Corrective Action Plans

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In 2024 we received funding from 22 different counties for foster care. These counties are required to provide documentation of the federal funds that were paid out to each agency. We received letters from 4 counties. We rely on these county agencies to provide us with accurate data. In many instanc...
In 2024 we received funding from 22 different counties for foster care. These counties are required to provide documentation of the federal funds that were paid out to each agency. We received letters from 4 counties. We rely on these county agencies to provide us with accurate data. In many instances we receive conflicting information from both counties and other funding agencies. It is our opinion that it is not in our best financial interest to question the agencies that provide us with both income and this data. We will make more inquiries to seek to obtain the correct data from our funding sources in the future. We will work diligently to provide a more accurate and complete SEFA report by the end of 2025 audit period including a secondary review process. Every effort is made to obtain California state issued letters presenting annual federal to state ratios of Foster Care.
The auditee will submit the required single audit report to the FAC immediately and will ensure proper controls are in place so the Single Audit reporting package is filed timely.
The auditee will submit the required single audit report to the FAC immediately and will ensure proper controls are in place so the Single Audit reporting package is filed timely.
Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director
Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director
Management will implement measures to ensure thst financial statements are completed as expeditiously as possibe to enable the Single Audit to be completed in the required time frame. A new Grants Manager has been employed to ensure timely completion of the Financial and Single Audits.
Management will implement measures to ensure thst financial statements are completed as expeditiously as possibe to enable the Single Audit to be completed in the required time frame. A new Grants Manager has been employed to ensure timely completion of the Financial and Single Audits.
Unexpected staffing challenges contributed to the late inspections. Action taken to date by the Vice President of Program Services. 1. Staffing Structure Strengthened: o A new Program Director has been hired and is fully trained in all HOPWA program requirements, including inspection procedures. o A...
Unexpected staffing challenges contributed to the late inspections. Action taken to date by the Vice President of Program Services. 1. Staffing Structure Strengthened: o A new Program Director has been hired and is fully trained in all HOPWA program requirements, including inspection procedures. o Additional staff members have now been trained to conduct HOPWA inspections to always ensure operational coverage. 2. Cross-Training of Staff: o Multiple team members, including the Director and program service staff, are cross-trained and able to step in to complete inspections if the assigned case manager is unavailable due to illness, emergency leave, or other unforeseeable circumstances. 3. Backup Coverage Plan Implemented: o A formal backup coverage system is now in place. In the event of staff absence, either the Program Director or another trained staff member will complete the scheduled inspection to avoid any delay. o Coverage responsibilities also include providing client support and ensuring continuity of services when primary staff are out. 4. Scheduling and Monitoring: o Inspection schedules are now reviewed monthly (between case mgr. and director) to ensure upcoming deadlines are clearly identified, monitored, and met. Outcome Expected: These corrective measures ensure that all annual HOPWA inspections will be completed on time, regardless of staffing changes or unforeseen absences. The increased number of trained staff and the implementation of a clear backup plan reduce the risk of future delays and strengthen program compliance.
To date, The Director of Housing Choice Vouchers (Section 8) have tested all our reports to ensure they are properly filtered to include all tenant with approaching recertifications will be performed timely.
To date, The Director of Housing Choice Vouchers (Section 8) have tested all our reports to ensure they are properly filtered to include all tenant with approaching recertifications will be performed timely.
2024-005 - In October 2023, NYSHCR implemented a new software system, requiring all Local Administrators to transition to the Emphasys Elite system. In 2025, NYSHCR determined that the Waiting List Reports for prior periods could not be regenerated due to system limitations. This issue was related t...
2024-005 - In October 2023, NYSHCR implemented a new software system, requiring all Local Administrators to transition to the Emphasys Elite system. In 2025, NYSHCR determined that the Waiting List Reports for prior periods could not be regenerated due to system limitations. This issue was related to the software system itself and was not the result of any error or omission by RUPCO. The NYS HCR Procedure Manual, released on July 14, 2025 (page 47), instructs Local Administrators to retain copies of all sort/draw reports when selecting applicants from the Waiting List. Moving forward, The Director of Housing Choice Voucher (Section 8) will maintain records of all sort/draw reports in accordance with NYSHCR guidance to ensure full compliance and ease of verification.
Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal procurement and suspension and debarment requirements, and it did not comply with federal suspension and debarment requirements.Name, address, and telephone of Dist...
Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal procurement and suspension and debarment requirements, and it did not comply with federal suspension and debarment requirements.Name, address, and telephone of District contact person: Kristina Ribellia 903 W. 3rd Ave. Moses Lake, WA 98837 509-765-9618 Corrective action the auditee plans to take in response to the finding: The District agrees with the finding. At the time of contracting, staff were unaware of the specific federal verification requirement under 2 CFR 180.220 and 2 CFR 200.213. Immediately upon notification, the District verified that the contractor was not suspended or debarred, and no questioned costs were identified. The District has developed formal written procurement procedures consistent with 2 CFR 200.318–200.327 and state procurement laws. These procedures will be presented to the Board of Supervisors for review and adoption at an upcoming public meeting and will be incorporated into the District’s Administrative and Operations Procedures Manual once approved. In addition, the District has drafted a Suspension and Debarment Verification Procedure, which will require verification of all contractors receiving $25,000 or more in federal funds through SAM.gov prior to contract execution. Documentation of this verification will be retained for all federally funded agreements once the procedure is adopted. The District appreciates the SAO’s constructive recommendations and remains committed to implementing these new policies promptly. We are dedicated to continuous improvement in our policies, processes, and internal controls to ensure ongoing compliance and transparency in the administration of public funds. Anticipated date to complete the corrective action: December 2025
Finding: Material weakness in internal control over Schedule of Expenditures of Federal Awards (SEFA) reporting Corrective action: Pacific Forum will ensure all new grants, including pass-through awards, are properly reviewed to ensure they are included in the SEFA, if necessary. The requirement to ...
Finding: Material weakness in internal control over Schedule of Expenditures of Federal Awards (SEFA) reporting Corrective action: Pacific Forum will ensure all new grants, including pass-through awards, are properly reviewed to ensure they are included in the SEFA, if necessary. The requirement to reconcile federal grant expenditures with federal financial reporting and cash draws will be incorporated into PFI financial reporting and cash management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted ...
Finding: Significant deficiency in internal control for late submission of data control form and Single Audit report package. Corrective action: Pacific Forum has authorized its outsourced accounting service to take on a larger role in fulfilling auditor requests to ensure the information submitted is accurate and complete. PFI has also consolidated financial management policies and other required documentation in a secure cloud network. PFI has also adopted more features available through Bill.com, which has enhanced documentation of expenditures and management reviews. Procedures for filing documents and utilizing financial management procedures available through Bill.com will be integrated into PFI financial management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Material weakness in internal control over documenting supervisory reviews of financial and performance reports prior to submission Corrective action: Pacific Forum has adopted a policy that requires the Executive Director to review performance and financial reports prior to submission to r...
Finding: Material weakness in internal control over documenting supervisory reviews of financial and performance reports prior to submission Corrective action: Pacific Forum has adopted a policy that requires the Executive Director to review performance and financial reports prior to submission to relevant grantor. The Grants Manager has established a suspense system to ensure reports are submitted in a timely manner. These procedures will be incorporated into PFI financial reporting guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Material weakness in internal control over documenting suspension and debarment reviews for vendors receiving federal funds Corrective action: PFI has adopted a policy to document the screening of all vendors receiving federal funds via the suspension and debarment list provided in SAM.gov....
Finding: Material weakness in internal control over documenting suspension and debarment reviews for vendors receiving federal funds Corrective action: PFI has adopted a policy to document the screening of all vendors receiving federal funds via the suspension and debarment list provided in SAM.gov. These procedures will be incorporated into PFI procurement policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Material weakness in internal control over procurement policies Questioned costs: ALN 81:113 ($31,120) ALN 19.901 ($15,000) Corrective action: While PFI accepts the finding and the rationale for identifying questioned costs based on Uniformed Guidance (UG) requirements for documentation reg...
Finding: Material weakness in internal control over procurement policies Questioned costs: ALN 81:113 ($31,120) ALN 19.901 ($15,000) Corrective action: While PFI accepts the finding and the rationale for identifying questioned costs based on Uniformed Guidance (UG) requirements for documentation regarding competitive bidding and contract types, it believes there is adequate documentation to justify incurred costs. PFI will update its procurement policy guidelines to reflect current UG requirements to include acquisition thresholds and competitive bidding procedures. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Significant deficiency in internal control over federal cash drawdowns Corrective action: Pacific Forum has adopted new financial controls policies to ensure federal cash drawdowns are completed in a timely manner and reviewed by management. The Director of Development prepares a financial ...
Finding: Significant deficiency in internal control over federal cash drawdowns Corrective action: Pacific Forum has adopted new financial controls policies to ensure federal cash drawdowns are completed in a timely manner and reviewed by management. The Director of Development prepares a financial report that shows the amount that can be invoiced/drawn down from federal funds based on actual expenditures. The Executive Director approves the request for funds prior to submission to the funding organization. These procedures will be incorporated into PFI cash management policy guidelines. Completion Date: February 1, 2026. Responsible Individual: Executive Director
Finding: Material weakness in internal control over period of performance Corrective action: Pacific Forum will incorporate policies into expense management and financial reporting guidelines to ensure all expenditure is completed within the period of performance and reviews by management are proper...
Finding: Material weakness in internal control over period of performance Corrective action: Pacific Forum will incorporate policies into expense management and financial reporting guidelines to ensure all expenditure is completed within the period of performance and reviews by management are properly documented. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Material weakness in internal control over allowable costs and compliance with requirement for written documentation of transactions review required for federally funded awards Corrective action: PFI has adopted a policy to document transaction reviews. Email approval documentation is requi...
Finding: Material weakness in internal control over allowable costs and compliance with requirement for written documentation of transactions review required for federally funded awards Corrective action: PFI has adopted a policy to document transaction reviews. Email approval documentation is required for all transactions, including initial approval by the Program Director and final approval by the Executive Director. This policy will be incorporated into PFI expense management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director
The District’s Business Manager will obtain quotes/bids when necessary.
The District’s Business Manager will obtain quotes/bids when necessary.
Management will complete the audit filing with the federal audit clearinghouse by the deadline going forward.
Management will complete the audit filing with the federal audit clearinghouse by the deadline going forward.
VIEWS OF RESPONSIBLE OFFICIALS As part of the Corrective Action Plan to address the identified findings, the following measures will be implemented: • We are currently in the process of drafting the corresponding administrative order, for which a preliminary draft has already been prepared. This doc...
VIEWS OF RESPONSIBLE OFFICIALS As part of the Corrective Action Plan to address the identified findings, the following measures will be implemented: • We are currently in the process of drafting the corresponding administrative order, for which a preliminary draft has already been prepared. This document aims to clearly and systematically establish the necessary processes and procedures, including those related to the identified deficiencies, to ensure the implementation of enhanced controls that guarantee regulatory compliance and operational efficiency. • A fiscal section within the Office of Federal Affairs will be established to manage the fiscal process of federal funds. This structure will ensure that all transactions, corrections, and journal entries are recorded in a timely and accurate manner in the federal accounting accounts. IMPLEMENTATION DATE Fiscal Year 2025-2026 RESPONSIBLE PERSON Maritza Torres López
VIEWS OF RESPONSIBLE OFFICIALS As part of the Corrective Action Plan to address the identified findings, the following measures will be implemented: • Prior to issuing the SEFA, a final review and approval process will be implemented which will include: o Confirmation that all active federal program...
VIEWS OF RESPONSIBLE OFFICIALS As part of the Corrective Action Plan to address the identified findings, the following measures will be implemented: • Prior to issuing the SEFA, a final review and approval process will be implemented which will include: o Confirmation that all active federal programs are included. o Validation of amounts, ALN, and expense classifications. • Responsible personnel will be retrained on the processes and requirements applicable to SEFA preparation, in order to strengthen compliance and accuracy in reporting. • We are currently in the process of drafting the corresponding administrative order, for which a preliminary draft has already been prepared. This document aims to clearly and systematically establish the necessary processes and procedures, including those related to the identified deficiencies, to ensure the implementation of enhanced controls that guarantee regulatory compliance and operational efficiency. • A fiscal section within the Office of Federal Affairs will be established to manage the fiscal process of federal funds. This structure will ensure that all transactions, corrections, and journal entries are recorded in a timely and accurate manner in the federal accounting accounts.. IMPLEMENTATION DATE Fiscal Year 2025-2026 RESPONSIBLE PERSON Maritza Torres López
VIEWS OF RESPONSIBLE OFFICIALS As part of the Corrective Action Plan to address the identified findings, the following measures will be implemented: • For the preparation of the SEFA, all accounts related to disaster funds will be included, considering that these accounts were segregated into revenu...
VIEWS OF RESPONSIBLE OFFICIALS As part of the Corrective Action Plan to address the identified findings, the following measures will be implemented: • For the preparation of the SEFA, all accounts related to disaster funds will be included, considering that these accounts were segregated into revenues and expenses by the Department of the Treasury. Both categories will be properly incorporated into the SEFA preparation process. • Federal reimbursements received will be immediately identified, and the corresponding journal entries will be prepared without delay to accurately reflect the associated expenses. • Journal entries related to the reimbursement received will be prepared, and the expenses will be recorded in the appropriate accounting accounts, ensuring proper classification and compliance with federal requirements. • We are currently in the process of drafting the corresponding administrative order, for which a preliminary draft has already been prepared. This document aims to clearly and systematically establish the necessary processes and procedures, including those related to the identified deficiencies, to ensure the implementation of enhanced controls that guarantee regulatory compliance and operational efficiency. • Responsible personnel will be retrained on the processes and requirements applicable to SEFA preparation, in order to strengthen compliance and accuracy in reporting. • A fiscal section within the Office of Federal Affairs will be established to manage the fiscal process of federal funds. This structure will ensure that all transactions, corrections, and journal entries are recorded in a timely and accurate manner in the federal accounting accounts. IMPLEMENTATION DATE Fiscal Year 2025-2026 RESPONSIBLE PERSON Maritza Torres López
Corrective Action Plan Fiscal Year 2024 Audit AYUDA, INC. Introduction AYUDA, INC. has prepared this Corrective Action Plan in response to observations identified during the Fiscal Year 2024 audit. This plan outlines management’s actions to further strengthen internal processes, enhance coordination...
Corrective Action Plan Fiscal Year 2024 Audit AYUDA, INC. Introduction AYUDA, INC. has prepared this Corrective Action Plan in response to observations identified during the Fiscal Year 2024 audit. This plan outlines management’s actions to further strengthen internal processes, enhance coordination, and support continued compliance with applicable financial and reporting requirements. The organization maintains established financial and governance practices and views the audit process as an opportunity to reinforce existing controls, clarify responsibilities, and formalize procedures that support efficiency and timeliness. The corrective actions described below are intended to enhance consistency and scalability as organizational operations continue to evolve. Finding 2: Single Audit Report Submission Timeline Condition The audit noted that the Single Audit report submission occurred later than the initially established timeframe. Contributing Factors Factors influencing this observation include: • Opportunities to initiate audit planning earlier within the fiscal cycle. • The need for more clearly defined internal timelines supporting audit coordination. • Increased audit scope and complexity requiring enhanced documentation readiness and cross-functional coordination. Corrective Action Plan 1. Early Audit Planning Management will initiate audit planning earlier in the fiscal year, including confirmation of audit timelines, documentation requirements, and key deliverables. Responsible Party: Sr. Accountant 2. Pre-Audit Readiness Procedures Standardized pre-audit preparation procedures will be followed, including advance completion of reconciliations, schedules, and supporting documentation. Responsible Party: Finance Department 3. Defined Internal Audit Timeline A formal internal audit timeline with clearly defined milestones will be established and monitored throughout the audit cycle. Responsible Party: Sr. Accountant and Executive Director 4. Ongoing Communication with Auditors Regular status check-ins with external auditors will be scheduled to monitor progress, address issues proactively, and support timely completion. Responsible Party: Finance Department 5. Resource and Capacity Planning Management will periodically assess staffing levels and workload distribution related to audit preparation to ensure adequate capacity during critical audit periods. Responsible Party: Finance Department Certification This Corrective Action Plan has been reviewed and approved by management of AYUDA, INC. Name: Miguel Chacon Title: Executive Director Date: 10/18/2025 Name: Paul Rivera Title: Sr. Accountant Date: 10/18/2025
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiate...
In October 2024, immediately after the above-referenced fraud was committed, SELF created a new policy with tighter internal controls in regard to ACH payments. The new policy requires multiple staff members to verify any banking information (in multiple ways) before any such payment can be initiated. The new policy was approved shortly thereafter by the organization’s board. SELF also contracted with a digital security company to train all employees about digital threat awareness including fraud and phishing attempts, specifically via email. As part of these new practices, all employees are required to participate in monthly training.
09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period:...
09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period: 9/1/2023 – 8/31/2025 Contract Number: 26030 2024-003 Internal Controls and Compliance over Allowable Costs and Activities – Payroll (Material Weakness and Material Noncompliance) Recommendation: We recommend the Organization review its timekeeping policies and procedures and provide additional training to employees to ensure time sheets are retained for all payroll transactions to support the allocation of compensation. We also recommend the Organization review and refine its policies to reconcile the percentage of hours charged on the time sheets to the budget estimates used to bill Federal and State grantors. This should be done in conjunction with monthly or quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Organization’s fiscal year). Corrective Action: AVDA implemented a formal Timekeeping and Payroll Compliance Policy in June 2025. All employees funded by Federal or State grants are now required to complete bi-weekly electronic functional time sheets that identify time spent on tasks by budgeted grant(s). Supervisors must review and approve all time sheets prior to submission. The Director of Finance will reconcile budget estimates to actual hours monthly, and quarterly reviews will ensure accuracy in allocations. Training on grant timekeeping standards (2 CFR §200.430) was provided to all program directors and staff in July 2025. Responsible Parties: - Lisa Mikosh, Director of Finance - Marcello Gonzales, Bookkeeper - Maisha Colter, CEO (policy approval and oversight) Date Corrected: August 15, 2025
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