Corrective Action Plans

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Suspension and Debarment – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies and procedures for internal staff to monitor all vendors for suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement wi...
Suspension and Debarment – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies and procedures for internal staff to monitor all vendors for suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies and procedures for internal staff to monitor all vendors for suspension and debarment. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
Reporting – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement a policy to record and retain review of all reports, and to retain proof of submission to verify timeliness of submission of required reports. Explanation of disagreement with audit find...
Reporting – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement a policy to record and retain review of all reports, and to retain proof of submission to verify timeliness of submission of required reports. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies to record and retain review of all reports, and to retain proof of submission to verify timeliness of submission of required reports. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
Cash Management – Assistance Listing Number 14.251 Recommendation: We recommend that management establish and implement policies to retain proof of amounts requested for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will establish and implement policies to retain proof of amounts requested for reimbursement. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2026
Procurement Policy – Assistance Listing Number 14.251 Recommendation: We recommend management update the procurement policy to be in line with Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The O...
Procurement Policy – Assistance Listing Number 14.251 Recommendation: We recommend management update the procurement policy to be in line with Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will update the procurement policy to be in line with Uniform Guidance. Name of the contact person responsible for corrective action: Joel Bailey Planned completion date for corrective action plan: December 31, 2027
With regard to Federal Award Finding 2025-002, Expenditure Approval Documentation –Significant Deficiency, in the audit report for Samaritan House, Inc. for the year ended December 31, 2025, we offer the following response: Reconciliation Reviews: Reconciliations for all bank accounts and organizati...
With regard to Federal Award Finding 2025-002, Expenditure Approval Documentation –Significant Deficiency, in the audit report for Samaritan House, Inc. for the year ended December 31, 2025, we offer the following response: Reconciliation Reviews: Reconciliations for all bank accounts and organizational credit cards are now reviewed by both the Board Treasurer and the Executive Director. This review requirement has been formally reinforced within Samaritan House’s internal financial policies and communicated across the finance team. Documentation of each journal entry and reconciliation review is maintained either electronically or in physical form, with verification records retained on file. These practices ensure consistent oversight, proper segregation of duties, and clear evidence of compliance with established financial controls. Cassidy Kipp and Jewel Groves-Goss are responsible for completing this corrective action by Dec 31, 2026.
Finding Number: 2025-003 Condition: The Organization failed to submit monthly reimbursement requests to HIAS by their due dates during the year ended June 30, 2025. Planned Corrective Action: The Organization has implemented system and process improvements to ensure timely submission. The Organizati...
Finding Number: 2025-003 Condition: The Organization failed to submit monthly reimbursement requests to HIAS by their due dates during the year ended June 30, 2025. Planned Corrective Action: The Organization has implemented system and process improvements to ensure timely submission. The Organization has and will continue to maintain appropriate staffing level and sufficient training to ensure timely submission. This plan does not account for circumstances beyond JFS’s control such as timing of funding approval from the grantor. Non-controllable delays will be documented by JFS and reports submitted in a reasonable amount of time following approval. Contact Person Responsible for Corrective Action: Justin Fisher, Senior Director of Accounting Anticipated Completion Date: August 31, 2026
Finding Number: 2025-002 Condition: The Organization failed to accumulate all expenditures of federal awards into their SEFA resulting in an understatement of expenditures on their 2025 SEFA. Planned Corrective Action: Management has implemented a formal SEFA preparation checklist that includes reco...
Finding Number: 2025-002 Condition: The Organization failed to accumulate all expenditures of federal awards into their SEFA resulting in an understatement of expenditures on their 2025 SEFA. Planned Corrective Action: Management has implemented a formal SEFA preparation checklist that includes reconciliation of total federal expenditures to the general ledger and grant records. This includes establishing a control to identify all federal awards by ALN, including pass-through funding, prior to SEFA finalization and enhanced management review procedures to include verification of completeness and accuracy. Additionally, management will coordinate with program personnel to ensure all sources of federal funding are captured. Contact Person Responsible for Corrective Action: Justin Fisher, Senior Director of Accounting Anticipated Completion Date: August 31, 2026
Finding Number: 2025-001 Condition: The Organization failed to correctly record grant revenue for certain federal programs with direct client assistance revenues during their 2025 fiscal year. Planned Corrective Action: Management will continue to evaluate current processes and practices to determin...
Finding Number: 2025-001 Condition: The Organization failed to correctly record grant revenue for certain federal programs with direct client assistance revenues during their 2025 fiscal year. Planned Corrective Action: Management will continue to evaluate current processes and practices to determine that contributions are being recognized on a gross or net basis dependent on the agency status of the transaction. This will include building out currently utilized flowcharts/checklists as well as adding indicators into their assessment which will result in additional clarity regarding the agency status of the transaction and ensuring that revenues and expenses are being appropriately matched in the correct period for these conditional contributions from the federal government. Contact Person Responsible for Corrective Action: Justin Fisher, Senior Director of Accounting Anticipated Completion Date: August 31, 2026
Root Cause: The organization failed to correctly process claims under the correct contract. Once errors were detected, a correction was attempted in the CMBHS system, but the system reprocessed the claim with the original incorrect data and it could not be corrected. In addition, finance personnel l...
Root Cause: The organization failed to correctly process claims under the correct contract. Once errors were detected, a correction was attempted in the CMBHS system, but the system reprocessed the claim with the original incorrect data and it could not be corrected. In addition, finance personnel lacked sufficient knowledge and training on how to prepare a Schedule of Expenditures of Federal Awards (SEFA) that accurately reconciles to the general ledger (GL). Corrective Action: 1. Review of existing policies and procedures for completeness. 2. Require supervisory review and approval of all grant-related expenditures prior to posting in external CMBHS system. 3. Continue to conduct training for finance staff on importance of data accuracy when processing in external systems. 4. Continue to reach out to CMBHS help desk and our contract manager to address issues as they arise. 5. Continue to perform monthly and quarterly internal monitoring reviews of grant expenditures to submitted claims. 6. Review of SEFA report with accounting team prior to submission to auditors Responsible Person: Patricia Guerra Implementation Date: • Supervisory review implementation: September 15, 2026 • Staff training: September 15, 2026 • Monthly and Quarterly monitoring reviews: Beginning September 30, 2026 Expected Outcome: All federal grant claims will be processed under the correct contract reducing the risk of future noncompliance
Finding Number: 2025-007 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...
Finding Number: 2025-007 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Finding Number: 2025-006 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corre...
Finding Number: 2025-006 Condition: The Township did not have the appropriate controls in place to ensure reports and reimbursement requests that were required to be submitted under the grant were complete and accurate as well as ensuring the matching requirement was properly reviewed. Planned Corrective Action: The Township will update the Grant Policy to include a requirement for dual review on all grant reporting. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Finding Number 2025-005 Condition: The Township did not have a control in place to retain evidence that it performed a check to verify the contractors used under these programs were not suspended or debarred. Planned Corrective Action: The Township will put controls in place around retaining support...
Finding Number 2025-005 Condition: The Township did not have a control in place to retain evidence that it performed a check to verify the contractors used under these programs were not suspended or debarred. Planned Corrective Action: The Township will put controls in place around retaining support for suspension and debarment verifications. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
ecommendation: We recommend management implement and enforce standardized payroll controls to ensure time punch cards or equivalent timekeeping documentation are completed, reviewed, and retained. Management should also ensure employee pay rates, whether salary or hourly, are authorized, supported i...
ecommendation: We recommend management implement and enforce standardized payroll controls to ensure time punch cards or equivalent timekeeping documentation are completed, reviewed, and retained. Management should also ensure employee pay rates, whether salary or hourly, are authorized, supported in personnel files, and agree to payroll system rates. Additionally, management should ensure hours are accurately applied between regular and overtime categories, and that supporting payroll documentation is retained in accordance with the Authority’s record retention policy and applicable requirements. Further internal controls have been implemented through the migration to iSolved software as part of MRI implementation for both housing software and fee accounting services. These additional changes are as follows: • Each employee must review and verify their entire timecard in the system after the pay period and prior to payroll processing. The supervisor must subsequently verify the timecard after the employee has done so. The timecard and these verifications are retained in the automated system indefinitely. • If an employee punches outside the geofenced work location, the supervisor must enter a note in the automated system explaining why this occurred and whether the punch was allowed within policy or not. Additionally, the geolocation of the punch is retained by the system indefinitely. • If an employee misses a punch, the supervisor must be the one to enter the correction and must enter a note regarding the reason for the error. These records are retained in the system indefinitely. • After payroll records are verified by the employee and supervisor, the Executive Director prints timecard reports for all employees and attaches supporting documentation for any extraordinary pay events, such as a pay rate change, mileage reimbursement, Medicare stipend, bereavement leave, etc. • These reports and documentation are forwarded to the Compliance Officer who reviews all records in accordance with a payroll processing checklist. This checklist ensures the supervisor has completed all steps listed above, and that all required supporting documentation are included with the timecard record and reflect correctly in the pre-payment pay register. • After Compliance Officer reviews pre-payment records, the Financial Specialist completes a second review using a second checklist, verifying all direct deposit information is correct, withholdings and benefits reflect correctly, and supporting documentation is included. Once all records are verified, the Financial Specialist executes payroll. • After Payroll is executed, records are returned to supervisor to file all documents back in each employee folder for retention with the employee’s permanent employee file. Corrective Action: Upon taking the position, and prior to this audit, the new Executive Director implemented an automated timekeeping system, eliminating the complicated hand-punch clock system. This first step eliminated hours of follow-up work needed by the bookkeeper. The new system required staff to be within a geo-fenced area when punching and provides management with a mapped location for every punch. Responsible Party: Executive Director Anticipated Completion Date: Complete
2025-005: Inadequate Monitoring of Tenant End-of-Participation Status Recommendation: We recommend management implement and enforce standardized procedures to (1) promptly identify and document tenant move-outs, (2) complete and retain end-of-participation documentation timely, and (3) ensure HAP pa...
2025-005: Inadequate Monitoring of Tenant End-of-Participation Status Recommendation: We recommend management implement and enforce standardized procedures to (1) promptly identify and document tenant move-outs, (2) complete and retain end-of-participation documentation timely, and (3) ensure HAP payments are discontinued effective the appropriate date. Management should also perform periodic supervisory reviews of tenant status changes to help ensure program records are accurate and current. Corrective Action: Upon taking the position, and prior to this audit, the new Executive Director (ED), began the transition away from the current housing software and has settled on PHA Pro as the replacement system. The new system will ensure standardized procedures for identifying move outs, verifying documentation, and ensuring HAP payments are discontinued in a timely manner with the appropriate move-out date. Additionally, the software provides tools for management, compliance staff, and outside agencies to review detailed work of HCV staff and run reports to confirm close-out actions are up to date. Responsible Party: Executive Director Anticipated Completion Date: November 30, 2026 Responsible Contact: Pamela Flowers, Executive Director Phone Number: 970-565-3831, ext 2270 Email Address: pflowers@mc-ha.org
urrent Year Finding 2025-002: Controls over cash disbursements Recommendation: We recommend management implement and enforce standardized cash disbursement controls requiring invoices to be reviewed and approved prior to payment. At a minimum, controls should include (1) documented evidence of revie...
urrent Year Finding 2025-002: Controls over cash disbursements Recommendation: We recommend management implement and enforce standardized cash disbursement controls requiring invoices to be reviewed and approved prior to payment. At a minimum, controls should include (1) documented evidence of review and approval (e.g., signature/initials and date or electronic approval), (2) segregation of duties between invoice approval and payment processing, and (3) retention of invoice approval documentation in accordance with the Authority’s document retention policy and applicable regulatory requirements. Corrective Action: Upon taking the position, and prior to this audit, the new Executive Director (ED) divided duties between general staff, the Financial Specialist (FS), the Deputy Director (DD), and herself to ensure several levels of review were required prior to payment of any invoices. The procedure is as follows: 1. All purchases must be approved by the ED prior to purchase. If the purchase is above her authority ($15K) she will seek approval from the Board Chairman or the full Board as appropriate. 2. After purchase, the staff will direct the invoice to the DD for review. The DD will ensure documentation of the prior ED approval is included with the invoice before it is brought forward for payment approval. Once all documentation is gathered, it is forwarded to the ED for approval. 3. The ED will review the approval package and stamp the invoice with the date of approval and sign or initial with her approval. Then the approved invoice and all supporting documentation are forwarded to FS for payment. 4. The FS puts all supporting documentation together, enters all information in the accounting system (QB), and executes final payment method with ED additional approval.This process will become even more protected and easily audited by the board and others in the coming months as we begin operations with a payment processor, AvidXchange. This processor’s system will automate the payment of well over 98% of our invoices, retaining all these records in an online system that will link to our new financial software (Lindsey) for highly transparent and detailed audit trail of all cash disbursement activities. All required approvals will still occur but will be facilitated electronically rather than in a paper system. Responsible Party: Executive Director Anticipated Completion Date: Complete
2025-003: Inadequate Documentation of Board Meeting Minutes Recommendation: We recommend management implement and enforce standardized procedures to ensure Board of Commissioner meeting minutes are prepared, reviewed, approved, and retained in a timely manner. Additionally, the Authority should main...
2025-003: Inadequate Documentation of Board Meeting Minutes Recommendation: We recommend management implement and enforce standardized procedures to ensure Board of Commissioner meeting minutes are prepared, reviewed, approved, and retained in a timely manner. Additionally, the Authority should maintain a centralized filing system, either electronic or physical, to ensure minutes are complete, safeguarded, and readily available for audit and regulatory review. Corrective Action: Upon taking the position, and prior to this audit, the new Executive Director (ED) implemented use of the shared data folders on the network drives for storage of important historic and auditable records. This is a highly secure method due to daily backups of the network drives and access controls for the folders within the drives. Among the files created is a folder at the address Admin (T:)\7. Board of Commissioners which contains sub folders organized by year. Within each year, there are folders labeled by meeting date and type of meeting, (i.e. “2026.01.22 Jan Regular Meeting”). Within this folder are all draft documents used to prepare for the meeting and a folder which contains all final documents contained in the published Agenda Packet. The final thing placed in this folder is the .pdf scan of the signed meeting minutes for that meeting after they are approved and signed at the subsequent board meeting. This has ensured an available copy of all approved and signed board meeting minutes is available for all meetings this year to date, and will ensure so in the future, regardless of board or staff turnover. Responsible Party: Executive Director Anticipated Completion Date: Complete
2025-004: Housing Choice Voucher (CFDA 14.871) [REPEAT] Recommendation: We recommend the Authority provide training to Housing Choice Voucher program staff emphasizing the importance of maintaining complete and accurate eligibility documentation. Additionally, the Authority should evaluate the implem...
2025-004: Housing Choice Voucher (CFDA 14.871) [REPEAT] Recommendation: We recommend the Authority provide training to Housing Choice Voucher program staff emphasizing the importance of maintaining complete and accurate eligibility documentation. Additionally, the Authority should evaluate the implementation of an electronic document management system to improve file organization, reduce the risk of misplacement, and ensure timely access to required records for compliance and audit purposes. Corrective Action: Upon taking the position, and prior to this audit, the new Executive Director (ED) hired a new Voucher Specialist. That specialist attended training and received a Certification as an Occupancy Specialist Voucher on January 23, 2026. In addition, the Housing Authority began the transition away from the current housing software and has settled on PHA Pro as the replacement system. This software will provide electronic documents and file management eliminating paper case files upon its implementation. This will allow wider audit capability and ensure tighter controls over processing timelines, ensuring compliance can be more readily verified by management and other agencies. Responsible Party: Executive Director Anticipated Completion Date: November 30, 2026
2025-001 Federal Awards Internal Control CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Commission will review policies and procedures to ensure compliance with the Uniform Gui...
2025-001 Federal Awards Internal Control CORRECTIVE ACTION PLAN (CAP): Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Actions Planned in Response to Finding: The Commission will review policies and procedures to ensure compliance with the Uniform Guidance. Official Responsible for Ensuring CAP: Jessica Beyer, Deputy Director, is the official responsible for ensuring corrective action. Planned Completion Date for CAP: June 30, 2026 Plan to Monitor Completion of CAP: The Board of Directors will be monitoring this corrective action plan. Jessica Beyer Deputy Director
Northeast Florida Community Action Agency, Inc. agrees with the findings. Our organization will take action to correct the composition of the tripartite board by appointing the required representatives as soon as possible. The Executive Director is responsible for ensuring the agency remains in comp...
Northeast Florida Community Action Agency, Inc. agrees with the findings. Our organization will take action to correct the composition of the tripartite board by appointing the required representatives as soon as possible. The Executive Director is responsible for ensuring the agency remains in compliance. Moving forward, the Executive Director will review the board composition quarterly to ensure that all vacant positions are filled. This will help maintain the integrity of the agency’s Board of Directors at all times.
Governance and management concur with this finding, and continue to build an effective team in the finance department.
Governance and management concur with this finding, and continue to build an effective team in the finance department.
Governance and management concur with this finding, and continue to build an effective team in the finance department.
Governance and management concur with this finding, and continue to build an effective team in the finance department.
Governance and management concur with this finding, and continue to build an effective team in the finance department.
Governance and management concur with this finding, and continue to build an effective team in the finance department.
Auditee Response The Commission will review their internal control policies for compliance with regarding Board Member's access to information from daily operations and document these policies. Management's Response - The Commission will review their internal control policies for compliance with reg...
Auditee Response The Commission will review their internal control policies for compliance with regarding Board Member's access to information from daily operations and document these policies. Management's Response - The Commission will review their internal control policies for compliance with regarding Board Member's access to information from daily operations and document these policies. Action Plan - The commission's management will review their internal control policies for compliance regarding Board Member's access to information from daily operations and document these policies and present it to the Board. present it to the Board.
Auditee Response The Commission will review their internal control policies for compliance with Resident Opportunity and Supportive Services Program tenants to ensure compliance with the program. Management's Response - The Commission will review their internal control policies for compliance with R...
Auditee Response The Commission will review their internal control policies for compliance with Resident Opportunity and Supportive Services Program tenants to ensure compliance with the program. Management's Response - The Commission will review their internal control policies for compliance with Resident Opportunity and Supportive Services Program tenants to ensure compliance with the program. Action Plan - The commission's management continues to review and update file deficiencies and has hired an outside firm to assist in this matter. We expect this process to be completed by June 30, 2026.
Auditee Response The Commission will review their internal control policies for compliance with PIH Family Self— Sufficiency Program tenants to ensure compliance with the program. Management's Response - The Commission will review their internal control policies for compliance with PIH Family Self— ...
Auditee Response The Commission will review their internal control policies for compliance with PIH Family Self— Sufficiency Program tenants to ensure compliance with the program. Management's Response - The Commission will review their internal control policies for compliance with PIH Family Self— Sufficiency Program tenants to ensure compliance with the program. Action Plan - The commission's management continues to review and update file deficiencies and has hired an outside firm to assist in this matter. We expect this process to be completed by June 30, 2026.
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