Corrective Action Plans

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CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature: The ...
CP-1011 CORRECTIVE ACTION PLAN Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 Signature: The following is a recommended format to be followed by the auditee for preparing a corrective action plan: 2. Finding 2025-002 a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, the project did not make the required monthly deposits to the replacement reserve in the amount of $2,521. b. Action(s) Taken or Planned on the Finding This finding has been corrected and the deposit was made within the first quarter of 2026.
Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be fo...
Project Legal Name: Winter Grove, Inc. HUD Project No.: 017-EE118 Audit Firm: Cohn Reznick Period covered by the audit: 12/31/2025 Corrective Action Plan prepared by: Name: Arlene Lawrence Position: Chief Financial Officer Telephone Number: 203-562-4514 The following is a recommended format to be followed by the auditee for preparing a corrective action plan: 1. Finding 2025-001 a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, the Corporation paid expenses in the amount of $305 on behalf of an affiliate from project cash without HUD approval. The amount due to the Project as of December 31, 2025 is $305. b. Action(s) Taken or Planned on the Finding This finding has been corrected and the affiliate reimbursed the property within the first quarter of 2026.
Going forward we have already put in place the following action items: • In order to maintain eligibility records in a location that is easy to locate, we will create a main, online depository to house all eligibility forms by year so that we can readily access proof of eligibility for all future au...
Going forward we have already put in place the following action items: • In order to maintain eligibility records in a location that is easy to locate, we will create a main, online depository to house all eligibility forms by year so that we can readily access proof of eligibility for all future audits. • In order to ensure that we don’t exceed federal procurement thresholds due to unforeseen increases in meal demand, we will be far more conservative in our meal forecasts and follow federal procurement guidelines any time we think we might get close to meeting threshold requirements. • In order to meet federal procurement requirements around receiving three bids for purchases, we will add an additional step to our procurement process that ensures we receive at least three formal bids or can document that we placed a formal request for bids in a regional publication such as the Seattle Journal of Commerce and did not receive three formal bids. We currently request bids from all vendors that service our area but we don’t always receive at least three formal bids back. This additional step will ensure that we made every effort to reach out to all possible vendors in the state even if they do not service our area.
CAPHMLC is implementing corrective actions to ensure full compliance and strengthen internal controls. 1. CAPHMLC will reinforce its requirement that all LIHEAP participant files include complete hard-copy documentation supporting eligibility determinations. 2. A standardized documentation checklist...
CAPHMLC is implementing corrective actions to ensure full compliance and strengthen internal controls. 1. CAPHMLC will reinforce its requirement that all LIHEAP participant files include complete hard-copy documentation supporting eligibility determinations. 2. A standardized documentation checklist will be implemented and required in each file to verify completeness prior to approval. 3. A documented supervisory review will be required for all applications. Evidence of this review must include the reviewer's initials or signature and the date ofreview. 4. Applications will not be processed until the required review is completed and documented. CAPHMLC will provide mandatory trammg to all LIHEAP staff and supervisors on documentation requirements, record retention standards, and supervisory review procedures. Updated policies will be formally communicated, and staff will be required to acknowledge their unde-rstanding e fc-these-requirements. To ensure ongoing compliance, CAPHMLC will implement monthly quality assurance reviews of a sample of participant files to verify completeness of documentation and evidence of supervisory review. Results will be reported to management, and any identified deficiencies will be addressed promptly. Procedures will also be strengthened to ensure consistency between electronic records maintained in F ACSPro and hard-copy files. These corrective actions will be implemented within 90 days, with trammg and policy reinforcement completed within 30 days, and monitoring procedures initiated within 60 days. Supervisors will be responsible for enforcing compliance, and instances of noncompliance will be addressed in accordance with CAPHMLC personnel policies and procedures. Management will monitor the effectiveness of these corrective actions through ongoing quality assurance activities and periodic internal reviews to ensure sustained compliance with applicable requirements.
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend Hazelden Betty Ford Graduate School review their policies and procedures relating to return of Title IV calculations to ensure the calculations are properly set up to round. Explanation of disagreement ...
Student Financial Assistance Cluster – Assistance Listing No. 84.268 Recommendation: We recommend Hazelden Betty Ford Graduate School review their policies and procedures relating to return of Title IV calculations to ensure the calculations are properly set up to round. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1) Rounding rules have been applied to the Return of Title IV calculation worksheets according to the federal Title IV regulations. 2) Discrepancies in R2T4 calculations due to the rounding issue have been corrected on COD on a student by student basis Name(s) of the contact person(s) responsible for corrective action: Yuan Fang Planned completion date for corrective action plan: April 1, 2026
REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2025-006 Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (SEF...
REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2025-006 Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (SEFA) and federal reporting package to be submitted to the federal audit clearinghouse within the earlier of 30 calendar days after the receipt of the auditor’s report(s), or 9 months after the end of the audit period. Condition – The District’s audited SEFA and federal reporting package for the fiscal year ended June 30, 2025, were not submitted to the federal audit clearinghouse within nine months after the end of the audit period. Corrective Action Plan Actions Planned – The completion of the District’s audited annual financial statements for the year ended June 30, 2025, which is a required component of the federal reporting package, was delayed beyond the nine-month deadline, primarily due to turnover in the District’s finance department. District management will ensure that all information required to comply with federal reporting requirements will be completed and submitted in a timely manner going forward. Official Responsible – Josh Anderson, the District’s Director of Finance. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Josh Anderson, the District’s Director of Finance, will monitor the year‑end financial closing and reporting process to ensure all federal and state reporting requirements are complied with in the future.
Federal Agency name: Department of Education Assistance Listing Number: 84.365C Program Name: English Language Acquisition, Language Enhancement, and Academic Achievement Program for Limited English Proficient Children Finding Summary: Indirect costs charged to the federal award did not agree to the...
Federal Agency name: Department of Education Assistance Listing Number: 84.365C Program Name: English Language Acquisition, Language Enhancement, and Academic Achievement Program for Limited English Proficient Children Finding Summary: Indirect costs charged to the federal award did not agree to the underlying direct costs for the award for the fiscal year ended June 30, 2025. Corrective Action Plan: Approved indirect costs on federal grants will be drawn down in the same fiscal year that the direct costs were incurred. If the draw down is not completed by the end of the fiscal year, a receivable will be recorded in the financial statements. Responsible Individuals: Andrea Eagle Bull, VP for Finance and John Hussman, Grants Manager Anticipated Completion Date: July 2026
Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01...
Finding #2025-004 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart had not performed a reconciliation of federal expenditures resulting in errors in reported expenditures. Additionally, subrecipient expenditures were not identified for two programs. There was no independent review of the SEFA. Recommendation: Emphasize adherence to established policies and procedures to reconcile the federal expenditures to the federal program revenue on a routine basis and formalize the independent review process for the SEFA and grant billings. Planned corrective action: Management has implemented strengthened federal reporting and reconciliation procedures to improve accuracy and oversight related to federal expenditures and SEFA preparation. Corrective actions include: 1) Implementation of a formal SEFA preparation and reconciliation process requiring reconciliation of federal expenditures to the general ledger and supporting documentation. 2) Quarterly federal expenditure reviews to identify discrepancies and improve reporting accuracy throughout the fiscal year. 3) Development of centralized federal awards tracking procedures to monitor expenditures, reimbursement activity, subrecipient activity, grant balances, and reporting requirements. 4) Independent review procedures for preparation and review of the SEFA prior to annual audit submission. 5) Strengthened coordination between accounting personnel and program leadership to improve federal reporting accuracy and monitoring of subrecipient activity. 6) Periodic internal compliance reviews to evaluate federal reporting accuracy and compliance with grant requirements. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-0...
Finding #2025-003 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract # NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: During our testing of payroll, non-payroll and indirect cost pool transactions, we identified the following exceptions: Controls over allowable cost and other non-compliance: AL #93.092 Affordable Care Act (ACA) Personal Responsibility Education Program. In a sample of 40 non-payroll transactions tested for internal controls and compliance for allowable cost we found one instance of an annual subscription for the term ending May 2026 charged to a grant which ended September 29, 2025 resulting in eight months, or approximately $1,200, charged outside the period of performance. Partial repeat of finding #2024-004. Controls over period of performance and other non-compliance: AL #93.332 Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges. In a period-of-performance sample of 18 vendor transactions with grant charges close to grant beginning or ending dates during the audit period, we found 3 instances or $1,003 of vendor costs charged outside the grant period of performance. Additionally, testing of payroll charged at the end of the grant period revealed that approximately $6,693 was charged outside the period of performance. Recommendation: Emphasize adherence to established policies and procedures to ensure maintenance and review of payroll spreadsheets and general ledger coding for all transactions. Planned corrective action: Management has implemented strengthened procedures related to payroll allocations, grant coding, allowable costs review, and monitoring of grant periods of performance. Corrective actions include: 1) Enhanced review procedures to ensure expenditures are charged to the appropriate funding source and grant period. 2) Review of payroll allocations against approved grant budgets and supporting time and effort certifications where applicable. 3) Monthly review meetings between finance personnel and program leadership to review coding accuracy, budget status, payroll allocations, and grant compliance requirements. 4) Additional staff training related to Uniform Guidance cost principles, allowable costs, grant periods of performance, and GAAP financial reporting requirements. 5) Improved grant expenditure tracking and monitoring procedures to identify coding errors or compliance concerns timely. 6) Strengthened documentation retention procedures to ensure expenditures are properly supported and audit ready. Responsible officer: Anita Bates, Chief Executive Officer. Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.
Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/2...
Finding #2025-002 – Significant Deficiency. Applicable federal programs: U. S. Department of Health and Human Services, Direct Federal Funding, Cooperative Agreement to Support Navigators in Federally-facilitated Exchanges, Assistance Listing #93.332, Contract #NAVCA240482-01-00, Contract year: 08/27/24 – 08/26/25. U. S. Department of Health and Human Services, Direct Federal Funding, Affordable Care Act (ACA) Personal Responsibility Education Program, Assistance Listing #93.092, Contract #90AK0075-03-03, Contract year: 09/30/23 – 09/29/25. Condition and context: Civic Heart’s internal controls over grant billing requests were not sufficient to ensure that grant billing requests were consistently independently reviewed and approved. Transaction testing for details and internal controls revealed the following: 1) 3 out of 12 grant billing requests did not have evidence of independent review and approval. 2) 3 of 3 pay period journal entries used to allocate payroll expense between departments and funding sources did not have evidence of independent review and approval. Recommendation: Same as finding reported as #2025-001. Planned corrective action: Management has implemented enhanced grant reimbursement and compliance procedures designed to strengthen oversight, documentation standards, and review procedures. Corrective actions include: 1) Implementation of a formal grant reimbursement and drawdown review process requiring complete supporting documentation prior to submission. 2) Required supporting documentation now includes invoices, proof of payment, payroll documentation, time and effort certifications where applicable, budget verification, and grant period review. 3) All federal reimbursement requests require independent review and approval by the Chief Executive Officer prior to submission to ensure compliance with grant terms and conditions, Uniform Guidance requirements, federal regulations, and GAAP reporting standards. 4) Monthly grant compliance meetings are conducted to review reimbursement activity, grant expenditures, reporting deadlines, allowable costs, and budget variances. 5) Program and finance staff are participating in ongoing grant compliance training related to federal regulations, grant-specific requirements, documentation standards, allowable costs, and financial management procedures. Training efforts include periodic reviews and testing where applicable to reinforce compliance expectations. 6) Implementation of standardized grant tracking and reimbursement monitoring procedures to improve accountability and strengthen oversight. 7) Periodic internal compliance reviews of grant files, reimbursement requests, and supporting documentation to identify and address deficiencies proactively. Responsible officer: Anita Bates, Chief Executive Officer Estimated completion date: Implementation is underway with continued monitoring and expected to be fully operational by August 31, 2026.
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen it...
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. The Hospital will strengthen its federal grant cash management procedures and will perform and document cost verification prior to all federal grant drawdowns beginning in fiscal year 2026.
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will implement a review and ...
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will implement a review and reconciliation process of the required reports to the underlying grant and accounting records.
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will modify and strengthen o...
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Planned Corrective Action: Management accepts the recommendation. It will modify and strengthen our policy and procedure regarding the procurement process to reflect the alignment with federal regulations. The Hospital will begin performing and documenting suspension and debarment checks on all vendors/contracts funded with grants in fiscal year 2026.
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: Completed. Views of Responsible Officials and Planned Corrective Action: The Hospital now has an automatic monthly transfer set to move $4,400 fro...
Personnel Responsible for Corrective Action: Karla Clubine, Chief Executive Officer, David Cichocki, Chief Financial Officer Anticipated Completion Date: Completed. Views of Responsible Officials and Planned Corrective Action: The Hospital now has an automatic monthly transfer set to move $4,400 from the operating account to the debt service account. Additionally, the fiscal year 2026 budget includes an expense assumption to set aside $4,400 per month into the debt service account.
Finding 2025-002: Reporting – Significant Deficiency in Internal Controls Over Compliance Programs: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) and SMART Innovation Program Management Response: Management concurs with the finding. Although grant reporting submissions we...
Finding 2025-002: Reporting – Significant Deficiency in Internal Controls Over Compliance Programs: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) and SMART Innovation Program Management Response: Management concurs with the finding. Although grant reporting submissions were not subject to a formal documented secondary review and approval process prior to submission, compensating controls existed. The Chief Executive Officer and Controller were copied on submissions and reviewed amounts charged to grants as part of monthly financial reporting and close procedures. No instances of noncompliance or questioned costs were identified. To strengthen controls over compliance reporting, management has implemented a formal review and approval process requiring the Chief Executive Officer to review all grant invoices and reporting submissions prior to submission to the grantor. Documentation of review and approval will be maintained to evidence compliance with established procedures. Corrective Action Planned/Implemented: • Formalized secondary review and approval procedures for all grant reporting submissions prior to submission. • Chief Executive Officer review and approval now required before grant invoices and reports are submitted. • Documentation of review and approval retained to support compliance with internal control procedures. Responsible Party: Chief Executive Officer / Controller / Accounting Department Implementation Date: Implemented as of April 2026
Finding 2025-001: Allowable Cost – Significant Deficiency in Internal Controls Over Compliance Program: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) Management Response: Management concurs with the finding. The exceptions identified resulted from a lapse in execution of ...
Finding 2025-001: Allowable Cost – Significant Deficiency in Internal Controls Over Compliance Program: Block Grants for Prevention and Treatment of Substance Abuse (ALN 93.959) Management Response: Management concurs with the finding. The exceptions identified resulted from a lapse in execution of established approval procedures, as 2 of the 25 sampled credit card transactions charged to the grant did not include documented supervisory approval prior to payment. However, compensating controls existed, including Finance Department review of all expenditures prior to payment of the Brex account and additional review of expenses charged to the grant during preparation of monthly grant invoices and reporting. No unallowable costs or, questioned costs, were identified. To remediate the finding, all supervisors have received additional training and reminders regarding requirements for timely review and approval of expenditures prior to payment processing. In addition, the accounting team has implemented procedures prohibiting payment processing until all required approvals have been completed and documented. Management believes these enhanced controls strengthen adherence to existing policies and reduce the likelihood of recurrence. Management notes that the supervisor associated with the exceptions is no longer employed by the Organization; however, corrective actions focus on strengthening processes and controls rather than reliance on personnel changes. Corrective Action Planned/Implemented: • Refresher training provided to supervisors regarding expenditure review and approval requirements. • Accounting procedures updated to prevent payment processing prior to completion and documentation of all required approvals. • Existing accounting department monitoring procedures will continue, including review of expenditures before payment and grant expenditure review during monthly reporting. Responsible Party: Controller / Accounting Department Implementation Date: Implemented as of April 2026
Material Weakness – Suspension and Debarment Recommendation: We recommend the Port re-implement its previous controls of using a tracking checklist and retaining documentation of the verification process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding...
Material Weakness – Suspension and Debarment Recommendation: We recommend the Port re-implement its previous controls of using a tracking checklist and retaining documentation of the verification process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Port Authority will revise their process to ensure controls are in place and documentation is retained. Name of the contact person responsible for corrective action: Jan Almquist, Controller. Planned completion date for corrective action plan: December 31, 2026
Auditee: Farrell-Bell Senior Housing Apartments, Inc. HUD Project Number: 073-EE119 Audit Firm: Agresta, Storms & O’Leary, PC Audit Period Ended December 31, 2025 Corrective Action Plan Prepared by: Name: John Renner Position: Chief Financial & Administrative Officer, United Church Homes, Inc. Telep...
Auditee: Farrell-Bell Senior Housing Apartments, Inc. HUD Project Number: 073-EE119 Audit Firm: Agresta, Storms & O’Leary, PC Audit Period Ended December 31, 2025 Corrective Action Plan Prepared by: Name: John Renner Position: Chief Financial & Administrative Officer, United Church Homes, Inc. Telephone Number: 740-382-4885 A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding No. 2025-001 A. Comments on the Finding and Each Recommendation: Management agrees with the finding. Management is aware withdrawals from reserve must have HUD approval and account must be fully funded. B. Action Taken or Planned on the Finding: Management will deposit the funds into the replacement reserve when available.
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE La Center School District No. 101 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of F...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE La Center School District No. 101 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with time and effort requirements. Name, address, and telephone of District contact person: Gary McGarvie, Business Manager PO Box 1840 La Center, WA 98629 (360) 263-2131 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for disagreement). As a new Business Manager completing year-end processes for the first time, I mistakenly overlooked attaching the semi-annual Time & Effort certification forms to the timesheets for our classified staff. While the District did maintain completed timesheets for all staff throughout the year, the formal Time & Effort certification documentation was not completed as required for federal grant compliance. To correct this and prevent it from happening again, the District has since implemented a more structured process to ensure Time & Effort documents are properly completed. This includes attaching semi-annual certification forms directly to timesheets for classified staff and sending certification forms to certificated staff twice a year. This process will ensure that the dollars being spent from federal grants are being used accurately and in accordance with federal requirements. Anticipated date to complete the corrective action: This process has already been implemented and we should not have this issue happen moving forward.
Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance.
Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance.
Finding 2025-003: Procurement, Suspension and Debarment The single audit report included the following recommendation: EY recommends that Amtrak include legal expenses within their procurement, suspension and debarment policy as outlined within each of the grant agreements. Management Response/Statu...
Finding 2025-003: Procurement, Suspension and Debarment The single audit report included the following recommendation: EY recommends that Amtrak include legal expenses within their procurement, suspension and debarment policy as outlined within each of the grant agreements. Management Response/Status of Action Plans: Pursuant to Section 26(j) of Amtrak’s annual grants, Amtrak’s policy is to fund most law firm engagements with Program Income without applying grant requirements that apply to other procurements. In FY2025, this was the case for all law firm engagements charged to operating activities. Also, in FY2025, Amtrak had a portion of its legal expenditures charged to capital projects based on the nature of the legal work performed. These capital projects were funded with federal grants. For legal expenditures which are by their nature related to projects funded by grants, Amtrak acknowledges the need to have the proper procurement process including competitive review and/or securing the contractor/law firms’ acceptance of required Supplemental General Provisions/flow-down based on the grants. By the end of FY2026, the Law Department will review and update its internal procedures to better prevent recurrence of legal expenditures that did not have proper competitive review and/or securing the contractor/law firms’ acceptance of required Supplemental General Provisions/flow-downs from being charged to projects funded by grants. As part of that review, Amtrak will consider whether it may be appropriate to utilize the Company’s broader procurement policies. The contacts for this item are Lucia Butts, AVP Funding and Grants and Thomas Bloom, Deputy General Counsel and Corporate Secretary. Amtrak anticipates fully remediating this finding by September 2026.
Finding 2025-002: Equipment and Real Property Management The single audit report included the following recommendation: EY recommends Amtrak set up a system with certain criteria for identifying sites at a higher risk for noncompliance with safeguard requirements, and creates an action plan for eval...
Finding 2025-002: Equipment and Real Property Management The single audit report included the following recommendation: EY recommends Amtrak set up a system with certain criteria for identifying sites at a higher risk for noncompliance with safeguard requirements, and creates an action plan for evaluating, and remediating potential noncompliance. EY recommends that management consider redesigning one of its key controls to help ensure that the monitoring of the observations is occurring on a preventive basis to help identify any exposure to non-compliance before it occurs and clearly identifies any follow-up steps and actions. For example, there should be established a protocol as well as timeline for when required observations are to take place, additionally, as it is known in advance, which items are coming up for inventory, Amtrak could prepare an annual schedule of inventories, that could be revised quarterly. Management Response/Status of Action Plans: Amtrak acknowledges the recommendation that Amtrak should have a system with certain criteria for identifying sites at a higher risk for noncompliance with safeguard requirements and create an action plan for evaluating and remediating potential noncompliance. As part of this effort, the Enterprise Asset Management and Disposition Team will work with Corporate Security to review and, as appropriate, align existing governance processes to reduce the likelihood of similar noncompliance. Amtrak agrees with the recommendation to redesign key controls to help ensure that the monitoring of the observations happens on a preventive basis to help identify any exposure to non-compliance before it occurs. Amtrak published an updated Equipment Control Policy and created an eLearning course, as well as implemented several processes, technologies, and reporting that help to proactively monitor and identify equipment that is 90 days or less of needing an inventory. This has improved the compliance rate from less than 70% in FY22 to over 97% in FY25. Amtrak understands that this is a repeat finding and will review with Infrastructure Maintenance and Construction Services, the owner of equipment that was out of compliance to strengthen the practice and reduce the likelihood of noncompliance. The contact for this item is Robert Hoban, Director Asset Management. Amtrak anticipates fully remediating this finding by September 2028.
Finding 2025-001: Review of Compliance Matrices and Narratives – Special Tests and Provisions The single audit report included the following recommendation: EY recommends that Amtrak update the control design with enough precision to ensure that reviews and updates to the compliance matrices are mad...
Finding 2025-001: Review of Compliance Matrices and Narratives – Special Tests and Provisions The single audit report included the following recommendation: EY recommends that Amtrak update the control design with enough precision to ensure that reviews and updates to the compliance matrices are made on a regular cadence to ensure that any updates, amendments or changes are monitored and updated timely. Management Response/Status of Action Plans: Amtrak recognizes the need to improve our controls over the updates of the compliance matrices and will review its control processes. The company specifically notes the need to update its compliance matrices in a regular cadence and after every amendment. Amtrak will develop a process document to create or update compliance matrices that will be used as a guide by compliance matrices preparers and reviewers when one is created or updated. The contact for this item is Lucia Butts, AVP Funding and Grants. Amtrak anticipates fully remediating this finding by September 2026.
Section III: Federal Award Findings and Questioned Costs 2025-001 Filing of the SF-425 - Noncompliance Management Response: We have implemented a centralized calendar that tracks all reports due under our contracts, including submission deadlines. This tool is actively used to monitor compliance and...
Section III: Federal Award Findings and Questioned Costs 2025-001 Filing of the SF-425 - Noncompliance Management Response: We have implemented a centralized calendar that tracks all reports due under our contracts, including submission deadlines. This tool is actively used to monitor compliance and ensure timely completion of all required reports. Additionally, we are enhancing our internal processes by cross-training staff to review and maintain the reporting calendar. This will provide redundancy, improve oversight, and reduce the risk of missed or delayed submissions. These measures are intended to ensure consistent compliance with contract requirements and address the concerns identified in the audit. Contact Person Responsible for Corrective Action: Lea Ringen, Chief Financial Officer, Anticipated Completed Date of Corrective Action: May 1, 2026.
Tuerk House, Inc. acknowledges the finding related to procurement and suspension and debarment requirements and recognizes the continued need for strengthened internal controls to ensure full compliance with Uniform Guidance and the Organization’s procurement policies. To address this repeat finding...
Tuerk House, Inc. acknowledges the finding related to procurement and suspension and debarment requirements and recognizes the continued need for strengthened internal controls to ensure full compliance with Uniform Guidance and the Organization’s procurement policies. To address this repeat finding, Tuerk House has implemented or is continuing to implement the following corrective actions: • Updated the procurement policy to explicitly include steps for verifying all vendors against the federal government’s System for Award Management (SAM) exclusion list prior to engaging in any procurement activity funded by federal awards. • Implemented a procurement checklist and documentation protocol to ensure proper procedures are followed for purchases exceeding $10,000, including competitive bidding, price or rate quotations, and appropriate vendor selection justification. • Conducted mandatory training for finance and program staff on updated procurement procedures, including documentation and vendor vetting protocols, with ongoing training to reinforce compliance. • Established a centralized record-keeping system to retain documentation related to procurement, vendor selection, and debarment checks in accordance with 2 CFR Part 200 and 2 CFR § 180. The Organization remains committed to full compliance and will continue to ensure that all future procurements charged to federal awards meet the applicable requirements. Organization Contact Person Responsible for Corrective Action – Kisun Peters, Director of Finance Anticipated Completion Date – June 30, 2026
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