Corporation (PHMC), should have been classified as vendors and not subrecipients. These entities were not responsible for programmatic decision-making. This error has been corrected in subsequent contracts. Despite the misclassification, appropriate vendor monitoring was conducted, including supervision of staff hiring and monitoring and reconciliation of monthly invoice packages. Contact Person: Jessica Caum, Director, Department of Public Health, 215-685-6731 Naomi Mirowitz, Performance and Compliance Officer, Department of Public Health, 215-964-5050
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the findings of the Office of the City Controllers. PDPH confirms that r...
Assistance Listing 93.136 Injury Prevention and Control Research and State/Community Based Programs Views of the Responsible Officials and Corrective Action Plan: The Philadelphia Department of Public Health (PDPH) acknowledges the findings of the Office of the City Controllers. PDPH confirms that risk assessments and related monitoring documentation for all subrecipients were not consistently completed or retained during the audit period, primarily due to staff turnover and limited administrative capacity within the grants management function. To address this, the Division of Substance Use Prevention and Harm Reduction (SUPHR) has initiated corrective measures to strengthen compliance with the requirements of 2 CFR 200.332. These measures include implementation of standardized tools and procedures to ensure that subrecipient risk assessments, monitoring activities, and the review of financial and performance reports are conducted in a consistent, timely, and well-documented manner. Implementation of these improvements will enhance internal controls, ensure appropriate oversight of subrecipients, and promote full compliance with federal regulations. The Department anticipates that tools and standard operating procedures will be finalized by December 19, 2025, with full implementation of corrective actions by March 3, 2026. Contact Person: Daniel Teixeira da Silva, Director, Division of Substance Use Prevention and Harm Reduction (SUPHR), 267-760-0307
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