Corrective Action Plans

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Finding 2025-002 – L. Reporting Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.069, Public Health Emergency Preparedness Award Period: January 1, 2025 through December 31, 2025 Summary of finding: A material weakness in i...
Finding 2025-002 – L. Reporting Identification of the federal program: Federal Agency: U.S. Department of Health and Human Services Assistance Listing No: 93.069, Public Health Emergency Preparedness Award Period: January 1, 2025 through December 31, 2025 Summary of finding: A material weakness in internal control over compliance was issues related to preparation of the Schedule of Expenditures of Federal Awards (the Schedule) for Norton Healthcare, Inc and Affiliates (the Corporation). The Corporation’s internal controls over the preparation of the Schedule were not sufficient to properly accumulate and accurately report expenditures of federal awards. Planned corrective action: To ensure accurate reporting of expenditures of federal awards on the Schedule, management will implement procedures for grants awarded by non-federal entities to determine if the Corporation is a subrecipient of federal funds including obtaining and retaining documentation of this conclusion directly from the awarding entity. Further, additional levels of review of this process as well as the compilation of the amounts reported on the Schedule will be implemented. Anticipated completion date: May 31, 2027 Responsible contact person: Jane Brooks
Audit Finding: 2025-002: Untimely Submission of Federal Financial Reports (SF 425) – Reporting – Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster (Repeat Finding) Type of Finding: Significant Deficiency in Internal Control Over Compliance Cause – Controls and procedur...
Audit Finding: 2025-002: Untimely Submission of Federal Financial Reports (SF 425) – Reporting – Assistance Listing Numbers: 93.224 and 93.527 Consolidated Health Center Cluster (Repeat Finding) Type of Finding: Significant Deficiency in Internal Control Over Compliance Cause – Controls and procedures designed to ensure timely preparation, review, and submission of required federal financial reports were not consistently followed during fiscal year 2025, resulting in delayed submission of SF-425 reports. Corrective Actions: 1. Due to turnover in the CFO role, there was a delay in the submissions of the FFR. This finding has been corrected with the implementation of a contractual financial services team. 2. Additional preventative internal control procedures were implemented designating a secondary individual responsible for submission of the Federal Financial Reports should the primary individual be absent, on leave, or terminated. 3. These procedures and internal controls were implemented in January 2026.
Responsible contact(s): Steve, Staff Accountant - AR, for financial reports; Program Directors/Managers for performance reports; Agnes, Controller, for financial review; Laura, CFO, for oversight. Participating staff: Program reporting staff and designated backups; Steve, with support from Sharon, f...
Responsible contact(s): Steve, Staff Accountant - AR, for financial reports; Program Directors/Managers for performance reports; Agnes, Controller, for financial review; Laura, CFO, for oversight. Participating staff: Program reporting staff and designated backups; Steve, with support from Sharon, for calendar/evidence support; Trina and AP staff for underlying reconciliations. During part of 2026, AEA did not submit the reports as required by the award on a timely manner, this was corrected for the August 2026 submissions. 1. Create a complete award-reporting calendar. Steve and each Program Manager will inventory executed agreements, amendments, and reporting instructions. The register will show award, report type, reporting period, actual contractual due date, submission method, preparer, reviewer, submitter, backup, and evidence link. Agnes will validate requirements and updates; an organization-wide assumed due date will not replace award terms. 2. Build in lead time. Using the external due date as D, AEA will target source data by D minus 10 business days, drafts by D minus 7, review by D minus 5, and submission by D minus 2. Where the reporting window is shorter, Agnes and the Program Director will set feasible earlier internal milestones without changing the external deadline. 3. Assign substantive review. Steve will prepare and reconcile financial reports to the ledger, approved payroll/allocations, prior cumulative reports, budget categories, and claim adjustments. Agnes will independently approve financial accuracy. Program staff will prepare performance results and explanations, and the Program Director will approve them. Finance and Programs will reconcile financial and performance data where related; authorized certifications will be obtained. 4. Retain proof and escalate risk. The designated submitter, program staff, will send a copy of the submitted report to Steve. Steve will save the email, copy of the submitted report, retain the final approved report, dated review, submission timestamp, portal receipt or transmission evidence, funder acknowledgment when available. Steve will index evidence and follow up on rejections. Missed internal milestones or threatened deadlines will be escalated to Laura within two business days. 5. Resolve prior reporting exceptions. Steve and Program Managers will review 2026, submit any outstanding reports promptly (where applicable), and document unresolved evidence gaps. Late reports will remain classified as late; later submission will not erase the original exception. Anticipated completion Validated complete registers and procedures: October 30, 2026. Historical reporting review: November 30, 2026. Anticipated completion after effectiveness review: January 29, 2027.
Responsible contacts: Laura, CFO; Agnes, Controller; Steve, Staff Accountant - AR; the Program Director responsible; Staff Accountant - AP (vacant). Interim AP: Trina performs the coding check under Agnes' review until AP is filled and trained. Program staff supply expense support; Trina supports hi...
Responsible contacts: Laura, CFO; Agnes, Controller; Steve, Staff Accountant - AR; the Program Director responsible; Staff Accountant - AP (vacant). Interim AP: Trina performs the coding check under Agnes' review until AP is filled and trained. Program staff supply expense support; Trina supports historical review. AEA will evaluate each expenditure based on its documented business purpose, the nature of the activity supported, and the benefit received by the Federal award. The approved budget will guide classification but will not, by itself, establish that a cost is allowable or allocable. Expenses supporting administrative activities will be classified under the applicable award’s administrative-cost requirements, with consistent direct or indirect treatment and no duplicate recovery. Classification decisions and supporting documentation will be retained. 1. Budgeted Expenses visibility. The Program Director will provide the current approved detailed budget, category definitions, and coding instructions to staff who request, incur, or approve expenses, and to AP, Steve, and Agnes. Approved amendments will be shared promptly. Program staff will document each expense's purpose, benefiting activity, fund/award, and proposed category. Evidence of budget distribution and staff instruction will be retained. 2. Expenses coding. AP should also review the invoice, business purpose, benefiting activity, and allocation support. A cost should not pass review merely because it fits an available budget line. Costs must satisfy award restrictions, budget category, receive consistent treatment, and be adequately documented. AP will compare each expense and its support with the approved budget categories and coding instructions before accepting grant coding. Incorrect, unclear, or unsupported submissions will be rejected as coded and returned to Program staff. AP will work with the Program to document corrections and escalate unresolved disagreements to Agnes, then Laura as needed. Disputed coding will not support an award charge or claim until resolved. 3. Budget – Actual expense review. Monthly and before each financial report, Steve will prepare an expense report with the approved budget, current-period and cumulative actual expenses, remaining budget, and variance by category. Actuals will reconcile to the general ledger. Program will review the transaction-level coding. AP and Program staff will investigate variances and classification errors, including administrative costs in program categories. Agnes will review the analysis and proposed corrections; Steve will update reports after approved entries are posted. Program retains financial-review responsibility. Steve or the designated submitter will release only the approved version; later coding changes require renewed review. Oversight and historical correction. Agnes, the Program Director, and Trina will review the expenditures and similar 2026 charges through implementation, document conclusions, and process supported corrections through the journal-entry approval workflow. Laura will oversee implementation and address significant classification judgments, required funder resolution, and report revisions. Anticipated completion For awards ending, Sept 30, 2026, historical review will be completed by October 15, 2026. Interim controls begin October 1, 2026; procedures and training by October 30, 2026; historical review by November 30, 2026. Anticipated completion: January 15, 2027. Monthly monitoring and pre-submission approvals continue thereafter.
Responsible contact(s): Agnes, Controller, for methodology and review; Laura, CFO, for approval; Program Managers for benefit evidence. Participating staff: AP Staff Accountant after onboarding; Trina for interim AP documentation; Steve for claim reconciliation; Trina for allocation-workpaper checks...
Responsible contact(s): Agnes, Controller, for methodology and review; Laura, CFO, for approval; Program Managers for benefit evidence. Participating staff: AP Staff Accountant after onboarding; Trina for interim AP documentation; Steve for claim reconciliation; Trina for allocation-workpaper checks. During 2026, management has been working on a documented, consistently applied allocation methodology. 1. Approve a written allocation plan. Agnes will finalize shared-cost pool, the activities benefiting, the allocation driver, calculation, source records, update frequency, and approval responsibility. Program Managers will substantiate benefit, and Laura will approve the plan. Personnel allocations will follow actual activity under finding 2025-006, not budget availability. 2. Use supportable drivers. Potential drivers include occupied square footage for space-related costs, assigned users for licenses, and documented usage for shared services. These are proposed examples, not AEA's established methodology. The selected basis must fit the benefit received, include all benefiting Federal and non-Federal activities, and be documented. Available grant balances will not determine the allocation. 3. Support each calculation. Trina, and subsequently the AP Staff Accountant, will retain the invoice and approved allocation worksheet showing the full cost, driver quantities, proportions, allocated amounts, and fund/category coding. Agnes and later Trina will check calculations and reconciliation to the source amount; Laura and subsequently Agnes will approve. Steve will reconcile the approved allocation to billed costs and retain supporting references. 4. Prevent inconsistent or duplicate recovery. Agnes will review changes in space, staffing, users, or program activity and update the basis when warranted, with formal quarterly review. Directly charged costs will be excluded from any indirect recovery of the same cost. General administrative pools will follow the applicable indirect-cost method and award limitations; costs will not be shifted to another award to overcome a funding deficiency. 5. Resolve the historical population. Agnes and Program Managers will review 2026 allocations through final implementation. Any reconstructed basis will use credible period-specific evidence, not unsupported hindsight percentages. Laura will approve supported corrections and direct funder resolution where needed. Training will cover invoice preparation, benefit documentation, and approval. Anticipated completion Documented review of all new shared-cost allocations: October 15, 2026. Written allocation plan and training: October 30, 2026. Review of cited items and similar allocations: November 30, 2026. Anticipated completion: February 15, 2027.
Responsible contact(s): Agnes, Controller, and Laura, CFO. Program Directors, Program Managers/Supervisors are accountable for approval of actual work performed. Participating staff: Steve is the allocation preparer; AP Staff Accountant after training; Trina for reconciliation; employees, supervisor...
Responsible contact(s): Agnes, Controller, and Laura, CFO. Program Directors, Program Managers/Supervisors are accountable for approval of actual work performed. Participating staff: Steve is the allocation preparer; AP Staff Accountant after training; Trina for reconciliation; employees, supervisors, and payroll support. Effective Jan 2026, AEA has replaced unsupported flat budget-based salary charges with documented allocations reflecting actual work performed. During the 1st half of 2026, allocation entries were not done monthly; starting in July 2026, the allocations entries have been done monthly. 1. Document actual activity. Employees are recording actual work by award/project and administrative or other non-Federal activity for each pay period in Salesforce. Supervisors and/or Program Managers with direct knowledge review accuracy, program benefit, and grant/category coding. A Paycom (payroll platform) check register report supplies gross pay, compensated absence, and benefit records. Payroll records cover total compensation activity. 2. Reconcile before charging awards. Steve prepares the payroll-to-award allocation. Laura has been reconciling allocations against the grant budgets, and program staff has approved the expenses before invoicing. Starting Q4, 2026, Steve will reconcile allocations to payroll and the ledger, Agnes/Trina will review and post the allocation entries; and the program staff will continue to approve before billing. 3. Control fringe and exceptions. Finance will support fringe and leave treatment under a written, consistently applied method and applicable award terms; it will not use an unsupported flat fringe percentage. Supervisors will resolve missing or changed activity records promptly. Unsupported amounts will be excluded from Federal claims pending resolution, without withholding employees earned pay. 4. Train and monitor jointly. The Salesforce support team has provided training for the employees for entering and for approval. Laura has trained the Finance, and payroll support on activity documentation, allocation changes, and deadlines. Steve will retain the approved allocation with each relevant billing package. Anticipated completion: For awards ending, Sept 30, 2026, historical review will be completed by October 15, 2026. Update written method: October 30, 2026. Anticipated completion after operating-effectiveness review: January 29, 2027.
Management did not fully document the level of effort for key personnel identified as Project Directors who were providing in-kind support to the grant program. Although this grant has ended, management recognizes the importance of maintaining adequate documentation and monitoring procedures for fut...
Management did not fully document the level of effort for key personnel identified as Project Directors who were providing in-kind support to the grant program. Although this grant has ended, management recognizes the importance of maintaining adequate documentation and monitoring procedures for future grants. Management will update its grant policies and procedures to include specific requirements for tracking and documenting in-kind personnel time, as well as an approval and review process to ensure compliance with grant requirements. Contact Person: Kris Sanders, SVP Network Development and Digital Care Delivery Krishandra.Sanders@childrens.com Expected Completion Date: December 31, 2026
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records ar...
Special Programs for the Aging, Title III, Part C, Nutrition Services - Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management should strengthen controls over Community Dining participant tracking to ensure participant records are reviewed and supported by appropriate documentation. Management should also implement monitoring procedures to verify that participant counts and listings are complete, accurate, and properly supported. Explanation of disagreement with audit finding: There is no disagreement with the finding. Action taken in response to finding: Sound Generations is updating procedures to strengthen controls over recording participant information, including participant profiles and meal services. Administrative staff will conduct regular site visits to train and monitor site staff and volunteers on these procedures. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2027.
Enhanced Mobility of Seniors and Individuals with Disabilities – Assistance Listing No. 20.513 Recommendation: Management should review and strengthen its controls over the allocation of expenditures to federal programs to ensure costs charged to federal awards are allowable, properly supported, and...
Enhanced Mobility of Seniors and Individuals with Disabilities – Assistance Listing No. 20.513 Recommendation: Management should review and strengthen its controls over the allocation of expenditures to federal programs to ensure costs charged to federal awards are allowable, properly supported, and allocated in accordance with applicable federal requirements. Management should also ensure that only allowable costs are included in the allocation methodology used to distribute indirect or shared expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations has improved and simplified the allocation of general disbursements to make it easier to follow for review and for auditors to follow. Planned completion date for corrective action plan: June 2026.
Special Programs for the Aging, Title III, Part C, Nutrition Services – Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate p...
Special Programs for the Aging, Title III, Part C, Nutrition Services – Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate processes and controls to ensure payroll is allocated correctly for Federal programs, in accordance with the underlying supporting documentation, and that only allowable costs are included in the allocation pool. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations has improved and simplified the allocation of payroll to make it easier to follow for review and for auditors to follow. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2026.
Special Programs for the Aging, Title III, Part C, Nutrition Services Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate pro...
Special Programs for the Aging, Title III, Part C, Nutrition Services Assistance Listing No. 93.045 Nutrition Services Incentive Program – Assistance Listing No. 93.053 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate processes and controls to ensure program income is recorded correctly for Federal programs, based on the underlying supporting documentation. Management should also continue to reinforce review procedures over program income reporting to help ensure recording errors are detected and corrected on a timely basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations is reviewing and revising our control structure using our new software and new staff with the appropriate experience. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: major initiative to be completed in 2027.
Enhanced Mobility of Seniors and Individuals with Disabilities – Assistance Listing No. 20.513 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate processes and controls to ensure the correct procurement methods are used and...
Enhanced Mobility of Seniors and Individuals with Disabilities – Assistance Listing No. 20.513 Recommendation: Management at Sound Generations should review its existing control structure and ensure that there are adequate processes and controls to ensure the correct procurement methods are used and that documentation of quotes, bids, vendor evaluations, and price analysis is appropriately maintained. Sound Generations should follow its policies and procedures and ensure suspension and debarment checks are performed on a timely basis for all covered transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Sound Generations converted to new software, and we have included a field for SAM.gov compliance and as part of our new vendor approval require a screen shot of the SAM.gov validation. Name(s) of the contact person(s) responsible for corrective action: Kristina Morgan, Controller, at 206-445-5671. Planned completion date for corrective action plan: June 2026.
2025-003 – Reporting Corrective Action Plan: Management is in communication with the audit firm working on completing the 2024 audit. The 2025 audit has been submitted timely and it is anticipated this will not be an issue in future years. Person(s) Responsible: Allan Scroggins, CFO Timing for Imple...
2025-003 – Reporting Corrective Action Plan: Management is in communication with the audit firm working on completing the 2024 audit. The 2025 audit has been submitted timely and it is anticipated this will not be an issue in future years. Person(s) Responsible: Allan Scroggins, CFO Timing for Implementation: Fiscal year 2026
Finding 1239546 (2025-003)
Material Weakness 2025
Upmc
PA
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Rya...
Federal Agency: U.S. Department of Health and Human Services Assistance Listing Nos.: 93.918, Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease (Ryan White, Part C) and 93.153, Coordinated Services and Access to Research for Women, Infants, Children, and Youth (Ryan White, Part D) Condition: Ryan White, Part C and Part D require the use of program income under the additive method, which requires program income earned from a federally funded program is added to the federal award amount and used to further program objectives. Under the method, allowable expenditures of program income are included on the SEFA. UPMC’s SEFA did not include expenditures related to program income, which were allowable. UPMC’s preliminary SEFA did not include these expenditures, which resulted in the incorrect identification of major programs. The SEFA was subsequently corrected. Corrective action plan: UPMC has remediated the control deficiency as of the period ending December 31, 2025, and has appropriately revised its processes and internal controls to expenditures of program income in the SEFA for impacted programs. Completion: September 2026
Finding 1239536 (2025-002)
Material Weakness 2025
Upmc
PA
Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance Condition: UPMC did not report three Federal Funding Accountability and Transparency Act (FFATA) to the Federal Fundi...
Federal Agency: U.S. Department of Health and Human Services Assistance Listing No.: 93.243, Substance Abuse and Mental Health Services Projects of Regional and National Significance Condition: UPMC did not report three Federal Funding Accountability and Transparency Act (FFATA) to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Corrective Action Plan: UPMC will track FFATA reporting at the System level to ensure overall compliance. Expected Timeline to Completion: December 31, 2026 Responsible Party: UPMC Financial Integrity
Finding 1239535 (2025-001)
Material Weakness 2025
Upmc
PA
Federal Grantor: U.S. Department of Health and Human Services Assistance Listing No.: 93.912, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Condition: UPMC did not timely submit two Federal Funding Accountability and Transpar...
Federal Grantor: U.S. Department of Health and Human Services Assistance Listing No.: 93.912, Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Condition: UPMC did not timely submit two Federal Funding Accountability and Transparency Act (FFATA) reports to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) within the timeframe designated by 2 CFR 170 Appendix A. Furthermore, evidence of review and approval of the FFATA reports and Federal Financial Reports required to be reported under were not maintained. Corrective Action Plan: UPMC will track FFATA reporting at the System level to ensure overall compliance. Expected Timeline to Completion: December 31, 2026 Responsible Party: UPMC Financial Integrity
Cause of Finding: Organization personnel recorded inputs to the sliding scale fee calculation, such as family size or annual household income, incorrectly in the medical billing software. This resulted in an inappropriate sliding scale fee adjustment for one patient identified during the audit sampl...
Cause of Finding: Organization personnel recorded inputs to the sliding scale fee calculation, such as family size or annual household income, incorrectly in the medical billing software. This resulted in an inappropriate sliding scale fee adjustment for one patient identified during the audit sample. Action: The CFO will ensure that all personnel responsible for determining and entering sliding scale fee information understand and follow the Organization's sliding fee policy and established procedures. The Financial Coordinator, who was hired at the end of 2025, will provide additional oversight of the sliding fee adjustment process and will assist in ensuring that supporting documentation is reviewed and accurately entered into the medical billing software. The Financial Coordinator will review the documentation used to determine patient eligibility and the applicable sliding fee adjustment, including family size and annual household income. The Financial Coordinator will ensure that information entered into the medical billing software agrees with the supporting documentation and that the appropriate sliding fee adjustment is applied in accordance with the Organization's sliding fee policy. The Financial Coordinator will provide training and ongoing support to staff responsible for determining eligibility, calculating sliding fee adjustments, and entering patient information into the medical billing software. Training will emphasize the requirements of the sliding fee policy, including documentation requirements, family size, household income, eligibility requirements, and appropriate fee calculations. The Financial Coordinator will perform monthly audits of sliding fee adjustments to identify data entry errors and ensure that patients receiving sliding fee adjustments meet the requirements of the Organization's policy. The monthly review will include verification of supporting documentation, family size, annual household income, eligibility, and the sliding fee adjustment applied. Any errors identified through the review will be corrected in a timely manner, and the CFO will determine whether additional training or corrective action is necessary. The CFO will also review the sliding fee policy and related procedures to ensure they provide clear guidance to staff regarding the documentation, calculation, approval, and application of sliding fee adjustments. The Organization will maintain documentation of eligibility determinations, monthly reviews, and any corrective actions taken to support compliance with the Health Center Program requirements and to ensure program income is appropriately calculated and collected.
Finding 2025-006 United States Environmental Protection Agency Federal Financial Assistance Listing #66.458/66.468 Capitalization Grants for Clean Water State Revolving Funds Material Weakness in Internal Control over Compliance Finding Summary: In our testing of procurement, suspension, and debarme...
Finding 2025-006 United States Environmental Protection Agency Federal Financial Assistance Listing #66.458/66.468 Capitalization Grants for Clean Water State Revolving Funds Material Weakness in Internal Control over Compliance Finding Summary: In our testing of procurement, suspension, and debarment it was identified that the City’s written policy did not address the requirements of 2 CFR sections 200.318 through 200.326. Responsible Individuals: Sarah Hellekson, City Administrator Corrective Action Plan: Management will establish a written policy that is in compliance with all of the procurement requirements for federal programs as identified in 2 CFR sections 200.318 through 200.326 and maintain adequate supporting documentation and records to document history and methods of procurement and the procedures performed to comply with these CFR sections. Anticipated Completion Date: December 31, 2026
The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Kathleen Wyatt, Director of Housing Operations, will be responsible to implement th...
The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed on a timely basis. Kathleen Wyatt, Director of Housing Operations, will be responsible to implement this corrective action by December 31, 2026.
Name of Auditee: Watertown Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2025 CAP Prepared by: Jacqueline Weir, Executive Director Phone: (617) 923-3950 (A)Current Findings on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 ...
Name of Auditee: Watertown Housing Authority Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: December 31, 2025 CAP Prepared by: Jacqueline Weir, Executive Director Phone: (617) 923-3950 (A)Current Findings on the Schedule of Findings and Questioned Costs (1) Finding 2025-001 (a) Comments on the finding and recommendation - The Authority agrees with the finding. The Authority also agrees with the recommendation. Please see below for action taken. (b) Action taken - The Authority will obtain the necessary documentation at the time of the next annual recertification.
Management agrees with the finding. The Organization has enhanced its capacity to address the identified issues by revising the organizational infrastructure to emphasize grant oversight and grant accounting, and by hiring additional staff with expertise in nonprofit administration and grant account...
Management agrees with the finding. The Organization has enhanced its capacity to address the identified issues by revising the organizational infrastructure to emphasize grant oversight and grant accounting, and by hiring additional staff with expertise in nonprofit administration and grant accounting practices to ensure robust grant oversight and compliance. The Organization is also reviewing best practices for program and non-program activities for revenue and expenses and has begun implementing additional controls designed to establish more rigor to the month-end and year-end close processes. Additional review processes for revenues and expenses with integration of our billing team will cohesively improve invoicing and alignment with the accounting team. The Organization will continue to continuously evaluate and improve its grant billing procedures, receivable reconciliation, and revenue recognition. Management will implement additional review procedures to ensure that grant receivables are not duplicated, that accounts receivable balances are cleared in a timely manner, and that reimbursable expenses and related grant revenue are recorded within the proper period.
CORRECTIVE ACTION PLAN September 17, 2026 Boys and Girls Club of Hawaii (BGCH) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: N&K CPAs, 999 Bishop Street, Suite 2200, Honolulu, HI 96813 Audit Per...
CORRECTIVE ACTION PLAN September 17, 2026 Boys and Girls Club of Hawaii (BGCH) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: N&K CPAs, 999 Bishop Street, Suite 2200, Honolulu, HI 96813 Audit Period: The calendar year ended December 31, 2025. Addressee: State of Hawaii, Department of Human Services Benefit, Employment and Support Services Division 1010 Richards Street, Suite 512 Honolulu, HI 96813 Primary Contact Person: Paddy Kauhane, President & CEO Contact Person Responsible: Florrie Charnaw, CFO Finding: The finding from the December 31, 2025 Schedule of Findings and Questioned Costs - #2025-001: Noncompliance with Grant Award Terms – Significant Deficiency Federal agency: Department of Health and Human Services Program: ALN No. 93.558 Temporary Assistance for Needy Families Pass-through entity: State Department of Human Services Award number and award year: DHS-24-TANF-0116, June 3, 2024 to August 2, 2025. Criteria: The DHS-24-TANF-0116 award specifically prohibits BGCH from charging youths or their families for programs or services provided under the award without prior approval from the State. Condition: While BGCH fully complied with providing the required services at the locations included in the Contract, BGCH did charge Summer Intersession fees to some youth at all nine BGCH Clubhouses without seeking prior approval of the STATE. Completion Date: September 30, 2026 Corrective Action Plan BGCH has made full refunds of the summer 2025 fees, provided all supporting documentation to DHS for them, and provided the Grant Policy and Grant Management Procedures by the required March 31, 2026 deadline. We remain compliant with this contract and will continue to fully comply with the DHS CAP executed in March 2026.
As of December 31, 2025, management has not fully funded the tenant security deposits cash account. The tenant security deposits cash account was underfunded by $7,581. a. Comments on the Finding and Each Recommendation Management agrees with the finding and recommendation. Due to a formula error, t...
As of December 31, 2025, management has not fully funded the tenant security deposits cash account. The tenant security deposits cash account was underfunded by $7,581. a. Comments on the Finding and Each Recommendation Management agrees with the finding and recommendation. Due to a formula error, the transfer amount was understated, resulting in the tenant security deposit account being underfunded by $7,581. b. Action(s) Taken or Planned on the Finding Management corrected the deficiency by transferring $7,581 from the operating account to fully fund the tenant security deposit account on January 14, 2026. Management has implemented enhanced reconciliations of tenant security deposits to ensure the security deposit account remains fully funded and accurate
Project paid expenses on behalf of an affiliate in the amount of $384.00 from Project funds without prior HUD approval. As of December 31, 2025, the affiliate owed the Project $384.00. a. Comments on the Finding and Each Recommendation Management agrees with the findings and recommendation. The paym...
Project paid expenses on behalf of an affiliate in the amount of $384.00 from Project funds without prior HUD approval. As of December 31, 2025, the affiliate owed the Project $384.00. a. Comments on the Finding and Each Recommendation Management agrees with the findings and recommendation. The payment was made in error due to an oversight into the invoice approval process. b. Action(s) Taken or Planned on the Finding The affiliate reimbursed the Project for the full amount of $384.00 on 04/29/2026.Management implemented an additional approval control in RealPage requiring review and approval by the Housing Director and/or the Property Manager prior to payment processing. This control helps ensure invoices are charged to the correct property and prevents one project from paying expenses on behalf of another project or affiliate. Management will continue to monitor compliance with these procedures.
Management acknowledges the delays identified in the submission of certain monthly progress reports corresponding to the 2025 reporting period. However, management respectfully notes that the dates reflected in PRDOH's reporting records should be considered in the context of PRDOH's established sequ...
Management acknowledges the delays identified in the submission of certain monthly progress reports corresponding to the 2025 reporting period. However, management respectfully notes that the dates reflected in PRDOH's reporting records should be considered in the context of PRDOH's established sequential reporting and approval process. Under the Puerto Rico Department of Housing's CDBG-DR/MIT Grant Compliance Portal (GCP) procedures, a subrecipient cannot submit a monthly report while a preceding report remains open and pending approval. Specifically, the PRDOH CDBG-DR/MIT Grant Compliance Portal (GCP) Manual, Version 5, dated April 4, 2024, page 35, states: “You cannot submit a report while there is an open past Report” and further provides that, “Once the open report is approved, you can submit the next monthly report.” Accordingly, delays in PRDOH's review, return, resubmission, and approval of one monthly report necessarily affect CRH's ability to submit the following month's report, even when CRH is otherwise prepared to proceed with the subsequent submission. Management therefore reviewed the complete submission and approval history for all twelvemonthly reports corresponding to 2025 in order to distinguish between reports that appear late based solely on the dates reflected in PRDOH's records and reports that were submitted late due to circumstances attributable to CRH. Out of the 12 months of 2025, five reports were submitted late. Of the five late submissions, three of which were due to the PRDOH’s delayed approval of the previous month’s report. Reporting Period Original CRH Submission PRDOH Approval Status January 3/26/25 4/3/25 Submitted late, in order to incorporate new PRDOH data and inventory requirements. February 4/23/25 5/26/25 Submitted late, in order to incorporate new PRDOH data and inventory requirements. March 5/28/25 5/28/25 Submitted late due to PRDOH approval date of previous report April 5/28/25 5/28/25 Submitted late due to PRDOH approval date of previous report. May 6/2/25 6/5/25 Submitted within term. June 7/1/25 7/9/25 Submitted within term. July 8/1/25 8/6/25 Submitted within term. August 9/2/25___ 9/19/25_ Submitted within term. September 10/2/25 10/17/25 Submitted within term. October 11/5/25 12/10/25 Submitted within term. November 12/15/25 12/23/25 Submitted late due to PRDOH approval date of previous report. December 1/5/26 2/4/26 Submitted within term. After considering the original submission dates, PRDOH approval dates, subsequent resubmissions, and the sequential reporting requirement established by PRDOH, only two reports were actually submitted late due to circumstances attributable to CRH. With respect to those reports that were actually submitted late by CRH, the delays occurred principally during a period in which PRDOH was establishing new requirements concerning the information, supporting documentation, classifications, and formatting required for inventory and data, which required overhauls of the CRH’s internal methodologies. In several instances, these requirements were communicated through comments and instructions associated with PRDOH's review of preceding reports, and in others, from e-mail requests establishing new inventory criteria. CRH has since incorporated PRDOH's data and inventory format requirements into its regular procedures, completed the necessary personnel transition and training, and strengthened its internal monitoring of monthly reporting deadlines. As of 2026, CRH's monthly reports have been submitted without a sinlge late submission. Management will continue documenting both CRH submission dates and PRDOH approval dates so that delays resulting from PRDOH's sequential review and approval process can be appropriately distinguished from delays attributable to CRH.
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