Corrective Action Plans

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Managements Corrective Action Plan Year Ending – December 31, 2024 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2024. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2024-001 – Reporting Contact: Jennifer Moore...
Managements Corrective Action Plan Year Ending – December 31, 2024 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2024. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2024-001 – Reporting Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2025 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Indiana, Kentucky has implemented a process improvement plan in 2024 that addresses each of the findings: • In 2024, a new team has taken over the reporting and filing process for our grant awards, including federal. This team is responsible for submitting the reporting and draws by the designated timeline, and it is confirmed as part of the month-end close process. • During this time, we have established a grant tracking document that notates – o The reporting month o Dollar amount expected o Date submitted ▪ This date should always be within the month following the required filing o Date the funding was received o An area to document any information or changes worth noting • In 2025, the following items have been added to the tracking document to allow for greater oversight – o Review approval o Reporting requirements o Due Dates (monthly, quarterly, etc.) o Proof of submission
Finding ref number: 2024-001 Finding caption: The Housing Authority did not have adequate internal controls and did not comply with the Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Authority contact person: Sasha Sleiman, ...
Finding ref number: 2024-001 Finding caption: The Housing Authority did not have adequate internal controls and did not comply with the Housing Quality Standards enforcement requirements of its Housing Voucher Cluster program. Name, address, and telephone of Authority contact person: Sasha Sleiman, 1555 Methow St. Wenatchee, WA 98801, 509-663-7421 Corrective action the auditee plans to take in response to the finding: In order to improve internal controls to ensure compliance with HQS and NSPIRE inspection requirements the Housing Authority will improve the established tracking system for inspections to better manage and track follow-up on HQS deficiency. Inspection staff will be more thoroughly trained on increased communication with landlords and tenants, using the tracking system regularly to ensure timely inspections and follow-up, and the updated tracking sheet will be audited on a regular basis and quality control inspections will be conducted by the Compliance Manager. The Housing Authority will also implement a peer-review system for staff to review files on a regular basis. Clients on the Housing Choice Voucher program are split between two staff members by last name, the peer-review system will require staff to audit on a quarterly basis the other person's case load at random to ensure errors are caught and addressed and further training can be conducted as needed. Anticipated date to complete the corrective action: January 2026
Finding 2024-005 – The Town did not have formal written policies that covered all federal award criteria, including determination of allowable costs, suspension and debarment and subrecipient monitoring. Corrective Action Planned: An amendment to the “Town of Clinton Federal Grant Management Procedu...
Finding 2024-005 – The Town did not have formal written policies that covered all federal award criteria, including determination of allowable costs, suspension and debarment and subrecipient monitoring. Corrective Action Planned: An amendment to the “Town of Clinton Federal Grant Management Procedures” that covers all federal award criteria to include determination of allowable costs, suspension and debarment and subrecipient monitoring will be reviewed by the Clinton Select Board and then distributed to pertinent grant personnel within the organization once approved. Anticipated Completion Date: November 1, 2025 Contact: Michael J. Ward, Town Administrator
Finding 2024-004 – Suspension and debarment compliance was not verified for five vendors. Corrective Action Planned: The Town of Clinton has verified that vendors listed in the period ending March 31, 2024 expenditure report were not on the Federal suspension or debarment list. The Town will review ...
Finding 2024-004 – Suspension and debarment compliance was not verified for five vendors. Corrective Action Planned: The Town of Clinton has verified that vendors listed in the period ending March 31, 2024 expenditure report were not on the Federal suspension or debarment list. The Town will review all applicable vendors for suspension and debarment compliance in the future. Completion Date: September 29, 2025 Contact: Michael J. Ward, Town Administrator
Finding 2024-003 – As of the March 31, 2024 reporting date, the Town reported projects approved by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. The Projects and Expenditure report for the period ending March 31, 2024 wa...
Finding 2024-003 – As of the March 31, 2024 reporting date, the Town reported projects approved by the Select Board as obligated rather than purchases, contracts and agreements that met the Federal criteria of an obligation. The Projects and Expenditure report for the period ending March 31, 2024 was not filed until March 25, 2025. Corrective Action Planned: The Projects and Expenditure report for period ending March 31, 2024 was filed after the deadline due to a technological issue preventing access to the portal that was documented with both the U.S. Treasury and Login.gov Helpdesk. A new managed service provider working for the Town of Clinton was successful in correcting the issue for a timely filing of the 2025 report and all State and Local Fiscal Recovery Fund (SLFRF) projects were obligated by the 12/31/24 deadline. Completion Date: April 30, 2025 Contact: Michael J. Ward, Town Administrator
2023-002: Deficiency in Internal Controls and Compliance Finding -COVID-19 – Education Stabilization Fund – ALN 84.425: Two final financial reports due during the prior fiscal years were not submitted. (Questioned Costs: None) The Town of Clinton/School Department will follow grants closeout procedu...
2023-002: Deficiency in Internal Controls and Compliance Finding -COVID-19 – Education Stabilization Fund – ALN 84.425: Two final financial reports due during the prior fiscal years were not submitted. (Questioned Costs: None) The Town of Clinton/School Department will follow grants closeout procedures, consequently, the district will monitor closely all grants spending throughout each grant cycle. For both state-administered and direct grants, regardless of the period of availability, the District must liquidate all obligations incurred under the award Reports not later than 90 days after the end of the funding period unless an extension is authorized. These procedures are included in the Financial Procedures Manual (pages 226-230 under Section G— Timely Obligation of Funds) Key Control Key Actions Resources Needed Timeline Outcome Grants Management Use appropriate resources to mitigate any errors, omissions and ensure timely maintenance of records and reporting Grant Management Form Grant Award Letter Internal Controls Guide GEM$ Trainings FY24, FY25 ongoing Implementation of preventive controls for ALL grant funding Contacts: School Business Manager & Town Accountant Submitted by, Annette Colón, Business Manager MBA, MCPPO, Notary Public Clinton Public Schools 150 School St. Clinton, MA 01510 (978) 365-4200 x 12241 colona@clinton.k12.ma.us
2024-001: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): A competitive procurement process, which includes suspension and debarment certifications, was not properly performed by the Town for the purchase of school lunch food p...
2024-001: Significant Deficiency in Internal Controls and Compliance Finding -Child Nutrition Cluster ALN (10.553, 10.555,10.559): A competitive procurement process, which includes suspension and debarment certifications, was not properly performed by the Town for the purchase of school lunch food product. (Questioned Costs: None) The Town of Clinton/School Department will maintain proper procurement procedures in compliance with Local, State and Federal laws and regulations. When there are exemptions from state procurement laws, or when federal regulations are stricter the district will use the strictest rules, under 2 CFR 200.318-327. These procedures are included in the Financial Procedures Manual (pages 231-240, under Section II Procurement System). The Town of Clinton/School Department will obtain individual contract with vendors competitively procured by French River Collaborative, of which the district is a member. Key Control Key Actions Resources Needed Timeline Outcome Competitive Procurement Process Use appropriate resources to mitigate any errors or omissions, and maintenance of records accurately Individual Contracts, including suspension/debarment clause Cooperative Purchasing Sheets Internal Controls Guide Online Resources: Sams.gov FY24, FY25 ongoing Streamlined procurement process & internal controls for ALL funding sources Contacts: Food Services Manager & School Business Manager Submitted by Annette Colón, Business Manager MBA, MCPPO, Notary Public Clinton Public Schools 150 School St. Clinton, MA 01510 (978) 365-4200 x 12241 colona@clinton.k12.ma.us
FINDING 2024-001 Mississippi Individual Responsible for Corrective Action Plan: MS Alliance – LaKenya Evans, Dominique Dye, Duran Davis Corrective Action: Claims will be finalized and reviewed at least three business days before the deadline. If delays are unavoidable, staff will immediately notify ...
FINDING 2024-001 Mississippi Individual Responsible for Corrective Action Plan: MS Alliance – LaKenya Evans, Dominique Dye, Duran Davis Corrective Action: Claims will be finalized and reviewed at least three business days before the deadline. If delays are unavoidable, staff will immediately notify MDHS to provide updates and request extensions. Claim submission timeliness will be reviewed monthly, and late submissions will be documented. Anticipated Completion Date: December 31, 2025
FINDING 2024-003 Massachusetts Individual Responsible for Corrective Action Plan: Alliance Director Jenn Aldworth Corrective Action: The organization is strengthening internal process for subrecipient monitoring including formalizing the documentation of the review and approval before reimbursing th...
FINDING 2024-003 Massachusetts Individual Responsible for Corrective Action Plan: Alliance Director Jenn Aldworth Corrective Action: The organization is strengthening internal process for subrecipient monitoring including formalizing the documentation of the review and approval before reimbursing the subrecipient in accordance with 2 CFR 200.303. Anticipated Completion Date: December 31, 2025
FINDING 2024-002 Massachusetts Individual Responsible for Corrective Action Plan: Alliance Director Jenn Aldworth Corrective Action: The Organization is refining subaward agreements for future awards and will ensure federal provisions required to be communicated by the grant and also 2 CFR § 200.332...
FINDING 2024-002 Massachusetts Individual Responsible for Corrective Action Plan: Alliance Director Jenn Aldworth Corrective Action: The Organization is refining subaward agreements for future awards and will ensure federal provisions required to be communicated by the grant and also 2 CFR § 200.332 are incorporated consistently for all subrecipients. Anticipated Completion Date: December 31, 2025
2024-003 The organization receives federal funding and is therefore subject to the requirements of the Uniform Guidance. A procurement policy is essential to ensure that all procurement activities are conducted in a manner that is consistent with federal regulations and best practices. Recommendatio...
2024-003 The organization receives federal funding and is therefore subject to the requirements of the Uniform Guidance. A procurement policy is essential to ensure that all procurement activities are conducted in a manner that is consistent with federal regulations and best practices. Recommendation: We recommend that the organization develop and implement a comprehensive procurement policy that aligns with the Uniform Guidance. This policy should include clear procedures for procurement planning, solicitation, evaluation, and contract management; provisions to ensure fair competition and prevent conflicts of interest; training for staff on the procurement policy and federal requirements; and regular reviews and updates to the policy to ensure ongoing compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Policy Development - COMPLETED: The Organization has developed and approved a comprehensive procurement policy that fully aligns with the Uniform Guidance requirements. Planned completion date for corrective action plan:9/10/2025 The planned corrective action will be completed by 9/10/2025. Name(s) of the contact person(s) responsible for corrective action: Amy Chen, VP, Finance If the oversight agency has questions regarding this plan, please call Amy Chen, VP, Finance at 646-727-5030.
2024-002 During our testing, we noted there was a lack of approval prior to submission to the funding agency for five financial and three performance reports tested during the audit. Recommendation: We recommend that the organization implement a formal review and approval process for all financial a...
2024-002 During our testing, we noted there was a lack of approval prior to submission to the funding agency for five financial and three performance reports tested during the audit. Recommendation: We recommend that the organization implement a formal review and approval process for all financial and performance reports submitted to the funding agency. This process should include clear guidelines and training for staff to ensure that all reports are reviewed and approved by the designated authority before submission. Additionally, regular audits should be conducted to verify compliance with the documentation requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Formal review and approval process has been created and implemented: Invoicing 1. Accounting Team completes month-end close process 2. Associate Director, Fiscal Grant Management creates monthly expense report in alignment with approved budget and statement of work and submits to Director, Proposal Management 3. Director, Proposal Management reviews, approves, and submits report to Executive Director 4. Executive Director reviews, approves, and submits report to agency for reimbursement Performance reports 1. Director, Proposal Management requests reporting period performance data from Program Operations, Data & Analytics Team and submits report to Executive Director 2. Executive Director reviews, approves, and submits report to agency Name(s) of the contact person(s) responsible for corrective action: Amy Chen, VP, Finance Planned completion date for corrective action plan: Implemented 8/28/2025 The planned corrective action will be completed by 8/28/2025.
DEPARTMENT OF THE TREASURY 2024-001 During our testing of payroll transactions for the major federal program, we were unable review the internal control of approved timesheets for any part time employees and seasonal employees with payroll periods selected for testing through September 2024. The Org...
DEPARTMENT OF THE TREASURY 2024-001 During our testing of payroll transactions for the major federal program, we were unable review the internal control of approved timesheets for any part time employees and seasonal employees with payroll periods selected for testing through September 2024. The Organization changed payroll service providers in September 2024 and could no longer access the timesheets requested. Recommendation: The Organization should ensure when there are changes in the Organizations service providers, there are procedures in place to ensure all necessary documentation is retained to support the controls in place for federal spending. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Immediate Action Completed: We have communicated to our People Operations team the requirement to maintain access to all payroll documentation, including approved timesheets for part-time and seasonal employees, to support federal spending controls. Policy Implementation: We have established procedures requiring that before any payroll service provider changes are finalized, the Finance and People Operations teams must verify that all necessary historical documentation will remain accessible for audit and compliance purposes, including but not limited to approved timesheets, payroll registers, and supporting documentation for all employee categories. Training and Communication: All relevant staff members have been trained on the new procedures and understand their responsibilities for maintaining documentation access during service provider transitions. Name(s) of the contact person(s) responsible for corrective action: Amy Chen, VP, Finance Planned completion date for corrective action plan: 9/10/2025 The planned corrective action will be completed by 9/10/2025.
Material Weakness, Allowable Costs- The following steps have been taken or will be taken to address Finding 2024-002: • Shalom Health Care Center, Inc. has been working on updating federal grant draws within the timeframe of payroll and not monthly. • Shalom Health Care Center, Inc. will also prepar...
Material Weakness, Allowable Costs- The following steps have been taken or will be taken to address Finding 2024-002: • Shalom Health Care Center, Inc. has been working on updating federal grant draws within the timeframe of payroll and not monthly. • Shalom Health Care Center, Inc. will also prepare semiannual attestation for management to review staff allocations. Contact Michael A. Nino, Chief Financial Officer anino@shalomhealthcenter.org 317-269-7198
Finding 1156978 (2024-002)
Material Weakness 2024
Management’s Response The Department Director changed in April of 2024, mid grant. The Director was unable to access the portal needed to submit reports. The process to change the PI for this grant, which started in 2024, took some time for the grantor to complete. After gaining access, reports were...
Management’s Response The Department Director changed in April of 2024, mid grant. The Director was unable to access the portal needed to submit reports. The process to change the PI for this grant, which started in 2024, took some time for the grantor to complete. After gaining access, reports were finally submitted in June 2025. The Tribe has implemented an online grant management system (CGMS) to accurately record and track all approved grants. This system enables department directors to generate reports within the platform and notify responsible parties via email for each report. The TA oversees these reports and can identify those that have not been submitted, reminding responsible parties to meet deadlines. With enhanced internal controls, the Tribe has successfully submitted nearly all required FFRs and PPRs on time. This system also helps onboard new directors of their grant requirements, documents and report deadlines. Another step the Tribe took to prevent such findings was developing a grant application checklist. The Tribal Administrator created a checklist, approved by the Tribal Council, to guide Department Directors on how to apply for grants and meet their requirements, including reporting. We will address this finding by establishing a clear grant report procedure which will outline step by step procedures required by the Tribe's Fiscal Management policies. Anticipated Completion Date December 31, 2025 Responsible Party Michelle Vassel, Tribal Administrator Farzad Forouhar, Fiscal Manager
Finding 1156977 (2024-001)
Material Weakness 2024
Management’s Response This grant was written and submitted by an outside third party, and the Tribe did not have access to the original grant application, the grant terms, or the portal where the grant was housed. After the grant began, the Tribe faced pushback from some sub-recipient entities regar...
Management’s Response This grant was written and submitted by an outside third party, and the Tribe did not have access to the original grant application, the grant terms, or the portal where the grant was housed. After the grant began, the Tribe faced pushback from some sub-recipient entities regarding the controls over subrecipient monitoring that the Tribe tried to establish, to the point where some entities considered leaving the program entirely. The Tribal Administrator developed a Grant Application Checklist, approved by the Tribal Council, to assist Departments in applying for grants and fulfilling their requirements. This grant submission policy prohibits Tribal departments from having third-party entities write and submit on their behalf Regarding ALN#84.229A, the noted policies will require sub-recipients to agree to these policies provided by the Wiyot Tribe, which include that payments will be made only on a reimbursement basis and will not be processed unless sufficient documentation is provided to the Tribal Administrator or her designee. We will address this finding by establishing a clear sub-recipient monitoring procedure. This procedure will outline the step-by-step process to be followed when the tribe contracts with a subrecipient to expend grant funds. Anticipated Completion Date December 31, 2025 Responsible Party Michelle Vassel, Tribal Administrator Farzad Forouhar, Fiscal Manager
Management’s Corrective Action Plan Year Ending – December 31, 2024 Schedule of Findings and Questioned Costs: Section III – Federal Award Finding: 2024-001 – Allowable Cost ALN #97.036 Contact: Matthew Vaughn Title: Regional Director of Financial Planning & Analysis Completion Date: Present Correct...
Management’s Corrective Action Plan Year Ending – December 31, 2024 Schedule of Findings and Questioned Costs: Section III – Federal Award Finding: 2024-001 – Allowable Cost ALN #97.036 Contact: Matthew Vaughn Title: Regional Director of Financial Planning & Analysis Completion Date: Present Corrective Action: January of 2022 saw a massive uptick in daily Covid-19 cases across the country. As a result of this crisis, the incident command (IC) structure established a labor pool that deployed volunteers into unfilled shifts at the hospital for a myriad of critical positions. These shifts were tracked and coordinated via the incident command structure on separate worksheets and as a result worked shifts were not coded directly on employee timecards as had been done previously over the course of the pandemic. All other payroll submissions of the county will refer to timecard-coded worked hours and expenses, which allow the user to generate standard payroll cost reports directly out of source financial systems rather than manually matching multiple data sources to calculate relevant costs
Recommendation: The Organization should establish and implement formal procedures to ensure timely submission of its single audit reporting package to the Federal Audit Clearinghouse. Planned Corrective Actions: The Organization is in the process of filing the delinquent single audit reporting packa...
Recommendation: The Organization should establish and implement formal procedures to ensure timely submission of its single audit reporting package to the Federal Audit Clearinghouse. Planned Corrective Actions: The Organization is in the process of filing the delinquent single audit reporting packages with the Federal Audit Clearinghouse. In addition, the Organization has assigned the responsibility for filing the single audit reporting package to its Chief Financial Officer and has developed a compliance calendar to track the submission deadline. If there are any questions regarding this corrective action plan, please contact Jill Barnes, Chief Financial Officer, at (843) 747-2273.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management will ensure all requested information is available for the auditor in order to facilitate timely completion of the audit by March 31.
Management will ensure all requested information is available for the auditor in order to facilitate timely completion of the audit by March 31.
Management will work with the fiscal agent to strengthen controls by ensuring more than one employee is involved in processing and recording cash transactions. In addition, management will provide board oversight thorugh periodic review of financial activity.
Management will work with the fiscal agent to strengthen controls by ensuring more than one employee is involved in processing and recording cash transactions. In addition, management will provide board oversight thorugh periodic review of financial activity.
Management will work with the fiscal gaent ot create and maintain a separate general ledger.
Management will work with the fiscal gaent ot create and maintain a separate general ledger.
1. We have filed the missing December 31, 2024 report with the pass-through grantor (Chesterfield County). 2. The COO and CEO have reviewed and verified that all subsequent reporting submissions have been correctly filed with relevant pass-through grantors. 3. Moving forward, Director of Operations ...
1. We have filed the missing December 31, 2024 report with the pass-through grantor (Chesterfield County). 2. The COO and CEO have reviewed and verified that all subsequent reporting submissions have been correctly filed with relevant pass-through grantors. 3. Moving forward, Director of Operations and Real Estate and CEO will be carbon copied on all reporting submissions for federal grants. 4. We are committed to achieving full compliance by December 31, 2025, with the CEO overseeing the process.
Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies...
Name of Contact Person: Grace Leatherman – Executive Director Contact Information: 410-440-9066 Corrective Action Plan: Finding 2024 – 002 Management is in agreement with the findings and will remind staff to include supporting calculations when submitting for reimbursement per Organization policies. Senior staff will review payroll data to ensure calculations are being made and reported. Expected Completion Date: The Organization expects all findings to be resolved by December 31, 2025
View Audit 369250 Questioned Costs: $1
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