Corrective Action Plans

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Management should immediately deposit the cumulative shortfall into the Reserve for Replacements account and implement strict cash management reviews to ensure monthly compliance. The issue was administrative rather than financial, and the Project is planning to make extra payments to fully fund the...
Management should immediately deposit the cumulative shortfall into the Reserve for Replacements account and implement strict cash management reviews to ensure monthly compliance. The issue was administrative rather than financial, and the Project is planning to make extra payments to fully fund the replacement reserve balance.
Management concurs with the finding and acknowledges that additional controls are necessary to ensure full compliance with Federal procurement requirements. During fiscal year 2026, the Organization revised procurement procedures and conducted training sessions for finance personnel and departmental...
Management concurs with the finding and acknowledges that additional controls are necessary to ensure full compliance with Federal procurement requirements. During fiscal year 2026, the Organization revised procurement procedures and conducted training sessions for finance personnel and departmental stakeholders responsible for purchasing activities. Management plans to continue quarterly compliance reviews of procurement transactions and enhance monitoring procedures related to bid documentation and suspension and debarment verification. Oversight responsibility has been assigned to the Vice President of Finance and Director of Finance.
- Management concurs with the finding and has continued implementing corrective actions to strengthen financial reporting processes and internal controls. The Organization hired a Vice President of Finance and Director of Finance to provide enhanced leadership, accountability, and technical oversigh...
- Management concurs with the finding and has continued implementing corrective actions to strengthen financial reporting processes and internal controls. The Organization hired a Vice President of Finance and Director of Finance to provide enhanced leadership, accountability, and technical oversight of the finance function. Management implemented revised monthly closing procedures, including formalized month-end checklists, assigned account ownership responsibilities, enhanced reconciliation requirements, and quarterly monitoring procedures. In addition, the Organization engaged an external CPA firm to assist with strengthening month-end and year-end closing processes, improving reconciliation procedures, enhancing review protocols, and standardizing supporting documentation practices. Management continues to focus on improving controls over receivables, payables, inventory, grant accounting, and overall financial reporting processes to support ongoing compliance with GAAP requirements. Oversight of these corrective actions remains the responsibility of the Vice President of Finance and Director of Finance.
Untimely Submission of Federal Financial Report (SF-425) Report Consolidated Health Center Cluster ALN # - 93.224 and 93.527 A Federal Financial Report (SF-425) report related to the Health Center Program Cluster was submitted after the applicable reporting deadlines. The finding was classified as a...
Untimely Submission of Federal Financial Report (SF-425) Report Consolidated Health Center Cluster ALN # - 93.224 and 93.527 A Federal Financial Report (SF-425) report related to the Health Center Program Cluster was submitted after the applicable reporting deadlines. The finding was classified as a significant deficiency in internal control over compliance. No questioned costs were reported. Management Response Management agrees with the finding and recognizes the importance of timely preparation, review, and submission of all reports required under federal awards. Corrective Action The Center will strengthen its controls over federal reporting by implementing the following procedures: • Maintain a centralized federal compliance calendar identifying each required report, the applicable award, reporting period, due date, responsible preparer, and reviewer. • Assign primary and backup responsibility for preparing and submitting each SF-425 report. • Establish internal preparation and review deadlines sufficiently in advance of the federal due date. • Require documented supervisory review and approval before submission. • Maintain evidence of submission, including confirmation receipts, in a centralized grant compliance file. • Perform periodic management monitoring of upcoming and completed reporting requirements and promptly investigate missed or approaching deadlines. Implementation and Monitoring The responsible official will review the compliance calendar at least monthly and will follow up with report preparers and reviewers regarding approaching deadlines. Completion of the review and evidence of timely submission will be documented and retained with the applicable grant records. Management will evaluate the effectiveness of these procedures after each reporting cycle and will revise the process as necessary. Status of Corrective Action Corrective action has been implemented as of the date of this report.
Sliding Fee Discount Program Eligibility and Application Auditor reference: Schedule of Findings and Questioned Costs, page 39 Finding addressed: In a nonstatistical sample of 25 encounters, two patients received sliding-fee adjustments that did not align with the approved discount category based on...
Sliding Fee Discount Program Eligibility and Application Auditor reference: Schedule of Findings and Questioned Costs, page 39 Finding addressed: In a nonstatistical sample of 25 encounters, two patients received sliding-fee adjustments that did not align with the approved discount category based on their documented household income and family size. The auditor reported no questioned costs related to this finding. Planned corrective action 1. Correct the identified exceptions. By November 2026, designated staff under the CFO’s oversight will review the two cited encounters against the board-approved sliding-fee policy and the discount schedule in effect on each service date, verify supporting records of household income and family size, and document the correct category and required account adjustments. Any patient credit or refund identified as due will be processed in accordance with approved billing and collections procedures. 2. Assess extent and system configuration. By December 2026, Finance will conduct a targeted retrospective review of at least 50 additional sliding-fee encounters across applicable service lines, locations, and discount categories. The review will compare documented income and family size with the assigned discount. EHR and billing-system discount tables, effective dates, and any manual override permissions will be checked against the board-approved schedules. Errors will be corrected, and the review will be expanded if a broader issue is identified. 3. Standardize eligibility verification. By December 2026, NHHC will issue a written step-by-step workflow that requires documentation of income, family size, eligibility determination, and application of the correct sliding fee tier before the adjustment is finalized. Manual adjustments or overrides will require a documented reason and supervisory authorization, with an audit trail retained. 4. Provide competency-based training. By January 2027, relevant front-desk, eligibility, registration, and billing personnel will be trained on the approved Sliding Fee Discount Program policy and on the use of the applicable schedule. Completion records and a brief competency validation will be retained. Any policy revisions will be submitted to the governing board for approval before implementation. 5. Monitor sustained adherence. During January and February 2027, Finance will review at least 25 newly processed sliding-fee encounters per month. Results will be reported to the CFO and CEO, with a goal of 100% agreement between documented eligibility and applied discounts. Any discrepancy will be promptly remediated, including additional staff coaching and further sampling until the control is operating effectively. Responsible contacts: Jason Wallace, Chief Executive Officer; Monica Lerma, Chief Financial Officer Anticipated completion: February 2027 Evidence of correction: Two-case correction log and account documentation; retrospective sampling results; approved policy and schedule; validated EHR/billing discount mapping; updated workflow; training and competency records; monthly quality-control samples; and documented supervisory follow-up.
Finding 2026-002 Federal Grant Cash Management and Federal Financial Reporting Auditor reference: Schedule of Findings and Questioned Costs, page 38 Finding addressed: One federal grant cash draw was partially disbursed before related disbursements, resulting in $180,641 in questioned costs. The aud...
Finding 2026-002 Federal Grant Cash Management and Federal Financial Reporting Auditor reference: Schedule of Findings and Questioned Costs, page 38 Finding addressed: One federal grant cash draw was partially disbursed before related disbursements, resulting in $180,641 in questioned costs. The audit also identified an inaccurate Annual Federal Financial Report for the H8N award ending August 31, 2025. Planned corrective action 1. Reconstruct and reconcile the transactions. By November 2026, the CFO will complete a transaction-level reconciliation of the $180,641 identified by the auditor and review the relevant draws for the H80 and H8N awards cited. The review will tie draw requests to the general ledger, bank activity, payment dates, grant budgets, supporting invoices or payroll, periods of performance, and submitted Federal Financial Reports. 2. Resolve questioned costs and reporting discrepancies. By December 2026, management will determine, based on source documentation and applicable award requirements, the amount, if any, that requires correction; communicate the results to the appropriate HRSA grants management and payment-system contacts; and obtain direction on any required return of funds, adjustment, or corrected reporting. NHHC will implement required remedies and retain correspondence, approvals, and transaction evidence. The $180,641 will remain an open questioned-cost matter until resolved through the applicable agency process. 3. Establish pre-draw controls. By December 2026, the CFO will revise and implement written cash-management procedures that require a grant-specific drawdown worksheet for each request. The worksheet will document eligible expenditures already disbursed or actual immediate cash requirements, planned payment dates, budget and award-period eligibility, available cash, and the requested amount. A designated Finance preparer will document the calculation, and the CFO will approve each draw before submission; exceptions will be escalated to the CEO. 4. Strengthen Federal Financial Report controls. By January 2027, Finance will implement an FFR preparation and review checklist that requires reconciling award-specific financial records with reported expenditures, disbursements, unliquidated obligations (where applicable), and reporting-period dates. The CFO will independently review and approve each FFR before submission. In coordination with HRSA and the payment-system administrator, Finance will address the identified H8N reporting error through the permitted correction process. 5. Test and monitor compliance. By March 2027, the CFO will document a review of all grant draw requests submitted during the first three months of the revised process and of any FFRs submitted during that period. The review will verify completed pre-draw support, approvals, cash timing, and report reconciliation. Exceptions will be investigated, corrected, and tracked to closure, with a summary provided to the CEO. Responsible contacts: Jason Wallace, Chief Executive Officer; Monica Lerma, Chief Financial Officer Anticipated completion: March 2027 Evidence of correction: Transaction-level draw reconciliation and questioned-cost analysis; HRSA and payment-system correspondence; written cash-management and FFR procedures; approved draw worksheets; FFR support and approval checklists; bank and expenditure records; and post-implementation testing reports. Agency-dependent resolution: NHHC’s completion target excludes agency-controlled determinations of questioned costs and acceptance of corrected federal reporting.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has recognized and acknowledges the deficiency in internal controls in regards to the determination, recording, and monitoring of the sliding fee discount process. Along with the safeguards that have been implemented previously, we are implementing a process that includes: - verification, during front desk eligibility check that slide information is complete; - if patient qualifies for the slide, note in billing notes, effective dates, slide category, and fee to be collected; - identify patients that are checking in that day and double check slide category and fee to collect; - if there is a discrepancy with any documentation, reach out to slide coordinator.
Management concurs with the finding. The tenant security deposit account deficiency was corrected on August 5, 2026, and the account was restored to the required balance. Management will ensure that tenant security deposit funds remain segregated and that the account balance is maintained at or abov...
Management concurs with the finding. The tenant security deposit account deficiency was corrected on August 5, 2026, and the account was restored to the required balance. Management will ensure that tenant security deposit funds remain segregated and that the account balance is maintained at or above the related tenant security deposit liability going forward.
Finding 2026-002: Significant Deficiency – Enrollment Reporting Program: Student Financial Assistance Cluster – Federal Direct Loans and Pell Grants Assistance Listing Number (ALN): Various Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federal Award Year: ...
Finding 2026-002: Significant Deficiency – Enrollment Reporting Program: Student Financial Assistance Cluster – Federal Direct Loans and Pell Grants Assistance Listing Number (ALN): Various Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federal Award Year: June 30, 2026 Condition: For one of 25 students who were tested, the student’s withdrawal status was reported to NSLDS late, 71 days after the date of determination. For one of 25 students who were tested, the student’s graduation date was reported incorrectly to NSLDS. The College’s controls over enrollment reporting did not detect the errors. The sample was not a statistically valid sample. Corrective Action Plan Management agrees with the finding and is committed to strengthening its procedures to avoid similar issues in the future. Beginning in September 2026, a second and new Registrar’s Office staff member will be trained in to complete an additional review of the National Student Clearinghouse status for all students withdrawing after a particular semester. This secondary review will be completed at the end of January and at the end of June to ensure the 60-day reporting period is met. We will manually update the graduated enrollment status start date for the impacted student to the correct date through the National Student Clearinghouse. We will reach out to the National Student Clearinghouse to determine why the graduation date that was reported on the degree file does not match the date that was used when the student’s enrollment record was updated by the Clearinghouse using the graduated enrollment status from the degree verified process. Completion Date: November 1, 2026 Name(s) of Contact Person(s) Responsible for Corrective Action: Nathan Engle, Controller Email: Engle1@stolaf.com
Finding 2026-001: Significant Deficiency – Return of Title IV Funds Program: Student Financial Assistance Cluster – Federal Direct Loans and Pell Grants Assistance Listing Number (ALN): 84.268 and 84.063 Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federa...
Finding 2026-001: Significant Deficiency – Return of Title IV Funds Program: Student Financial Assistance Cluster – Federal Direct Loans and Pell Grants Assistance Listing Number (ALN): 84.268 and 84.063 Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federal Award Year: June 30, 2026 Condition: 2 of the 2 students in the sample selected that required a return of Title IV funds had an amount returned by the College that was incorrect due to an incorrect number of days for the term being used in the R2T4 calculation. For the fall term, the College incorrectly omitted 2 break days, and for the spring term the College used an incorrect end of term date that was 7 days earlier than the actual end of period per the academic calendar. The student from the fall term had $18 too much and the student from the spring term had $50 less returned than required, both of Federal Direct Unsubsidized Loans. The College’s controls over the term dates input and R2T4 calculation reviews did not detect the errors. The sample was not a statistically valid sample. Upon learning of these exceptions the College corrected the days used in the calculation for the 2 students noted above and the auditor viewed the corrected R2T4 calculations, student accounts and COD screen prints. The College performed a review of all other withdrawn students noting an additional 7 students impacted from each term. For the fall term an additional $70 too much was returned ($8 Direct Loans and $62 Pell Grants). For the spring term an additional $434 ($220 Direct Loans and $214 Pell) was required to be returned. The College corrected these amounts for all but 1 student ($3 direct loans). The auditor viewed the corrected R2T4 calculations, student accounts and COD screen prints for the 13 students. Corrective Action Plan Management agrees with the finding and considers this to be an isolated incident that will not re-occur in future years. Since discovering this error in the 25-26 Academic Year, three staff members have reviewed the 26-27 Academic Calendar to ensure that start dates, end dates and breaks are correctly entered into PowerFAIDS. Additionally, the staff member who managed this process in the 25-26 Academic Year is no longer employed by the College. A new staff member will be responsible for this process and will receive supplemental training to ensure knowledge and accuracy. Completion Date: September 30, 2026 Name(s) of Contact Person(s) Responsible for Corrective Action: Nathan Engle, Controller Email: Engle1@stolaf.com
The center corredcted the advance draw by expending the draws during the year ended Janaury 31, 2026 and did not complete an advance draw again in 2026. The center will review its cash management polcies to consider modification to account for certain circumnstances to allow for flexibility advance ...
The center corredcted the advance draw by expending the draws during the year ended Janaury 31, 2026 and did not complete an advance draw again in 2026. The center will review its cash management polcies to consider modification to account for certain circumnstances to allow for flexibility advance draws. The center will remit the excess interest earned to the Department of Health and Human Services.
The center will perform addional education to ensure proper documentation is retained and sliding fee discount applied.
The center will perform addional education to ensure proper documentation is retained and sliding fee discount applied.
H.S.C. No. 6 Housing Development Fund Co. Inc. agrees with the finding and the required deposit in the amount of $22,477 was made on August 24, 2026.
H.S.C. No. 6 Housing Development Fund Co. Inc. agrees with the finding and the required deposit in the amount of $22,477 was made on August 24, 2026.
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS appli...
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS appli...
Contact Person Nadine Boe, CEO Corrective Action Plan Management will work to ensure that the SFS discount applications are completed accurately and that the SFS discounts are recorded accurately in the system by auditing the SFS applications and verifying the SFS in the system matches the SFS application. In addition, Management will audit a sample of the SFS discounts on a monthly basis to assure the SFS is applied correctly. Management will also provide additional training to staff as needed and provide further guidance on the internal SFS policies and procedures.
ACM Management will work closely with software vendor to ensure HAP amounts agree to the HAP contracts
ACM Management will work closely with software vendor to ensure HAP amounts agree to the HAP contracts
Unearned Funds – Public Housing Capital Fund: HACM Management will process checks to be paid from Capital Fund on the same day that funds are drawn down in LOCCS but dated as of the date funds are expected to be deposited. Receipt of Capital Funds will be confirmed via online banking and then checks...
Unearned Funds – Public Housing Capital Fund: HACM Management will process checks to be paid from Capital Fund on the same day that funds are drawn down in LOCCS but dated as of the date funds are expected to be deposited. Receipt of Capital Funds will be confirmed via online banking and then checks sent out. Re: Federal Awards Findings: Unearned Funds - Sec􀆟on 8 Housing Choice Vouchers HACM Management will work closely with so􀅌ware vendor to ensure HAP amounts agree to the HAP contracts.
Criteria: HUD requires that all units under the Housing Choice Vouchers Program meet specific Housing Quality Standards (HQS). In cases of failed inspections, timely re-inspections are mandatory, and if compliance is not achieved, abatement of Housing Assistance Payments (HAP) or voucher cancellatio...
Criteria: HUD requires that all units under the Housing Choice Vouchers Program meet specific Housing Quality Standards (HQS). In cases of failed inspections, timely re-inspections are mandatory, and if compliance is not achieved, abatement of Housing Assistance Payments (HAP) or voucher cancellation is required. Condition: During the audit, it was noted that in three (3) instances, a unit that failed its HQS inspection and was not properly abated. Context: This finding represents an issue within the Housing Voucher Cluster program, as it was identified in three (3) files tested out of a sample of four (4) cases. It highlights a need for more rigorous enforcement and monitoring of HQS compliance.Cause: The non-compliance appears to stem from oversight or procedural lapses in the enforcement of HQS within the Housing Voucher Cluster program. This may be due to inadequate monitoring, or failure to adhere to established protocols.Effect This non-compliance undermines the integrity of the Housing Choice Vouchers Program and may lead to tenants living in substandard conditions. It also represents a risk of improper use of federal funds and can impact the credibility and effectiveness of the program. Recommendations Implement more stringent procedures for monitoring HQS compliance, including timely reinspection and enforcement of HAP abatement or voucher cancellation. Enhance training for staff involved in the HQS process to ensure a thorough understanding of compliance requirements. Establish a system of regular audits to identify and rectify lapses in HQS enforcement promptly. Management Views The auditee acknowledges the deficiency in enforcing Housing Quality Standards (HQS) as highlighted in the finding. In response to this issue, management commits to implementing a comprehensive Corrective Action Plan. Questioned Costs The exact monetary impact needs further investigation to determine the amount of HAP that
By October 20, 2026, the Township fully funded the reserve accounts up to the October 1, 2026 required and fully funded the bond reserve account to the accumulated 10 year balance. The Township board adopted a policy to make qarterly payments from now on.
By October 20, 2026, the Township fully funded the reserve accounts up to the October 1, 2026 required and fully funded the bond reserve account to the accumulated 10 year balance. The Township board adopted a policy to make qarterly payments from now on.
2026-002 Suspension and Debarment Corrective action planned: CSV verifies each vendor’s exclusion status in SAM.gov before entering into any contract, purchase order, or agreement of $25,000 or more paid with federal funds. Each verification is documented, and active vendors are re-verified annually...
2026-002 Suspension and Debarment Corrective action planned: CSV verifies each vendor’s exclusion status in SAM.gov before entering into any contract, purchase order, or agreement of $25,000 or more paid with federal funds. Each verification is documented, and active vendors are re-verified annually. Initial verification records for new vendors are retained in the Vendor Record within CSV’s general ledger system. Annual vendor verification records are documented and maintained in CSV’s electronic files. These procedures apply to all federal awards received by the organization Anticipated completion date: Completed in June 2026 Contact person responsible for corrective action: Harjeet Sidhu, Chief Financial Officer
2026-001 Period of Performance Corrective action planned: The organization will implement an additional step to review personnel cost categories that may have the potential of including out-of-period costs (e.g., performance bonus payments, contractual lump sum payments) and verify that these expens...
2026-001 Period of Performance Corrective action planned: The organization will implement an additional step to review personnel cost categories that may have the potential of including out-of-period costs (e.g., performance bonus payments, contractual lump sum payments) and verify that these expenses are allocated to the correct award cycle. If out-of-period transactions are identified, the organization will ensure that these expenses are allocated to unrestricted general operating funds. Anticipated completion date: October 2026 Contact person responsible for corrective action: Harjeet Sidhu, Chief Financial Officer
U.S. Department of Housing & Urban Development Community Planning and Development Office of Economic Development- Congressional Grants Division -Assistance Listing No. 14.251 Recommendation: We recommend the grantee strengthen internal controls over federal reporting by: • Establishing a reporting c...
U.S. Department of Housing & Urban Development Community Planning and Development Office of Economic Development- Congressional Grants Division -Assistance Listing No. 14.251 Recommendation: We recommend the grantee strengthen internal controls over federal reporting by: • Establishing a reporting calendar with assigned responsibilities and submission deadlines. • Developing a standardized DRGR preparation and review checklist. • Requiring reconciliation of all financial information reported in DRGR to the general ledger before submission. • Performing and documenting supervisory review of all reports prior to submission • Providing training to personnel responsible for federal grant report ing requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will consider establishing a reporting calendar, developing a DRGR preparation and review checklist, performing a supervisoryreview, and training personnel for federal grant reporting requirements. Name(s) of the contact person(s) responsible for corrective action: Benny Marcier, Mayor at 815-432-2711 Planned completion date for corrective action plan: April 30, 2027
In Finding 2026-002, the Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain wage authorization approvals for all employees. Management recognizes the importance of the f...
In Finding 2026-002, the Organization failed to follow its policy to maintain time and effort reports that coincide with the Organization’s payroll cycle (at least on a monthly basis) and failed to maintain wage authorization approvals for all employees. Management recognizes the importance of the federal requirements regarding personnel cost and time and effort. In response to Finding 2026-002, procedures. will be established to ensure that wage authorizations are approved for all employees and that salaried employees maintain time and effort reports that coincide with the Organization’s payroll cycle.
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discount for six sliding fee patients tested. In addition, ten patients received discounts without completed applications. Management recognizes the importance of complying with sliding fee guidelines a...
In Finding 2026-001, it was reported that the Organization did not properly apply the sliding fee discount for six sliding fee patients tested. In addition, ten patients received discounts without completed applications. Management recognizes the importance of complying with sliding fee guidelines and the Organization’s sliding fee policy. In response to Finding 2026-001, proper training will be given to employees and sliding fee discounts will be reviewed on a monthly basis by a supervisor to ensure compliance with the sliding fee policy.
The prior year’s underfunded cash balance was not supplemented with additional deposits due to excessive operating costs. Management indicated that recovery efforts will be pursued in the current year. Brian Conde, the Controller, will work with the Organization to resolve this matter. The anticipat...
The prior year’s underfunded cash balance was not supplemented with additional deposits due to excessive operating costs. Management indicated that recovery efforts will be pursued in the current year. Brian Conde, the Controller, will work with the Organization to resolve this matter. The anticipated completion date is June 30, 2027.
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