Corrective Action Plans

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Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management overrid...
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management override, Cayuga Centers has implemented standardized procedures to ensure grant expenditures are properly classified in our financial system. Each transaction are supported by detailed documentation, including invoices, receipts, and grant-specific identifiers. Individuals responsible for grant oversight will undergo mandatory training to deepen their understanding of grant requirements, allowable costs, and reporting obligations. Additionally, Cayuga Centers is working to ensure open communication between staff and the Board. Under new leadership, the agency continues to enforce its Non-Retaliation Policy (Whistleblower). The Acting President’s office is establishing quarterly “Grant Compliance Forums” for employees to raise concerns related to grant administration.
Filing of Data Collection Form and Reporting Package Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete the filing of data collection form and reporting package on a timely b...
Filing of Data Collection Form and Reporting Package Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete the filing of data collection form and reporting package on a timely basis. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over filing and reporting on the Data Collection Form and has reviewed the policies and procedures with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely filing. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
Improve Controls over the Preparation of the Schedule of Expenditures of Federal of Awards Department’s Response: Management is in agreement with the recommendation and has updated their policy subsequent to year-end. Views of Responsible Offices and Corrective Action Plan: Management agrees with th...
Improve Controls over the Preparation of the Schedule of Expenditures of Federal of Awards Department’s Response: Management is in agreement with the recommendation and has updated their policy subsequent to year-end. Views of Responsible Offices and Corrective Action Plan: Management agrees with this and will implement the below to its financial policies and procedures manual: Post-Award Procedures - After an award has been made, the following steps shall be taken: 1.Verify the specifications of the grant or contract. The finance department shall review the terms, time periods, award amounts and expected expenditures associated with the award. A CFDA (Catalog of Federal Domestic Assistance) number shall be determined for each award. All reporting requirements under the contract or award shall be summarized. 2.Create new general ledger account numbers. New accounts shall be established for the receipt and expenditure categories in line with the grant or contract budget. 3.Gather documentation. A file is established for each grant or contract. The file contains the proposal, all correspondence regarding the grant or contract, the final signed award document and all reports submitted to the funding sources. 4.Management will prepare a SEFA and share with the auditor to determine when the schedule is presented fairly in all material respects in relation to the financial statements as a whole. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors...
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors will be adjusted each period to ensure that account and ledger totals are properly maintained and recorded. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over bank reconciliations, accounts payable and grants receivable. Controls and the policies and procedures have been reviewed with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely reconciliations. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income doc...
2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2026
2024-004—Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are co...
2024-004—Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: May 31, 2026
The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Prefe...
The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Preference will be included in future contracts where federal funds are expended. The Safety-Service Director will check for SAM exclusions and will request a waiver to this requirement if necessary.
Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended December 31, 2024, management did not properly accrue federal grant expenditures that were incurred during the fourth quarter of fiscal year 2024. As a result, federal grant expenses on...
Finding 2024-001 – Material Weakness – Accounting Recordkeeping All Programs Other Condition During the year ended December 31, 2024, management did not properly accrue federal grant expenditures that were incurred during the fourth quarter of fiscal year 2024. As a result, federal grant expenses on cost reimbursement grants and related revenues were understated as of December 31, 2024, and required year end audit adjustments to properly reflect expenditures incurred but not invoiced or recorded as of year end. Recommendation We recommend that individuals overseeing the accounting and finance department continue to review the Organization’s current accounting policies and update existing policies or implement new policies, as needed, to ensure that federal grant expenditures are accrued for and recorded in the proper period and reconciliations between incurred expenditures, invoices submitted and amounts recorded in the general ledger are completed and reviewed monthly or quarterly, as appropriate. Management’s Corrective Action Plan Management is working to improve the timeliness of reconciliations and has implemented procedures to identify and accrue grant expenditures incurred but not yet invoiced at period end, as needed. Management will perform periodic reconciliations between incurred expenditures, invoices submitted to grantors, and amounts recorded in the general ledger, and will ensure such reconciliations are reviewed and approved by the appropriate personnel. Management is confident that the issues that have been noted have been rectified. Contact Person: Patricha Paul, Finance Director Anticipated Completion Date: June 30, 2026
We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.
We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.
Management’s response/corrective action plan: The District ensured that vendors and contractors for the DWP SRF Watermain Replacement Projects and Keene Woods Watermain Extension Project were qualified through a competitive bid process. Vendors had to meet rigorous requirements imposed by the Distri...
Management’s response/corrective action plan: The District ensured that vendors and contractors for the DWP SRF Watermain Replacement Projects and Keene Woods Watermain Extension Project were qualified through a competitive bid process. Vendors had to meet rigorous requirements imposed by the District, project engineers, and the State of Maine Drinking Water Revolving Loan Fund which included verifying that the vendor is not debarred/suspended by looking up the entity on Sam.gov. The District will discuss internal procedures for projects involving federal funds and will develop a formal written policy to minimize the risk of possible non-compliance with federal regulations if a policy is not already in place by program administers through which federal funds are administered.
SUSPENSION AND DEBARMENT – HIGHWAY PLANNING AND CONSTRUCTION Recommendation: It is recommended the County design controls to ensure an adequate review process is in place to review potential vendors to determine they are not suspended or debarred prior to entering into transactions with vendors. Exp...
SUSPENSION AND DEBARMENT – HIGHWAY PLANNING AND CONSTRUCTION Recommendation: It is recommended the County design controls to ensure an adequate review process is in place to review potential vendors to determine they are not suspended or debarred prior to entering into transactions with vendors. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure they review all vendors for suspension and debarment. Name of the contact person responsible for corrective action plan: Candace Sonnek, Finance Director Planned completion date for corrective action plan: December 31, 2025
CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. Th...
CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-003 Document Policies and Procedures Over Federal Awards Views of responsible officials: The Town agrees with the recommendation to implement written policies and procedures to be in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action: The Town plans to implement recommendations for the next fiscal year. Official Responsible for Implementing Corrective Action: Kurt Ginthwain Finance Director/Town Accountant
2024-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b...
2024-003: Activities Allowed or Unallowed, Allowable Costs/Cost Principles Type of Finding: Noncompliance, Material Weakness Condition: The school lacked adequate internal controls over its accounting disbursements to ensure that a) all financial activities were properly processed and recorded and b) the School remained in compliance with federal requirements. Context: During our review of the school’s accounting records and internal controls, as well as through management inquiry, we noted the following: • For two of 25 accounts payable transactions tested out of the 15.044 grant, the School did provide adequate documentation to support the allowability of the expenditure. • For three of 25 accounts payable transactions tested out of the 15.046 grant, the School did provide adequate documentation to support the allowability of the expenditure. Repeat Finding: Repeated and modified. Action planned in response to the finding: The Principal will conduct an internal review of records management practices to verify that all accounts payable disbursements are properly supported. This evaluation will include random checks of purchase orders and their complete supporting documentation, once per month, to ensure accuracy, compliance, and integrity in financial operations. Keep all documents audit ready, at all times. Planned completion date for a corrective action plan: June 30, 2025 Name of the contact person responsible for corrective action: Marie Rose, Principal | Lynnette Greyeyes, Business Manager
2024-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The School did submit their audit for the fiscal year ending June 30, 2024 timely. The audit was submitted May 1, 2026, which was 396 days past the March 31, 2025 deadline. Action plan in response to the finding: The Pr...
2024-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The School did submit their audit for the fiscal year ending June 30, 2024 timely. The audit was submitted May 1, 2026, which was 396 days past the March 31, 2025 deadline. Action plan in response to the finding: The Principal will ensure that all required audit documentation is organized, complete, and readily available to the auditors upon request. This includes maintaining updated financial records, supporting documents, reconciliations, and schedules throughout the fiscal year so that materials can be provided promptly during the audit process. To support timely completion of the annual audit, the Principal will formally request the 2025 audit to be completed by August 30, 2026. This timeline allows adequate opportunity for fieldwork, review, and finalization of the audit report. The Principal will monitor progress, respond quickly to auditor inquiries, and verify that the final audit report is submitted within the required timeframe. The 2026 Audit Request for Proposal will be submitted at the End of April 2026 for School Board approval. Repeat Finding: No. Planned completion date for a corrective action plan: June 30, 2026 Name of the contact person responsible for corrective action: Marie Rose, Principal | Lynnette Greyeyes, Business Manager
Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit...
Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit for the year ended December 31, 2024 within the required nine month deadline under 2 CFR 200.512. As of September 30, 2025, no single audit report has been issued or filed, resulting in noncompliance with federal audit requirements. Views of Responsible Officials and Corrective Action Plan: Management has developed and implemented corrective actions to address this finding. As of January 1, 2026, formal procedures for FAC submission have been established, including defined roles, internal deadlines, and review protocols. A compliance tracking system has been implemented to monitor key reporting deadlines, and staff have received training on federal requirements. Management will continue to monitor adherence to these procedures to ensure timely submission in future reporting periods. Implementation date: January 1, 2026
Finding No.2024-002: Maintain Supporting Documentation for Required Federal Reports Finding: During our testing of 24 reporting samples, we identified two (2) instances wherein Quarterly Expenditure Reports related to the grant of Council on American Islamic Relations, San Francisco Bay Area Office ...
Finding No.2024-002: Maintain Supporting Documentation for Required Federal Reports Finding: During our testing of 24 reporting samples, we identified two (2) instances wherein Quarterly Expenditure Reports related to the grant of Council on American Islamic Relations, San Francisco Bay Area Office (CAIR-SFBA), including the evidence of submission (e.g. confirmation emails or system-generated receipts), were not available for review. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already implemented reporting procedures to include the retention of submission confirmations as part of its grant documentation. Because the organization’s first single audit in FY2023 was conducted concurrently with the FY2024 single audit, there was limited opportunity for these procedural improvements to be reflected in the FY2024 single audit testing cycle. As a result, the impact of these changes will be more fully reflected in the FY2025 single audit, which is scheduled to commence this year. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Implementation date: October 31, 2025.
Finding No. 2024-001 Implement System-Based Tracking of Federal Expenditures Finding: During our review of the SEFA, we noted that CAIR-CA utilizes workbooks outside of its accounting software to track federal expenditures. The workbooks do not reconcile directly with the general ledger (GL), so man...
Finding No. 2024-001 Implement System-Based Tracking of Federal Expenditures Finding: During our review of the SEFA, we noted that CAIR-CA utilizes workbooks outside of its accounting software to track federal expenditures. The workbooks do not reconcile directly with the general ledger (GL), so management performs a separate reconciliation to support the SEFA amounts. This approach was similarly observed in the prior year's audit. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already updated the accounting system to incorporate grant-specific tracking codes to further align with federal reporting standards. Because the organization’s first single audit in FY2023 was conducted concurrently with the FY2024 single audit, there was limited opportunity for these procedural improvements to be reflected in the FY2024 single audit testing cycle. As a result, the impact of these changes will be more fully reflected in the FY2025 single audit, which is scheduled to commence this year. As part of a layered approach to internal controls, excel worksheets will continue to be used as a supplementary monitoring tool, providing an additional cross-check to the system-generated reports. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Implementation date: November 20, 2025
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this material weakness and has considered adding additional personnel to assist in the monthly reconciliations and financial statement preparation. Management reviews and approves the monthly inte...
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this material weakness and has considered adding additional personnel to assist in the monthly reconciliations and financial statement preparation. Management reviews and approves the monthly interim financial statements and uses the knowledge that management and the Board of Directors has of operations by having them review certain accounting records and reports. Also, management monitors the effectiveness of the above actions and makes changes as considered appropriate.
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this significant deficiency and addresses it by obtaining the auditor's assistance in the preparation of the Organization’s annual financial statements. Management reviews and approves the complet...
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this significant deficiency and addresses it by obtaining the auditor's assistance in the preparation of the Organization’s annual financial statements. Management reviews and approves the completed statements and distributes them to the users.
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following: (1) Identif...
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this condition and believes that it is not economically feasible to attain the ideal segregation of duties. Management attempts to mitigate the associated risks by doing the following: (1) Identifies areas where the lack of segregation of duties exists and where there are higher risks of errors or fraud occurring. (2) Implements limited segregation to the extent possible to reduce risks without impairing efficiency. (3) Uses the knowledge that management and the Board of Directors has of operations by having them review certain accounting records and reports. (4) Monitors the effectiveness of the above actions and makes changes as considered appropriate.
Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the orga...
Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the organization is in the process of evaluating and implementing an electronic system to streamline and document approvals for accounts payable and credit card transactions. These steps will strengthen internal controls and ensure proper documentation of all approvals in accordance with organizational policies and federal requirements. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: May 31, 2026
Corrective Action Plan: Management acknowledges the delay in submission of the audited financial statements, which was partly due to this being the organization’s first Single Audit and delays in completing the year-end close process. To address this, the organization will implement a structured yea...
Corrective Action Plan: Management acknowledges the delay in submission of the audited financial statements, which was partly due to this being the organization’s first Single Audit and delays in completing the year-end close process. To address this, the organization will implement a structured year-end closing timeline, including a detailed checklist, assigned responsibilities, and internal deadlines to ensure all reconciliations and journal entries are completed prior to the audit. Management will also establish a pre-audit review process and coordinate closely with auditors to ensure timely completion and submission to the Federal Audit Clearinghouse within required deadlines. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: December 31, 2025
Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual acco...
Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual accounting principles, aligning revenue with the period in which eligible expenditures are incurred. A year-end cutoff review will be performed to identify and record any receivables for incurred but unreimbursed costs. Additionally, grant tracking schedules and reconciliation processes will be enhanced to ensure accurate and timely revenue recognition. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: December 31, 2025
School’s contract with management indicates that purchases of equipment for school operations and federal programs are to be handled by the management organization. Records related to capital assets purchased with Educational Stabilization Funds did not contain all the required information for the g...
School’s contract with management indicates that purchases of equipment for school operations and federal programs are to be handled by the management organization. Records related to capital assets purchased with Educational Stabilization Funds did not contain all the required information for the governing authority or the Treasurer to record the capital assets in the school’s financials. The operator will ensure future purchases of capital assets made with federal dollars are submitted to the Treasurer for review and capitalization determination and the management of recorded capital assets.
CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all requi...
CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all required deadlines. • Assign a designated preparer and reviewer for each reporting cycle. • Provide training on the Treasury reporting portal. • Implement a pre-submission checklist to ensure completeness and accuracy. • Conduct semiannual internal reviews of reporting processes and documentation. Responsible Staff Chief Financial Officer (CFO) Target Completion Date July 31, 2026
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