Corrective Action Plans

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Nonmaterial Noncompliance: See Finding 2025-002 Recommendation: We recommend the Organization document the cause of the late filing and retain evidence that the form was submitted. Action Taken: We agree with the auditor and will ensure that timely filed reports are made. Anticipated Date of Complet...
Nonmaterial Noncompliance: See Finding 2025-002 Recommendation: We recommend the Organization document the cause of the late filing and retain evidence that the form was submitted. Action Taken: We agree with the auditor and will ensure that timely filed reports are made. Anticipated Date of Completion: December 31, 2026
Recommendation: We realize that with a limited number of office employees, segregation of duties is difficult. However, the Organization should review the operating procedures to obtain the maximum internal control possible under the circumstances. The Organization should also consider the potential...
Recommendation: We realize that with a limited number of office employees, segregation of duties is difficult. However, the Organization should review the operating procedures to obtain the maximum internal control possible under the circumstances. The Organization should also consider the potential consequence of reliance on one person for financial, grant and payroll reporting. Action Taken: This issue is reviewed annually through the audit review with the Board of Directors. The Organization has implemented a segregation of duties action plan effective December 31, 2025 to address this issue going forward. Anticipated Date of Completion: December 31, 2026
Finding 2025-005: Data Collection Form compliance Corrective Action Management agrees with the recommendation. Management recognizes the importance of timely submission of the Data Collection Form and reporting to the Federal Audit Clearinghouse. The Center will establish a formal audit completion t...
Finding 2025-005: Data Collection Form compliance Corrective Action Management agrees with the recommendation. Management recognizes the importance of timely submission of the Data Collection Form and reporting to the Federal Audit Clearinghouse. The Center will establish a formal audit completion timeline that includes internal deadlines for financial statement preparation, audit fieldwork, report review, and Federal Audit Clearinghouse submission. Progress toward audit completion will be reviewed periodically by management to help ensure future submissions are completed within the timeframe required by 2 CFR 200.512. Implementation Timeline Procedures will be implemented beginning with the fiscal year ending June 30, 2026, and reviewed periodically as necessary. Responsible Parties Chief Financial Officer and Finance Department Management.
Finding 2025-004: Documented Procurement Procedures Corrective Action Management agrees with the recommendation. During fiscal year 2026, the Center began developing formal procurement policies and procedures designed to comply with Uniform Guidance procurement requirements. Management will formally...
Finding 2025-004: Documented Procurement Procedures Corrective Action Management agrees with the recommendation. During fiscal year 2026, the Center began developing formal procurement policies and procedures designed to comply with Uniform Guidance procurement requirements. Management will formally adopt written procurement procedures that address methods of procurement, documentation requirements, contractor selection, and contract administration. The Center wilt also implement written conflict-of-interest standards applicable to employees, officers, board members, and agents involved in procurement activities. Procedures will require documentation of contractor eligibility verification through SAM.gov or other approved methods prior to execution of federally funded contracts. Future federally funded contracts will be reviewed to ensure required federal provisions, including suspension and debarment requirements, are incorporated when applicable. Implementation Timeline Policies and review procedures to be implemented during fiscal year 2026 with quarterly monitoring thereafter. Responsible Parties Chief Financial Officer, Compliance Officer, and Program Management.
Finding 2025-003: Internal Controls Over Expenditures, Financial Reporting, and Program Income Corrective Action Management agrees with the recommendation. The Center will strengthen compliance monitoring procedures by requiring documented evidence of review for expenditures, payroll, federal financ...
Finding 2025-003: Internal Controls Over Expenditures, Financial Reporting, and Program Income Corrective Action Management agrees with the recommendation. The Center will strengthen compliance monitoring procedures by requiring documented evidence of review for expenditures, payroll, federal financial reports, and other compliance activities. Written procedures will be developed to define review responsibilities and documentation requirements. The Center will establish a formal process to track, reconcile, and monitor program income and will provide training to personnel involved in federal award administration. Periodic internal compliance reviews will be performed to verify controls are functioning effectively. Implementation Timeline Policies and review procedures to be implemented during fiscal year 2026 with quarterly monitoring thereafter. Responsible Parties Chief Financial Officer, Compliance Officer, and Program Management.
Finding 2025-12 Special Tests and Provisions: Title IV Credit Balance Disbursements – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will enhance monitoring of Title IV credit balances to ensure balances are identified, reviewed, and...
Finding 2025-12 Special Tests and Provisions: Title IV Credit Balance Disbursements – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will enhance monitoring of Title IV credit balances to ensure balances are identified, reviewed, and disbursed within the required 14-day period. Student account and financial aid personnel will establish a recurring review of outstanding credit balances, document follow-up and resolution, and escalate unresolved balances before the federal deadline.; Anticipated Completion Date: July 1, 2027
Finding 2025-11 Special Tests and Provisions: NSLDS Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen procedures for identifying and reporting enrollment status changes, including degree conferrals occurring ...
Finding 2025-11 Special Tests and Provisions: NSLDS Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen procedures for identifying and reporting enrollment status changes, including degree conferrals occurring outside the normal graduation cycle. Appropriate personnel will periodically review enrollment and graduation activity to identify changes requiring submission to the National Student Clearinghouse and NSLDS, and documentation of the review and reporting will be retained.; Anticipated Completion Date: July 1, 2027
Finding 2025-10 Special Tests and Provisions: Key Personnel Changes –Significant Deficiency in Internal Control Over Compliance, Planned Corrective Action Plan: APU will establish a centralized process for identifying key personnel requirements contained in federal awards. Grant records will identif...
Finding 2025-10 Special Tests and Provisions: Key Personnel Changes –Significant Deficiency in Internal Control Over Compliance, Planned Corrective Action Plan: APU will establish a centralized process for identifying key personnel requirements contained in federal awards. Grant records will identify positions or individuals subject to agency notification or prior approval requirements. Key personnel assignments will be reviewed periodically and when personnel changes occur and required agency or pass-through entity communications and approvals will be retained with the grant record.; Anticipated Completion Date: July 1, 2027
Finding 2025-09 Equipment and Real Property Management: Lack of Documentation Supporting Physical Inventory Counts – Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will establish a documented process for physical inventory of federally funded equipmen...
Finding 2025-09 Equipment and Real Property Management: Lack of Documentation Supporting Physical Inventory Counts – Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will establish a documented process for physical inventory of federally funded equipment at least once every two years. Results of the physical inventory will be reconciled to the University's property records, discrepancies will be investigated and resolved, and documentation of the inventory and reconciliation will be retained.; Anticipated Completion Date: July 1, 2027
Finding 2025-08 Allowable Costs/Cost Principles: Insufficient Documentation of Expenditure Review and Approval – Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen documentation requirements for credit cards and other nonpayroll expenditur...
Finding 2025-08 Allowable Costs/Cost Principles: Insufficient Documentation of Expenditure Review and Approval – Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen documentation requirements for credit cards and other nonpayroll expenditures charged to federal awards. Required approvals and supporting documentation will be obtained and retained before costs are charged to the applicable federal award. Finance will periodically review federal credit card transactions for compliance with approval and documentation requirements.; Anticipated Completion Date: July 1, 2027
Finding 2025-07 Allowable Costs/Cost Principles: Indirect Costs Charged in Excess of Approved Rate – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU corrected the identified indirect cost overcharges. Going forward, grant setup docume...
Finding 2025-07 Allowable Costs/Cost Principles: Indirect Costs Charged in Excess of Approved Rate – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU corrected the identified indirect cost overcharges. Going forward, grant setup documentation will identify the indirect cost rate authorized by each award, and Finance will review the applicable award terms before establishing or changing the rate used to calculate indirect costs. Periodic review of indirect cost calculations will be performed to verify that amounts charged agree with award requirements.; Anticipated Completion Date: July 1, 2027
Finding 2025-06 Procurement and Suspension and Debarment: Inadequate Documentation of Competitive Bidding Procedures – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen its procurement procedures to require retention of ...
Finding 2025-06 Procurement and Suspension and Debarment: Inadequate Documentation of Competitive Bidding Procedures – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen its procurement procedures to require retention of documentation supporting the procurement method used, solicitations, bids or proposals received, evaluation of responses, vendor selection, and the basis for the procurement decision when competitive procurement requirements apply. Procurement documentation will be retained in a centralized procurement file.; Anticipated Completion Date: July 1, 2027
Finding 2025-05 Procurement and Suspension and Debarment: Retention of Debarment Checks – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will revise its federal procurement procedures to require verification of vendor suspension and ...
Finding 2025-05 Procurement and Suspension and Debarment: Retention of Debarment Checks – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will revise its federal procurement procedures to require verification of vendor suspension and debarment status before entering into applicable covered transactions. Evidence of verification, including SAM.gov documentation, vendor certification, or applicable contractual language, will be retained in the procurement file.; Anticipated Completion Date: July 1, 2027
Finding 2025-04 Inadequate Documentation and Review of Reimbursement Requests - Material Weakness in Internal Control Over Compliance; Planned Corrective Action Plan: APU will implement written procedures requiring federal reimbursement and drawdown requests to be reconciled to supporting expenditur...
Finding 2025-04 Inadequate Documentation and Review of Reimbursement Requests - Material Weakness in Internal Control Over Compliance; Planned Corrective Action Plan: APU will implement written procedures requiring federal reimbursement and drawdown requests to be reconciled to supporting expenditure records and reviewed and approved prior to submission. Each request will retain the underlying expenditure support, reconciliation, evidence of preparer and reviewer approval, and documentation of the amount ultimately drawn. Records will be maintained in a centralized grant file and made available for audit and monitoring.; Anticipated Completion Date: July 1, 2027
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Procurement, Suspension and Debarment Finding Summary: Testing of the federal program identified the following: a. The Organ...
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Procurement, Suspension and Debarment Finding Summary: Testing of the federal program identified the following: a. The Organization’s formally documented procurement policy is missing one required element as it relates to domestic preferences (2 CFR 200.322). b. Two lease agreements were entered into where the Organization did not follow the procurement process as detailed in the procurement policy. The lease agreements with the vendors were also missing a required contract provision in accordance with Uniform Guidance and there was no review performed by the Organization to ensure the vendors were not suspended or debarred as the lease agreements with the vendors were over $25,000. Corrective Action Plan: Management will implement a checklist to ensure the Procurement Policy is being followed. In addition, management will review the procurement policy elements and update our procurement policy to ensure it incorporates all required elements. Responsible Individuals: Teena Conrad, SSVF Program Manager, Lysa Allison, Executive Director and Christina Thoelke, Business Manager Anticipated Completion Date: September 2026
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: In our sample of expenditures selected ...
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: In our sample of expenditures selected for testing, we noted the following items: a) Calculation errors for payroll expenses allocated to the grant based upon review of supporting timesheets, payroll documentation and management’s true-up calculations to allocate actual costs rather than budgeted costs (5 instances). b) Identification of benefits not being allocated in a similar manner as salaries and wages (1 employee impacted). c) Grant was overcharged as it relates to a travel reimbursement (1 instance). Corrective Action Plan: Management staff will conduct a secondary review of all payroll and travel related allocations to ensure accuracy. Responsible Individuals: Teena Conrad, SSVF Program Manager, Lysa Allison, Executive Director, and Christina Thoelke, Business Manager Anticipated Completion Date: September 2026
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Reporting Finding Summary: No review and approval processes were in place over 2 quarterly progress reports. Corrective Acti...
Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Reporting Finding Summary: No review and approval processes were in place over 2 quarterly progress reports. Corrective Action Plan: Management has implemented procedures and control processes to incorporate an independent review and approval over quarterly reporting effective for the quarterly report ending June 30, 2025. Responsible Individuals: Teena Conrad, SSVF Program Manager, Lysa Allison, Executive Director and Christina Thoelke, Business Manager Anticipated Completion Date: June 2025
CORRECTIVE ACTION PLAN September 24, 2026 U.S. Department of Housing and Urban Development St. John’s Health Care Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bonadio & Co., LLP 171...
CORRECTIVE ACTION PLAN September 24, 2026 U.S. Department of Housing and Urban Development St. John’s Health Care Corporation respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Bonadio & Co., LLP 171 Sully’s Trail Pittsford, NY 14534 Audit Period: January 1, 2025 - December 31, 2025 The findings from the December 31, 2025, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. FINDINGS – FEDERAL AWARD PROGRAMS AUDIT FINDING 2025-001: Section 232, CFDA 14.129 Recommendation: Adhere to the HUD regulatory agreement in relation to obtaining prior written approval from HUD before encumbering the Project. Action Taken: The Home executed these transactions as a prudent business decision to meet operating expenses and improve the facility to promote enhanced revenue generation. The Home has implemented procedures to ensure that prior written approval is obtained from HUD before encumbering the Project in the future. If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Sabrina McLeod at (585)-760-1401. Sincerely yours, _______________________________ Sabrina McLeod Chief Financial Officer
Finding 2025-003 Allowable Cost/Cost Principles and Cash Management – Compliance and Internal control over Allowable Costs/Cost Principles and Cash Management The City is implementing enhanced grant management procedures and review of allowable costs. Grant tracking will be improved with the impleme...
Finding 2025-003 Allowable Cost/Cost Principles and Cash Management – Compliance and Internal control over Allowable Costs/Cost Principles and Cash Management The City is implementing enhanced grant management procedures and review of allowable costs. Grant tracking will be improved with the implementation of the new financial software with the grant management module. The SEFA will be reviewed by the Administrative Services Director and the Finance Manager. The City has set up monthly meetings between the Finance Department and the Public Works Department to discuss and review capital improvement projects, grant funding, grant expenditures and allowable costs, and other funding requirements for those projects. Responsible Persons: Administrative Services Director, Finance Manager, Public Works Director Expected Implementation Date: July 1, 2025, though implementation of new finance software at July 1, 2027.
Finding 2025-002 Procurement and Suspension Debarment – Internal Control over Suspension and Debarment The City has incorporated the Uniform Guidance requirements into a procedure in our decentralized environment to ensure the City is in compliance with the requirements. Prior to contract award the ...
Finding 2025-002 Procurement and Suspension Debarment – Internal Control over Suspension and Debarment The City has incorporated the Uniform Guidance requirements into a procedure in our decentralized environment to ensure the City is in compliance with the requirements. Prior to contract award the Management Analysts in Finance and Public Works will access SAM.gov to check for possible ineligibility and keep a record of that check with the time stamped for every contract using federal funds. The Finance Management Analyst currently monitors meeting agendas, the bidding process, and grant funding to ensure the process is completed. Upon agenda monitoring, the Finance Management Analyst will confirm with the Public Works Management Analyst to ensure the SAM.gov check was completed before the award of the contract. Responsible Persons: Finance Manager, Management Analyst Implementation Date: March 1, 2025
The BOCC acknowledges the finding and I will improve reconciliation and review procedures used in preparing federal reports. County officials involved in grant reporting will work together to ensure repotted obligations and expenditures are reconciled to supporting records before submission.
The BOCC acknowledges the finding and I will improve reconciliation and review procedures used in preparing federal reports. County officials involved in grant reporting will work together to ensure repotted obligations and expenditures are reconciled to supporting records before submission.
The current Board of County Commissioners acknowledges the finding. The Board is committed to strengthening written procedures related io federal grant administration, including allowable costs, procurement requirements, reporting, and compliance monitoring. Additional review processes will continue...
The current Board of County Commissioners acknowledges the finding. The Board is committed to strengthening written procedures related io federal grant administration, including allowable costs, procurement requirements, reporting, and compliance monitoring. Additional review processes will continue to be implemented to improve oversight and documentation.
The current Board of County Commissioners acknowledges the finding. While portions of this finding relate to prior fiscal years, the current Board is committed to strengthening county-wide internal controls over federal programs. The Board has reviewed the audit recommendations and will continue imp...
The current Board of County Commissioners acknowledges the finding. While portions of this finding relate to prior fiscal years, the current Board is committed to strengthening county-wide internal controls over federal programs. The Board has reviewed the audit recommendations and will continue implementing procedures addressing risk assessment, communication, monitoring, and compliance oversight for federal grants.
The current Board of County Commissioners acknowledges the finding. The Board is committed to improving the identification, tracking, and reporting of federal awards. County officials will continue working with auditors and department heads to strengthen reconciliation and review procedures and ensu...
The current Board of County Commissioners acknowledges the finding. The Board is committed to improving the identification, tracking, and reporting of federal awards. County officials will continue working with auditors and department heads to strengthen reconciliation and review procedures and ensure federal activity is accurately reported on the Schedule of Expenditures of Federal Awards.
VIEWS OF RESPONSIBLE OFFICIALS Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP an...
VIEWS OF RESPONSIBLE OFFICIALS Management is responsible for designing and maintaining internal controls over financial reporting that is sufficient to provide reasonable assurance that management can prepare the financial statement and the Uniform Guidance Audit Report in conformity with US GAAP and federal regulations. Management will improve accounting and financial reporting policies and procedures to include the timely insurance of the financial statement and the uniform guidance report. IMPLEMENTATION DATE March 31, 2027 RESPONSIBLE PERSON Naelia Cruz Cañals, CFO
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