Corrective Action Plans

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The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...
The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.
Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, D...
Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, Director of Finance. Estimated Completion Date: May 15, 2025
Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Au...
Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Audits by location will be carried out by CBO staff and financial analysts, with results shared with administrators and CARs for accountability. Clinics showing minimal improvement will receive additional training. Two mandatory sliding fee scale training sessions will be schedules for all CARs, accounts receivable staff, and administrators. Persons Responsible: Steven Hansen, President & CEO; Peral Lujan, Central Billig Office Director Estimated Completion Date: December 31, 2025
Finding 572934 (2024-001)
Material Weakness 2024
FINDING 2024-001 Finding Subject: 20.205 Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Commissioner Ron Jarman, Auditor Tammy Justice Contact Phone Number and Email Address: 765.745.0013, rjarman@rushcounty.in.gov; 765.932.2077, auditor@rushcounty....
FINDING 2024-001 Finding Subject: 20.205 Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Commissioner Ron Jarman, Auditor Tammy Justice Contact Phone Number and Email Address: 765.745.0013, rjarman@rushcounty.in.gov; 765.932.2077, auditor@rushcounty.in.gov Views of Responsible Officials: Rush County concurs with the finding. Description of Corrective Action Plan: The Commissioners will create a Procurement, Suspension & Debarment Policy with all necessary requirements. Anticipated Completion Date: September 2025
2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporti...
2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporting Compliance Requirement. Corrective Action Plan The employee responsible for this negligence no longer works for the City. The City will endeavor to comply with all reporting requirements for our Federal Grants and monies received. Responsible Person for Corrective Action Plan Gregory Donovan, Director of Finance (SLFRF) Tenille Rose Martin, Grants Manager (SS4A) Elliot Liebson, Director of Planning (FEMA) Gary Bainter, Asst. Fire Chief (FEMA) Implementation Date of Corrective Action Plan January 1, 2025
Finding 572658 (2024-003)
Material Weakness 2024
Finding 2024-003 – Subrecipient Monitoring Corrective Action Planned In 2024, management finalized revisions to the reports used to complete subrecipient risk assessments. Corrective actions have been implemented as of January 1, 2025 and the reports and process are functioning as intended and asses...
Finding 2024-003 – Subrecipient Monitoring Corrective Action Planned In 2024, management finalized revisions to the reports used to complete subrecipient risk assessments. Corrective actions have been implemented as of January 1, 2025 and the reports and process are functioning as intended and assessments are current. Control processes for subrecipients monitoring checklists have been modified to ensure complete and timely documentation is retained. Persons Responsible for Corrective Action Susan Norby, Division Chair - Research Finance Completion Date January 1, 2025
Finding 572657 (2024-002)
Significant Deficiency 2024
Finding 2024-002 – Cash Management Corrective Action Planned In 2024, management finalized revisions to the reports used to monitor subrecipient payments. Corrective actions have been implemented as of March 31, 2025 and the reports and monitoring process are functioning as intended and all reviews ...
Finding 2024-002 – Cash Management Corrective Action Planned In 2024, management finalized revisions to the reports used to monitor subrecipient payments. Corrective actions have been implemented as of March 31, 2025 and the reports and monitoring process are functioning as intended and all reviews are current. Persons Responsible for Corrective Action Susan Norby, Division Chair - Research Finance Completion Date March 31, 2025
The Housing Authority takes the recommendation from the audit regarding CFP. All CFPs after 2021 have been designated 25% to operating. CFP 21 was changed with permission from the Portfolio Manager at the time and the annual plan included this money to go to operating. All future designations in ...
The Housing Authority takes the recommendation from the audit regarding CFP. All CFPs after 2021 have been designated 25% to operating. CFP 21 was changed with permission from the Portfolio Manager at the time and the annual plan included this money to go to operating. All future designations in EPIC will show the amount to go to operating. However, the HA is not currently able to access CFP 21 in EPIC to edit it – it is locked.
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Mercy Apartments agrees with the audito...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Mercy Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
Finding Number: 2024-001 Planned Corrective Action: I will work with ODEW to make sure that the school bus partially purchased with federal grant funds is tracked and reported appropriately. Anticipated Completion Date: 09/01/2025 Responsible Contact Person: Lowell Bailey, Treasurer, Wellington...
Finding Number: 2024-001 Planned Corrective Action: I will work with ODEW to make sure that the school bus partially purchased with federal grant funds is tracked and reported appropriately. Anticipated Completion Date: 09/01/2025 Responsible Contact Person: Lowell Bailey, Treasurer, Wellington Exempted Village Schools
The selection checklist will be performed by the selection team, and the resulting scorecards will be forwarded to the Contracts Department and retained in their files. This step has been added to the Procurement Checklist to ensure there is confirmation by someone outside of the selection team that...
The selection checklist will be performed by the selection team, and the resulting scorecards will be forwarded to the Contracts Department and retained in their files. This step has been added to the Procurement Checklist to ensure there is confirmation by someone outside of the selection team that the proper scoring has been documented. Contracts requiring a scorecard will not be compiled without this documentation.
Finding 572650 (2024-003)
Significant Deficiency 2024
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.
Written procedures and conflict of interest policies in accordance with the Uniform Guidance will be established and implemented during the year ended June 30, 2026.
Written procedures and conflict of interest policies in accordance with the Uniform Guidance will be established and implemented during the year ended June 30, 2026.
Finding 572646 (2024-001)
Significant Deficiency 2024
The Organization will submit the current year audit reporting package and data collection forms as soon as the audits are complete and available. The Organization is reviewing its procedures to file and submit audits timely beginning in the fiscal year ending June 30, 2025.
The Organization will submit the current year audit reporting package and data collection forms as soon as the audits are complete and available. The Organization is reviewing its procedures to file and submit audits timely beginning in the fiscal year ending June 30, 2025.
Finding Number: 2024-002 Recommendation: Inform subrecipients of the required federal award info outlined in § 200.332 Requirements for pass-through entities. Action Taken: 1. AANA has posted on its MAST website and application that: “The MAST program is funded by the United States Federal Governmen...
Finding Number: 2024-002 Recommendation: Inform subrecipients of the required federal award info outlined in § 200.332 Requirements for pass-through entities. Action Taken: 1. AANA has posted on its MAST website and application that: “The MAST program is funded by the United States Federal Government and is subject to all applicable federal statutes, regulations, and requirements. The receiving entity is not debarred, suspended, or otherwise excluded from using federal funds.” 2. AANA will include the following as a footnote on any MAST manuscripts and printed text: “Supported by a grant administered by The Arthroscopy Association of North America (AANA), with funding provided by the Military Advanced Surgical Treatment (MAST) Program.” 3. Request and/or ensure the following information through the contracting process with any MAST Subrecipient: a. Subrecipient's name (must match the name associated with its unique entity identifier) b. Subrecipient's unique entity identifier c. Subaward Period of Performance Start and End Date d. Subaward Budget Period Start and End Date e. Amount of Federal Funds Obligated in the subaward f. Total Amount of Federal Funds Obligated to the subrecipient by the pass-through entity, including the current financial obligation g. Total Amount of the Federal Award committed to the subrecipient by the pass-through entity h. Federal award project description, as required by the Federal Funding Accountability and Transparency Act (FFATA) i. Identification of whether the Federal award is for research and development j. Indirect cost rate for the Federal award (including if the de minimis rate is used in accordance with § 200.414) i. An approved indirect cost rate negotiated between the subrecipient and the Federal Government. If no approved rate exists, a pass-through entity must determine the appropriate rate in collaboration with the subrecipient. The indirect cost rate may be either: 1. An indirect cost rate negotiated between the pass-through entity and the subrecipient. These rates may be based on a prior negotiated rate between a different pass-through entity and the subrecipient, in which case the passthrough entity is not required to collect information justifying the rate but may elect to do so; or 2. The de minimis indirect cost rate. k. A requirement that the subrecipient permit the pass-through entity and auditors to access the subrecipient's records and financial statements for the pass-through entity to fulfill its monitoring requirements l. Verify that a subrecipient is audited as required Responsible Contact Person for Planned Corrective Action: Dennis Siena Anticipated Completion Date: September 30, 2025
Finding Number: 2024-001 Recommendation: Create a procurement policy that meets the requirements detailed in 2 CFR 200.318– 200.327 Action Taken: AANA will implement a new Procurement Policy as it relates to purchases and grants supported by the MAST program. See document “MAST Procurement Policy” R...
Finding Number: 2024-001 Recommendation: Create a procurement policy that meets the requirements detailed in 2 CFR 200.318– 200.327 Action Taken: AANA will implement a new Procurement Policy as it relates to purchases and grants supported by the MAST program. See document “MAST Procurement Policy” Responsible Contact Person for Planned Corrective Action: Dennis Siena Anticipated Completion Date: September 30, 2025
Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Office...
Action Taken: Management agrees with the finding noted above. Management will also note that as a repeated finding we do not so much offer a corrective action plan as we do a summarization of steps already taken to close this finding for fiscal 2025. A new and highly qualified Chief Financial Officer with over 30 years of public housing experience was hired by the agency in April of 2024. The CFO has fully staffed the department with competent and qualified individuals including a new and fully qualified Controller and Director of Finance. All individuals hired have received targeted training from both internal and external sources. In June 2024 the new financial management team implemented a policy/procedure for the records requirement and payment timeframes for all capital fund draw downs. This policy requires the hand signing of eLOCCS forms and reconciliation of individual draws at the time of drawdown. During fiscal 2025 the entire Finance staff was trained extensively on all matters related to HUD accounting. Specific training was directed to the Capital Fund program, its eligibility standards, accounting processes, and drawdown procedures. This training was conducted by a nationally recognized HUD-specific trainer. The Authority has hired a qualified, experienced internal auditor. The internal auditor has completed a 100% testing sample on capital fund draws made in fiscal 2025. His observations were rectified, and the policy revised where needed. The sampling assured that supporting documentation was sufficient for audit, that it matched the amounts drawn, and that invoices were paid within HUD dictate s timeframes. Management feels that with this policy and enhanced testing in place the finding will not be repeated in 2025. Management expects closure of this finding, under the direction of the Chief Financial Officer, for the Fiscal 2025 audit.
View Audit 363741 Questioned Costs: $1
Action Taken: Management agrees with the finding noted above. It is the stated practice of the management of the Housing Authority of the City of Tampa to comply with all rules and regulations regarding its programs. Management feels this condition is more the result of errors than process. It is ma...
Action Taken: Management agrees with the finding noted above. It is the stated practice of the management of the Housing Authority of the City of Tampa to comply with all rules and regulations regarding its programs. Management feels this condition is more the result of errors than process. It is management's feeling that this resulted from staffing turnover, available administration funding and the sheer volume of files processed annually. There is a highly refined review and quality control process in place which will be re-evaluated and changed as needed. Staff, under the direction of the Director of Assisted Housing, remains dedicated to processing files as accurately is possible. We are hopeful to close this finding in the next fiscal audit. If the Department of Housing and Urban Development has questions regarding this plan, please contact Jerome Ryans, President/CEO at (813) 3419101 .
Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the d...
Finding 2024-03 - Significant Deficiency in Internal Control over Compliance with Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the single audit not being completed and submitted to the Federal Audit Clearinghouse be the due date. As of the audit report date, the Council has engaged an outside accounting firm to provide financial oversight. Action: Develop procedures to ensure required single audits are completed and submitted to the Federal Audit Clearinghouse by the 9-month due date. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director Carrie Castillo, Executive Director, is the official responsible for implementing each corrective action plan.
Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being up...
Finding 2024-02 – Material Weakness in Internal Control over Compliance with Allowable Costs and Reporting Management agrees that due to turnover in staff during 2023 and 2024, there were gaps in communication leading to the cost allocation formulas and leadsheet account reconciliations not being updated on a continuing basis as reimbursement requests were being to the California Department of Social Services. Management believes that all key accounting positions have since been filled by qualified personnel. A formal close process and reconciliation of all balance sheet accounts and indirect cost allocations each month will ensure reimbursement requests are complete and accurate. Process documentation is also being prepared to help personnel in the accounting department follow proper control procedures. Action: Develop and document process for drawdown calculation and year end reconciliation to accounting records. Due Date: 10/1/25 Staff: Carrie Castillo, Executive Director
Finding Type: Internal Controls over Federal Programs. Name of Contact Person: Mr. Robert Knodell, City Manager, (573) 686-8620. Recommendation: We recommend that the City check the Excluded Parties List System or collect certification from the entity for any vendor in which the City expects to...
Finding Type: Internal Controls over Federal Programs. Name of Contact Person: Mr. Robert Knodell, City Manager, (573) 686-8620. Recommendation: We recommend that the City check the Excluded Parties List System or collect certification from the entity for any vendor in which the City expects to spend more than $25,000 of federal grant funds for the year. Corrective Action: We will ensure we comply going forward. Proposed Completion Date: Immediately.
Contact Person Dara A. Lee, Executive Director Corrective Action Plan The Authority will review is policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately.
Contact Person Dara A. Lee, Executive Director Corrective Action Plan The Authority will review is policies and procedures over program compliance requirements and continue to provide occupancy training to staff to prevent future exceptions. Planned Completion Date for CAP Immediately.
The Management of the Authority agrees with the finding; We are in the process of implementing strengthened internal controls to ensure that all annual recertitications · include the required eligibility documentation an.d t hat all records are maintained in an organized and auditable format. For t...
The Management of the Authority agrees with the finding; We are in the process of implementing strengthened internal controls to ensure that all annual recertitications · include the required eligibility documentation an.d t hat all records are maintained in an organized and auditable format. For the MTW SB Program, Jackie Rojas, Section 8 Director, is responsible for compliance. She is currently finalizing the implementation of the Rent Cafe module within our Yardi property management sottware systern. This module automates and tracks key steps in the recertification process and includes built-in internal controls to improve compliance with eligibility requirements. She will also conduct an internal audit of all current client files for completion. For the Public Housing Program, Tasha Nelson, Deputy Director of Property Management, is responsible for compliance. She has implemented updated training and standard operating procedures (SOPs) to ensure consistent execution of eligibility determinations and file documentation. New internal controls will be implemented by the end of the fiscal year ending December 31, 2025. If the Department of Housing and Urban Development has questions regarding this plan, please contact Kim Wilford, Deputy Executive Director at (801) 428-0541.
View of Responsible Official (This was implemented at the end of the 22/23 Audit, however, that audit was completed after the beginning of the next fiscal year. Therefore, the timing overlapped, and the changes implemented were not yet evident at the beginning of the new fiscal year.) Currently, bas...
View of Responsible Official (This was implemented at the end of the 22/23 Audit, however, that audit was completed after the beginning of the next fiscal year. Therefore, the timing overlapped, and the changes implemented were not yet evident at the beginning of the new fiscal year.) Currently, based on the capacity of the Organization’s staffing pool, the most efficient and effective means of review and reconciliation of cash disbursements and payroll is the Organization’s Board Chair and CEO reviewing the cash disbursements and payroll every two weeks, prior to payments being made. The Organization’s Director of Operations forwards the Board Chair and CEO a listing of cash disbursements and payroll due with the suggested payments. The Board Chair and CEO each will ask questions and formally “approve” or “disapprove” each transaction, prior to any disbursements. Once reviewed, the CEO will return the reviewed materials to the Director of Operations with the amounts to pay. Also, the Organization’s outsourced accountant will review and approve each monthly bank reconciliation and bank statement for all Organizational accounts, as well as the monthly credit card statements. The outsourced accountant does not have the ability to access the monthly bank statements or make purchases.
View of Responsible Official The CEO has implemented a policy that all signed documents and contracts will be uniformly kept in a corresponding file, and the files will be stored in a locked filing cabinet at the corporate office. The Director of Operations will be responsible to ensure that the doc...
View of Responsible Official The CEO has implemented a policy that all signed documents and contracts will be uniformly kept in a corresponding file, and the files will be stored in a locked filing cabinet at the corporate office. The Director of Operations will be responsible to ensure that the documents and contracts are filed in a timely fashion.
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