Corrective Action Plans

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Effective immediately, the required timeframe for contractors and consultants to submit trip reports to WISHH has been reduced from 30 days to 15 days following completion of travel. This revised requirement has been incorporated into ASA/WISHH contracting documents and provides additional time for ...
Effective immediately, the required timeframe for contractors and consultants to submit trip reports to WISHH has been reduced from 30 days to 15 days following completion of travel. This revised requirement has been incorporated into ASA/WISHH contracting documents and provides additional time for internal review and processing before the federal 45-day reporting deadline. The shortened submission timeline will significantly enhance our ability to monitor reporting requirements and ensure timely submission of all trip reports.
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting schedules Reconciliation • Perform quarterly true-ups between budget and actual Training • Train staff on allocation methodology and documentation Monitoring • Conduct periodic reviews and report results to management
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in Paylocity reflecting actual time worked Integration with Payroll Allocation • Ensure payroll allocations are based on actual time and effort • Perform monthly Finance review of payroll allocations Policy Updates • Update payroll and cost allocation policies to align with Uniform Guidance (§200.430) Training • Provide training to staff and annual refresher courses Monitoring and Oversight • Perform quarterly reviews and report to Audit and Finance Committees
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitorin...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitoring • Perform quarterly compliance reviews
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Implementation of Time and Effort Reporting • Establish a formal time and effort reporting system for all personnel charged to programs • Require bi-weekly certified timesheets in Paylocity reflecting actual time worked Integration with Payroll Allocation • Ensure payroll allocations are based on actual time and effort • Perform monthly Finance review of payroll allocations Policy Updates • Update payroll and cost allocation policies to align with Uniform Guidance (§200.430) Training • Provide training to staff and annual refresher courses Monitoring and Oversight • Perform quarterly reviews and report to Audit and Finance Committees
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we wil...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we will perform a detailed review of all salaries charged to federal grants to ensure there is no salary over the cap. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules and/or enhance monitoring controls where possible. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-001 AL Numbers: Various assistance listing numbers Program: Research and Development Cluster Correction Action: Brown Health management concurs with this finding. Based on the review, the underlying procurement procedures were general...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-001 AL Numbers: Various assistance listing numbers Program: Research and Development Cluster Correction Action: Brown Health management concurs with this finding. Based on the review, the underlying procurement procedures were generally performed in accordance with established policy; however, supporting documentation was not consistently retained to evidence compliance. We have already initiated re-training at the department level and will be performing a detailed review of current purchase history to ensure appropriate documentation is retained. For fiscal year 2026, we will be reviewing all federal grant activity to ensure the appropriate documentation is maintained and/or sole source documentation is prepared including a lookback analysis of expenditures to date that did not retain the proper documentation. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules in advance of spend. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
The Organization reviewed its current process and determined that procedures can be implemented when unforeseen circumstances arise to ensure the single audit reporting package is submitted by the 9 month deadline. The Organization has implemented new procedures which will ensure the reporting packa...
The Organization reviewed its current process and determined that procedures can be implemented when unforeseen circumstances arise to ensure the single audit reporting package is submitted by the 9 month deadline. The Organization has implemented new procedures which will ensure the reporting package is filed by the nine month deadline, when unforeseen circumstances arise, which include if the CEO or COO are both unable to file the reporting package by the 9 month deadline, another member of the leadership team will be responsible for making sure the reporting package is filed in a timely manner. The corrective action has been implemented as of June 29, 2026.
Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has reviewed their procedures for performing and documenting follow up of HQS inspections to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2026
Contact Person Emajean Hanson-Ford, Executive Director Corrective Action Plan The Authority has reviewed their procedures for performing and documenting follow up of HQS inspections to ensure compliance moving forward. Planned Completion Date for CAP December 31, 2026
2025-001 Special Test & Provisions – Contract Rent Adjustment Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time.. Proposed Completion Date: April 9, 2026 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs T...
2025-001 Special Test & Provisions – Contract Rent Adjustment Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time.. Proposed Completion Date: April 9, 2026 Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Telephone Number: (340) 772-4099 ext. 106
Corrective Action: Currently, we are reviewing scheduling priorities to be able to meeting HUD timeline. Proposed Completion Date: December 27, 2024
Corrective Action: Currently, we are reviewing scheduling priorities to be able to meeting HUD timeline. Proposed Completion Date: December 27, 2024
Name of Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time. Proposed Completion Date: April 9, 2026
Name of Contact Person: Dasil Thomas-Williams, Director of Financial Affairs Corrective Action: Currently, we are reviewing scheduling priorities to be able to submit the budget within the mandated time. Proposed Completion Date: April 9, 2026
Finding 2025-001 - Procurement Policy Contact Person Responsible for Corrective Action: Gregory F. Sherman, General Manager Houlton Water Company Corrective Action To address Finding 2025-001 regardingthe absence of a formal Procurement Policy, the Houlton Water Company will implement the following ...
Finding 2025-001 - Procurement Policy Contact Person Responsible for Corrective Action: Gregory F. Sherman, General Manager Houlton Water Company Corrective Action To address Finding 2025-001 regardingthe absence of a formal Procurement Policy, the Houlton Water Company will implement the following corrective measures: Houlton Water Company is actively developing a comprehensive Procurement Policy to remedy the deficiency identified in the audit. Management is currently drafting the policy, ensuring it aligns with applicable regulatory requirements, industry standards, and internal operational needs. Upon completion of the internal draft, the policy will be presented to the HWC Board of Directors at the May 19, 2026 Board Meeting for review and preliminary approvaL. Should the Board request revisions, management will incorporate the necessary changes and resubmit the updated policy for final approval at the June 16, 2026 Board Meeting. Anticipated Completion Date: June 17, 2026
Effective immediately, the Executive Director will conduct a mid-year review each June to confirm that the first required subrecipient monitoring has been completed, and ensuring the second monitoring is scheduled and completed prior to fiscal year-end.
Effective immediately, the Executive Director will conduct a mid-year review each June to confirm that the first required subrecipient monitoring has been completed, and ensuring the second monitoring is scheduled and completed prior to fiscal year-end.
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and proce...
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and procedures in place for timely reimbursement requests will ensure that the County is receiving funds it is owed. In addition, this will ensure there are no cash flow shortages and increase opportunities for investment earnings. Cause: The County had one highway project for which costs were incurred in October and November 2024, and the related reimbursement was submitted and approved in June 2025. Possible Effect: By submitting untimely reimbursement requests, the County is not receiving funds it is owed in a timely manner, which has the potential to cause cash flow shortages. Repeat Finding: No. Recommendation: We recommend County management review internal controls currently in place and design and implement procedures to request reimbursements in a timelier fashion and to submit requests for reimbursements on at least a quarterly basis. Views of Responsible Officials: There is no disagreement with the audit finding. The County will implement procedures to ensure timely submission of reimbursement requests. Anticipated Completion Date: December 31, 2026.
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: ...
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: We intend to include a section in all future agreements with the town to confirm that contractors/vendors acknowledge their suspension and debarment status. These agreements and contracts will be signed and approved by multiple Town officials. Anticipated Completion Date: This adjustment to agreements and contracts will go into effect April 24, 2026.
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with ...
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: Prior to the submission of the P&E report, a copy will be printed and reviewed by another individual from our office (Town Manager or Utility Office Manager), or a member of our Town Council and that individual will initial or sign off on the document after their review. Anticipated Completion Date: This procedure will go into effect on June 1, 2026.
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: Testing of the federal program identified: • The Entity’s formally documented pro...
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: Testing of the federal program identified: • The Entity’s formally documented procurement policy was missing the required elements detailed under Uniform Guidance. • Four instances where the Entity did not follow the procurement process and did not have any formal documentation in place with vendors. • Four instances where the Entity entered into a contract with a vendor over $25,000 and there was no review performed to ensure the vendor was not suspended or debarred. Responsible Individuals: Sara Morris, Chief Financial Officer and Jay Watkins, Sr. Vice President of Broadband Services Corrective Action Plan: Management will update their procurement policy to ensure it includes all required elements in accordance with Uniform Guidance. In addition, management will implement procedures and control processes related to the review of procurement to ensure the procurement methods are being followed and documentation isretained to support compliance. Management will also ensure vendors are not suspended or debarred from doing business with the federal government prior to entering into a procurement transaction. Anticipated Completion Date: October 2026
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: The Entity does not have an internal control system designed to provide for a com...
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: The Entity does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards (the schedule) being audited. We requested our auditors to assist with the preparation of the schedule and accompanying notes to the schedule . Responsible Individuals: Sara Morris, Chief Financial Officer and Jay Watkins, Sr. Vice President of Broadband Services Corrective Action Plan: It is not cost effective to have an internal control system designed to prepare the schedule of expenditures of federal awards. We requested that our auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. We have designated a member of management to review the drafted schedule of expenditures of federal awards, and we have reviewed with and agree with the final Schedule of Expenditures of Federal Awards. Anticipated Completion Date: Ongoing
Finding Reference Number: 2025-04 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Organization acknowledges the importance of preparing a complete and accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with Uniform Guidance requirements. ...
Finding Reference Number: 2025-04 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Organization acknowledges the importance of preparing a complete and accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with Uniform Guidance requirements. Management will strengthen internal controls over the identification, tracking, reconciliation, review, and reporting of federal awards to ensure all federal expenditures are properly captured and rep01ted in future periods. 1. Develop and implement a fom1al year-end SEFA preparation checklist that identifies all required information, including federal agency, pass-through entity, Assistance Listing Number, program name, award amount, expenditures, and any amounts passed through to subrecipients 2. Review all revenue sources, grant agreements, reimbursement activity, and general ledger accounts at least quarterly lo identify any federal awards that must be included on the SEFA. 3. Perform a documented reconciliation of SEFA expenditures to the general ledger and supporting grant records before the SEFA is submitted for audit. 4. The SEFA will be prepared by the third party outside accountant and reviewed by the Finance Director to ensure that all federal awards are accurately reported. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures for the specific grants will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. l. The Organization will update and maintain a fom1al policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. 1. The Organization will update and maintain a formal policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
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