Corrective Action Plans

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The Center is evaluating case management systems that can easily create comprehensive billing statements. In the meantime, employees will maintain timesheets, indicting time spent at work, with a supervisor review of the timesheets, and are tracking time spent on cases assigned to grants in the curr...
The Center is evaluating case management systems that can easily create comprehensive billing statements. In the meantime, employees will maintain timesheets, indicting time spent at work, with a supervisor review of the timesheets, and are tracking time spent on cases assigned to grants in the current case management software. The portion of employee time spent on the relevant grant is determined by evaluating case time tracking by employees.
Untimely Submission of Federal Financial Reports (SF 425) – Reporting – Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding – Significant Deficiency in Internal Control over Compliance Cause – Controls and procedures designed to ensure timely preparation,...
Untimely Submission of Federal Financial Reports (SF 425) – Reporting – Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster Type of Finding – Significant Deficiency in Internal Control over Compliance Cause – Controls and procedures designed to ensure timely preparation, review, and submission of required federal financial reports were not consistently followed, resulting in delayed submission of SF-425 reports. Corrective Actions: 1. Improvement of Data Entry and Documentation Management a. The process for submitting, processing, and storing sliding fee applications will be reviewed and streamlined to ensure that all supporting income level documents are properly collected, verified, and stored at the time of application submission. b. Employees involved in handling sliding fee applications and supporting documents will be provided with training on the importance of accurate documentation and the procedures for proper filing, both physically and electronically. 2. Implement Regular Monitoring and Auditing: a. A regular internal review and audit process will be revisited to ensure that backup, storage and retention practices are followed. These audits will focus on verifying that all sliding fee applications and related documents are stored correctly and are retrievable as needed. b. Any discrepancies or issues identified during audits will be addressed promptly, and corrective action will be taken to ensure compliance with the established procedures. 3. Staff Training and Awareness: a. Training sessions will be conducted for all relevant staff on the updated backup, storage and retention procedures for sliding fee applications and income documentation. This training will emphasize the importance of maintaining accurate and accessible records to comply with regulatory and organizational standards. b. Refresher training will be provided quarterly to ensure ongoing compliance and awareness.
Please accept this correspondence as the Alfred Saliba Family Services Center, Inc. 's formal corrective action response to Finding 2025-001: Reporting, related to the review and documentation process for Federal Financial Reports, including SF-425 reports. During the prior audit cycle, management b...
Please accept this correspondence as the Alfred Saliba Family Services Center, Inc. 's formal corrective action response to Finding 2025-001: Reporting, related to the review and documentation process for Federal Financial Reports, including SF-425 reports. During the prior audit cycle, management became aware of deficiencies related to the review and documentation process for Federal Financial Reports. While the 2024 audit was occurring and these deficiencies were being identified, the previous Grants Manager was relieved from her position. Following that personnel change, the Alfred Saliba Family Services Center undertook a reorganization of fiscal management responsibilities to strengthen oversight, accountability, and internal controls. As part of this corrective action, the organization reviewed, rewrote, and codified its Fiscal Policies and Procedures, which were formally adopted by the Board of Directors. These revised policies clarified reporting responsibilities, strengthened the review and approval process, and established clearer expectations for documentation, supervisory review, and retention of records related to grant reporting. The revised fiscal policies also include a new Federal Financial Report (SF-425) Review & Approval Form, located in Appendix X of Standard 2 - Fiscal Policies and Procedures, to ensure consistent documentation of management review prior to submission. Since the personnel and fiscal management changes were implemented, SF-425 reports have been prepared and provided to the Executive Director in a timely manner prior to submission. The Executive Director reviews the reports, verifies the information as appropriate, and signs the reports to document management review and approval. This process provides clear evidence that financial reports are revi_ewed before submission and that appropriate oversight is occurring. The Alfred Saliba Family Services Center believes these corrective actions have addressed the condition noted in the finding. The organization will continue to monitor this process as part of its ongoing fiscal management framework to ensure sustained compliance, timely reporting, and proper documentation of management review. Anticipated Completion: Immediately Responsible Party: Jim Hartnett, Executive Director
Condition: The Corporation’s cash management policies were not in conformance with Uniform Guidance requirements. Although cash management transactions tested were performed in accordance with existing practices, the Corporation did not have a written cash management policy that met Uniform Guidance...
Condition: The Corporation’s cash management policies were not in conformance with Uniform Guidance requirements. Although cash management transactions tested were performed in accordance with existing practices, the Corporation did not have a written cash management policy that met Uniform Guidance requirements. Planned Corrective Action: The Corporation will implement and formally adopt written cash management policies and procedures that conform to Uniform Guidance requirements and should ensure those procedures are consistently followed and documented. Contact person responsible for corrective action: Michelle Toups and Brian Balutanski Anticipated Completion Date: 1/1/2027
Condition: The Corporation’s procurement and suspension/debarment policies and procedures were not in conformance with Uniform Guidance requirements. In addition, procurement records for the items tested did not contain sufficient documentation to support the procurement method used, the basis for c...
Condition: The Corporation’s procurement and suspension/debarment policies and procedures were not in conformance with Uniform Guidance requirements. In addition, procurement records for the items tested did not contain sufficient documentation to support the procurement method used, the basis for contract selection, or compliance with suspension and debarment requirements. Planned Corrective Action: The Corporation will update and formally adopt written procurement, suspension, and debarment policies and procedures to conform to Uniform Guidance requirements and should implement procedures to ensure those policies are consistently followed and documented for all federally funded procurements. Contact person responsible for corrective action: Michelle Toups and Brian Balutanski Anticipated Completion Date: 1/1/2027
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Huma...
HEC will implement the following actions to correct the error and prevent recurrence: 1. Repayment of Overclaimed Funds HEC will return the full amount of overclaimed funds to the respective grant programs: - $2,986.76 to SFA AR - $5,687.74 to SFA MS 2. Payroll System Controls Enhancement HEC’s Human Assets department will coordinate with its payroll processing vendor (UKG) to: - Review payroll configuration settings related to bonus payments. - Implement controls to ensure bonus compensation is excluded from grant-related labor distributions. 3. Monitoring and Oversight Reinforcement The VP of Government Grant Compliance will reinforce internal review procedures by: - Providing targeted guidance to the Investor Relations Grant Compliance and Fiscal teams on identifying anomalies in Wage and Hour Reports, including unusual or inflated hourly rates
• Management Response - SERCAP will improve lease accounting controls by: Creating and maintaining accurate model spreadsheet of centralized lease inventory for all operating and financing leases. Establishing written procedures requiring all lease agreements, amendments, renewals, and extensions to...
• Management Response - SERCAP will improve lease accounting controls by: Creating and maintaining accurate model spreadsheet of centralized lease inventory for all operating and financing leases. Establishing written procedures requiring all lease agreements, amendments, renewals, and extensions to be communicated to the Finance Department immediately upon execution. Performing an annual review of all lease agreements to determine whether modifications require remeasurement under ASC 842. Preparing documented lease calculations and reconciliations for supervisory review. Updating accounting policies and procedures related to lease accounting and providing additional staff training regarding ASC 842 requirements. In addition, setup a policy and procedure for the review and documentation review of all contracts for a potential embedded lease transaction. SERCAP has hired new staff for capacity and support. • Contact Person: • Contact Phone Number: • Expected Completion Date: Charles Denny, Jr. - Finance & Operations 540-345-1184 ext. 128 September 30, 2026
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognitio...
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognition Checklist for all new grant awards to identify conditional barriers, allowable costs, reporting requirements, and revenue recognition criteria. Maintain a centralized grant tracking schedule that identifies grant conditions, expenditures incurred, revenue recognized, refundable advances, and remaining deferred revenue. Perform monthly reconciliations between grant schedules and the general ledger. Implement a documented two-level review process whereby the preparer completes the reconciliation and a supervisory reviewer verifies the accuracy and completeness before month-end close. Provide additional training to finance and program management staff regarding ASC 958 revenue recognition requirements for conditional contributions. Update internal accounting procedures to document the review and approval process for recognizing grant revenue. These procedures will be incorporated into the monthly financial close process and monitored throughout FY2026. SERCAP has hired new staff for capacity and support • Contact Person: Charles Denny, Jr. - Finance & Operations • Contact Person: Beth Pusha - Loan Fund • Contact Phone Number: 540-345-1184 • Expected Completion Date: September 30, 2026
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requ...
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requirements under Uniform Guidance (2 CFR, Part 200.303) Planned Corrective Action: Road Commission is in the process of developing and implementing a written federal policies and procedure addressing the administration of federal awards to ensure compliance with Uniform Guidance (2 CFR, Part 200). The policy will address the following key compliance areas: allowable costs, cash management, procurement, and conflict of interest. The policy shall be reviewed and modified to included all the necessary items outlined in the Uniform Guidance. Contact Person responsible for corrective action: Destain Gingell, Managing Director / CHE, Kathleen Cunningham, Finance Director Anticipated Completion Date: July 30, 2026
Action Taken: The Management of the Authority agrees with the findings. We will implement improved internal controls to ensure that all annual recertifications are performed in a timely manner and that all required documents are kept in an organized manner. The Compliance Specialist will perform mon...
Action Taken: The Management of the Authority agrees with the findings. We will implement improved internal controls to ensure that all annual recertifications are performed in a timely manner and that all required documents are kept in an organized manner. The Compliance Specialist will perform monthly quality checks on the files and work with staff to eliminate errors. The HCV Director is the responsible party, and controls will be in place by the end of the September 30, 2026 fiscal year.
Action Taken: The Management of the Authority agrees with the findings. We will implement improved internal controls to ensure that all annual recertifications are performed in a timely manner and that all required documents are kept in an organized manner. The Compliance Specialist will perform mon...
Action Taken: The Management of the Authority agrees with the findings. We will implement improved internal controls to ensure that all annual recertifications are performed in a timely manner and that all required documents are kept in an organized manner. The Compliance Specialist will perform monthly quality checks on the files and work with staff to eliminate errors. The Director of Asset Management is the responsible party, and controls will be in place by the end of the September 30, 2026 fiscal year.
Condition: The Organization allocates personnel costs to federal programs based on wage forms that reflect estimated time expected to be worked across programs. Supervisors perform biweekly reviews of employee time charged within the Paylocity system and compare allocations to supporting information...
Condition: The Organization allocates personnel costs to federal programs based on wage forms that reflect estimated time expected to be worked across programs. Supervisors perform biweekly reviews of employee time charged within the Paylocity system and compare allocations to supporting information such as program schedules and caseloads. However, we noted that: - There is no formal documentation retained evidencing the supervisor's review of supporting records (e.g., caseloads, schedules) to substantiate that recorded time aligns with actual work performed; and - The only evidence of review is system approval within Paylocity, which indicates the timecard was approved but does not demonstrate the nature, extent, or basis of the review performed. Planned Corrective Action: Family Guidance Centers will require direct supervisors to document their review of supporting records (e.g., caseloads, schedules) of direct reports to substantiate that recorded time aligns with actual work performed as a part of their bi-weekly timesheet reviews. Family Guidance Centers will retain this documentation in accordance with its document retention policy. Contact person responsible for corrective action: Jim Hagestad, CFO Anticipated Completion Date: July 1, 2026
Condition: The Organization's SEFA for the year ended June 30, 2024 was not complete. Specifically, certain federal expenditures were omitted from the SEFA. Planned Corrective Action: In addition to current procedures, management will confirm with grantors directly when grant award agreements are si...
Condition: The Organization's SEFA for the year ended June 30, 2024 was not complete. Specifically, certain federal expenditures were omitted from the SEFA. Planned Corrective Action: In addition to current procedures, management will confirm with grantors directly when grant award agreements are silent on whether awards are sourced from federal funding and document the confirmations from grantors. Contact person responsible for corrective action: Jim Hagestad, CFO Anticipated Completion Date: July 1, 2026
The Clerk's Office will work to develop better standardized procedures and update current procedures to ensure that proper actions have been taken prior to and at the time of procurement. We anticipate having reviewed and/or developed these procedures by the end of the first quarter of the of FY26/2...
The Clerk's Office will work to develop better standardized procedures and update current procedures to ensure that proper actions have been taken prior to and at the time of procurement. We anticipate having reviewed and/or developed these procedures by the end of the first quarter of the of FY26/27.
Management acknowledges the finding. El Proyecto has implemented corrective actions, including tracking the FFR submission due dates separately from any closeout documentation submission due dates to help ensure both requirements are monitored and completed within the required timeframes. Person Res...
Management acknowledges the finding. El Proyecto has implemented corrective actions, including tracking the FFR submission due dates separately from any closeout documentation submission due dates to help ensure both requirements are monitored and completed within the required timeframes. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: June 1, 2026
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, t...
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, the following corrective actions are being implemented: 1. Revised Application and Documentation Requirements: o The Sliding Fee Program application forms are being updated to include structured sections for staff to record income from supporting documentation (e.g., pay stubs, tax returns), rather than relying on the patient to write their income on the application, which will greatly reduce incorrect income stated on support. Staff will be responsible for calculating annual gross income based on supporting documentation and have a checklist to ensure documentation is complete and retained/uploaded in the system. 2. Two-Step Review Process: o A staff member (the “Preparer) will calculate the annual gross income, determine the household size, and determine the eligible sliding fee discount, and a second staff member (the “Reviewer”) will independently review and verify the Preparer’s calculations and determinations based on the supporting documentation. Both parties will document their review of the application to establish accountability. 3. Staff Training and Ongoing Competency Checks: o Comprehensive refresher training will be provided to all staff involved in the sliding fee program process, including the use of the poverty guidelines, income calculation methods, the new forms, entering income and household size into the system, and uploading support to the system. 4. Formal Ongoing Monitoring and Review: o The Billing Department will conduct regular audits of completed sliding fee applications and eligibility determination forms to ensure compliance with policies. Errors will be tracked and addressed through corrective action and coaching. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: August 31, 2026
Views of Responsible Officials and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Moving to Work Demonstration Programs to ensure that established internal control policies are being follo...
Views of Responsible Officials and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Moving to Work Demonstration Programs to ensure that established internal control policies are being followed on a timely basis. Bart Cook, Executive Director, is responsible for implementing this corrective action by September 30, 2026.
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility f...
Recommendations: The Organization should implement stronger internal controls to ensure that reporting deadlines are effectively monitored and met. This may include: - Developing and maintaining a reporting calendar with clearly defined deadlines for financial reporting. - Assigning responsibility for tracking and ensuring timely submission of reports. Additionally, the Organization should conduct a root cause analysis to address any underlying issues and implement corrective actions to prevent future delays. Views of responsible officials and planned corrective actions: Management agrees with the finding and will implement processes to mitigate the risk of future late file reports. Anticipated Completion Date: June 2026
Management will provide documentation to the auditors in a timely manner in order to complete the audit prior to the deadline.
Management will provide documentation to the auditors in a timely manner in order to complete the audit prior to the deadline.
Management will provide documentation to the auditors in a timely manner in order to complete the audit prior to the deadline.
Management will provide documentation to the auditors in a timely manner in order to complete the audit prior to the deadline.
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
The auditor recommends that the Village ensure compliance with the 9 month requirements and have the audits and single audit reporting package submitted by the end of February each year.
The auditor recommends that the Village ensure compliance with the 9 month requirements and have the audits and single audit reporting package submitted by the end of February each year.
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
HCS currently has in place Policy 2095 – Procurement Standards, which requires obtaining three quotes for goods and services above $5,000. This policy was not followed by the agency’s leadership when the goods and services referenced in this finding were procured, despite counsel recommending that i...
HCS currently has in place Policy 2095 – Procurement Standards, which requires obtaining three quotes for goods and services above $5,000. This policy was not followed by the agency’s leadership when the goods and services referenced in this finding were procured, despite counsel recommending that it be followed. Corrective action taken during the prior year included termination of the individual who violated the policy. Beginning on 11/15/2024, the above-referenced policy has been, and will continue to be, adhered to. Because certain expenses related to the prior-year procurement activity trailed into the 2024–2025 fiscal year, the finding was repeated; however, no new violations of Policy 2095 occurred in 2024–2025. HCS will continue to monitor procurement activity and maintain full compliance with Policy 2095 going forward.
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