Corrective Action Plans

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1. Documentation Recovery — Completed (September 2025) ○ Contacted vendors to obtain duplicate invoices and receipts for all transactions with missing documentation. 2. Current Transaction Review — Completed (October 2025) ○ Conducted a comprehensive review of all pending and recent transactions. 3....
1. Documentation Recovery — Completed (September 2025) ○ Contacted vendors to obtain duplicate invoices and receipts for all transactions with missing documentation. 2. Current Transaction Review — Completed (October 2025) ○ Conducted a comprehensive review of all pending and recent transactions. 3. Documentation Requirements Policy — Completed (September 2025) ○ Corrected identified gaps and implemented a Pending Documentation File system to track incomplete transactions. ○ Prepared expense memoranda describing goods/services, business purpose, and program benefit for any unrecoverable items. ○ Organized all recovered documentation into auditable files for review. ○ Establishes documentation standards for all expenditures. ○ Implements enhanced requirements for federal awards in compliance with 2 CFR §200.302 and § 200.303. ○ Requires submission of receipts/invoices within five (5) business days. ○ Aligns retention and compliance standards with federal and state regulations. ○ Defines clear consequences for non-compliance. 4. Strengthened Documentation Controls — Completed (October 2025) Purchases over $500 require prior written approval. ○ All receipts must be submitted within five (5) business days of the transaction. ○ Missing documentation triggers a 48-hour follow-up hold on spending authorizations. ○ Monthly certifications confirm all transactions are fully supported. 5. Enhanced Federal Award Documentation — Completed (October 2025) ○ Implemented a federal expenditure checklist requiring itemized receipts, program benefit descriptions, budget references, and authorizing signatures. ○ The Finance Director conducts monthly reviews of all federal expenditures. 6. Staff Training — Completed (October 2025) ○ Conducted mandatory training on documentation standards, federal compliance, and allowable costs under 2 CFR Part 200. ○ Training materials added to new employee orientation with annual refreshers scheduled. 7. Ongoing Monitoring — Ongoing ○ Monthly sample audits conducted by the Finance Director to verify compliance. ○ Quarterly reporting to the COO summarizing documentation metrics. ○ Annual compliance results presented to the Board Finance/Audit Committee.
Finding Number: 2024-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2024 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching...
Finding Number: 2024-003 Finding Name: Data Collection Form Late Submission Finding Synopsis: The organization did not submit the December 31, 2024 data collection form and reporting package to the Federal Audit Clearinghouse in a timely matter. Action Steps: The late submission was due to switching audit service providers. Systems and procedures are already in place to ensure timely completion of audit and submission of the audit package to the Federal Audit Clearinghouse. Management is now aware that when switching audit firms. we will have to allocate more time for the new firm to get familiar with the agency. Contact Person(s): William Chatman, Executive Director/CEO, 815-963-6236 Claudia Seijas, Director of Finance, 815-963-6236 Anticipated Completion Date: Continues
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contra...
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contractors are eligible to receive federal funds and not excluded or disqualified from doing business. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawy...
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
The 2025 audit will be scheduled sooner
The 2025 audit will be scheduled sooner
This was corrected during 2024
This was corrected during 2024
The manager has assigned the P.O. process to the County Finance Director for records maintenance. The Grants Manager is being placed on a "growth plan" to ensure compliance with records requirements.
The manager has assigned the P.O. process to the County Finance Director for records maintenance. The Grants Manager is being placed on a "growth plan" to ensure compliance with records requirements.
Federal Procurement Regulations Planned Corrective Action: Heartland Alliance Health developed and implemented a comprehensive Procurement Policy to ensure full compliance with federal Uniform Guidance requirements. The policy outlines required procurement methods, approval thresholds, documentation...
Federal Procurement Regulations Planned Corrective Action: Heartland Alliance Health developed and implemented a comprehensive Procurement Policy to ensure full compliance with federal Uniform Guidance requirements. The policy outlines required procurement methods, approval thresholds, documentation standards, and procedures for competitive bidding, price analysis, and sole-source justifications. The policy was reviewed and approved by the Board of Directors (October 2025) and is now in effect organization wide. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now ...
Compliance with Allowable Activities Planned Corrective Action: Heartland Alliance Health has partnered with an outside revenue cycle management firm to strengthen documentation oversight, billing accuracy, and compliance monitoring. Together with internal Revenue Cycle staff, the external firm now generates and reviews weekly documentation and billing completeness reports to identify and resolve missing or incomplete encounter records. Clinic managers and providers receive weekly follow-ups to ensure that documentation is corrected promptly and that all billed services are properly supported. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
Inaccurate and Late Reporting Planned Corrective Action: Regarding underlying support, HAH now utilizes drawdown documentation for all draws; this will provide support for all draws and facilitate submission of accurate and timely SF-425 documentation. Some SF-425 submissions for FY25 will not be su...
Inaccurate and Late Reporting Planned Corrective Action: Regarding underlying support, HAH now utilizes drawdown documentation for all draws; this will provide support for all draws and facilitate submission of accurate and timely SF-425 documentation. Some SF-425 submissions for FY25 will not be submitted timely, because the federal project officer has not approved the budget or because the drawdowns have not been completed; the federal shutdown has exacerbated this circumstance for FY25. As HAH gets caught up with federal drawdowns, HAH expects to be able to submit SF-425 documentation in a timely and accurate fashion. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: April 2026
Compliance with Cash Management Requirements Planned Corrective Action: Heartland Alliance Health has established a formal Drawdown Policy and Procedure designed to ensure compliance with federal cash management regulations and to prevent premature or excessive drawdowns of grant funds. The policy i...
Compliance with Cash Management Requirements Planned Corrective Action: Heartland Alliance Health has established a formal Drawdown Policy and Procedure designed to ensure compliance with federal cash management regulations and to prevent premature or excessive drawdowns of grant funds. The policy includes specific requirements for timing, documentation, reconciliation of expenditures to draw requests, and internal approvals prior to submission. The Drawdown Policy and Procedure was reviewed and approved by the Board of Directors in October 2025. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
Reasonable Rent Review Planned Corrective Action: The Continuum of Care (CoC) program was transitioned to another organization during FY2024 as part of a broader realignment of programs and services. Heartland Alliance Health no longer administers this program, and all compliance responsibilities, i...
Reasonable Rent Review Planned Corrective Action: The Continuum of Care (CoC) program was transitioned to another organization during FY2024 as part of a broader realignment of programs and services. Heartland Alliance Health no longer administers this program, and all compliance responsibilities, including tenant files and rent documentation, were transferred to the receiving entity. At the request of the auditors, Heartland Alliance Health has initiated contact with the new organization to confirm that all required program and tenant records have been properly transferred, secured, and maintained in compliance with HUD regulations. Person Responsible for Corrective Action Plan: Steve Knox, Controller Anticipated Date of Completion: Resolved
REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2024-007 - Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (S...
REPORTABLE NONCOMPLIANCE WITH FEDERAL REPORTING REQUIREMENTS – ALL FEDERAL PROGRAMS AWARDED UNDER THE UNIFORM GUIDANCE 2024-007 - Federal Reporting Deadline Finding Summary Criteria – 2CFR Part 200, Subpart F, § 200.512(a)(1) requires the District’s audited Schedule of Expenditures Federal Awards (SEFA) and federal reporting package to be submitted to the federal audit clearinghouse within the earlier of 30 calendar days after the receipt of the auditor’s report(s), or 9 months after the end of the audit period. Condition – The District’s audited SEFA and federal reporting package for the fiscal year ended June 30, 2024, were not submitted to the federal audit clearinghouse within nine months after the end of the audit period. Corrective Action Plan Actions Planned – The completion of the District’s audited annual financial statements for the year ended June 30, 2024, which is a required component of the federal reporting package, was delayed beyond the nine-month deadline, primarily due to turnover in the District’s finance department. District management will ensure that all information required to comply with federal reporting requirements will be completed and submitted in a timely manner going forward. Official Responsible – Josh Anderson, the District’s Director of Finance. Planned Completion Date – December 31, 2025. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – Josh Anderson, the District’s Director of Finance, will monitor the year‑end financial closing and reporting process to ensure all federal and state reporting requirements are complied with in the future.
Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.
Action Taken: We agree with the findings and have established new written policies and procedures to ensure the SEFA is properly reconciled and reviewed prior to the start of the audit.
New Hope Development Services, Inc. is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
New Hope Development Services, Inc. is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
The Organization accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will maintain signed income certifications for all tenants in accordance with HUD guidelines to ensure proper documentation is maintained in tenant files.
The Organization accepts the recommendation of Deming, Malone, Livesay & Ostroff and, accordingly, management will maintain signed income certifications for all tenants in accordance with HUD guidelines to ensure proper documentation is maintained in tenant files.
New Hope Services, Inc. and Subsidiary is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
New Hope Services, Inc. and Subsidiary is hiring a new Chief Financial Officer to ensure all financial functions are completed promptly and accurately and to simplify workflows, thereby enhancing efficiency and enabling the audit to be on schedule.
Condition: The organization intended to use a competitive proposal process to procure a van. However, it failed to publicly advertise the request for proposals, limiting the pool of potential vendors to only those known to the organization. Additionally, the request for proposals did not include a c...
Condition: The organization intended to use a competitive proposal process to procure a van. However, it failed to publicly advertise the request for proposals, limiting the pool of potential vendors to only those known to the organization. Additionally, the request for proposals did not include a complete and accurate list of specifications, nor did it include the evaluation and selection criteria that would be used to assess the proposals. While the organization did obtain three proposals and documented its rationale for selecting a vendor that was not the lowest bidder, the overall process did not meet the standards for full and open competition required by federal regulations. Corrective Action Plan: To address this, we are committing to develop and implement a comprehensive procurement policy and procedures manual that strictly aligns with requirements within the Uniform Guidance. This manual will include detailed checklists for all procurement methods, covering public advertising, clear specification development, and the use of pre-established, documented evaluation criteria, followed by mandatory training for all staff involved in procurement. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025
Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount tr...
Condition: During our audit of the financial management system and cash management practices for the Ryan White Federal Program, we identified the following deficiencies: Transposed Drawdown Amount: A drawdown request submitted to the PMS system for the Ryan White Program had the requested amount transposed with the amount of another federal program. This resulted in an over-request of a material amount on the Ryan White Program. Duplicate Invoice Reimbursement: An invoice was requested and received for reimbursement on a prior drawdown and was subsequently included again in a draw after year-end, resulting in a duplicate reimbursement. Incomplete Expenditure Tracking: The entity did not have a complete system for tracking all expenditures eligible for reimbursement. The drawdown process was limited to cash disbursement and payroll transactions and excluded expenditures incurred and recorded by journal entries. This resulted in the entity having unreimbursed expenditures that could have offset the over-requests noted above. Corrective Action Plan: To correct the deficiency, we are implementing a plan focused on establishing a review and approval process for all drawdown requests and revising our policies to ensure that all eligible incurred expenditures are properly captured and reconciled, thereby assuring strict compliance with federal cash management regulations and preventing federal funds from exceeding our immediate needs. Responsible Party: Austin Maddox, CFO Anticipated Completion Date: December 31, 2025
View Audit 372206 Questioned Costs: $1
2024-002 Suspension and Debarment Recommendation: The City should perform SAM checks for all vendors or contractors prior to entering into covered transactions and retain documentation of these processes. Management Response: Management concurs with the recommendation. The City recognizes the import...
2024-002 Suspension and Debarment Recommendation: The City should perform SAM checks for all vendors or contractors prior to entering into covered transactions and retain documentation of these processes. Management Response: Management concurs with the recommendation. The City recognizes the importance of complying with 2 CFR 180.300 and 2 CFR 200.303 to ensure that vendors and contractors are not suspended, debarred, or otherwise excluded from participation in federally funded programs. To strengthen compliance and documentation going forward, the City will implement the following corrective actions: 1. Establish a Standardized SAM Verification Process: The City will formalize written procedures requiring verification of all vendors and contractors in the System for Award Management (SAM) prior to entering into any covered transaction. 2. Maintain Documentation: Copies or screenshots of SAM verifications will be retained in the vendor file and/or attached within the City’s financial management system to ensure documentation is readily available for audit purposes. 3. Designate Responsibility: The Finance Department will assign a staff member to perform and document the SAM verification process, with supervisory review prior to vendor approval. 4. Provide Staff Training: Relevant staff will receive training on federal procurement requirements, including SAM verification procedures and documentation standards. 5. Ongoing Monitoring: Management will periodically review vendor files to confirm compliance with these requirements and ensure documentation is properly maintained. Management expects these measures will strengthen internal controls, ensure continued compliance with federal regulations, and prevent similar documentation issues in future audits. The responsible party is Carolina Rodriguez, Grants Coordinator. The findings will be corrected by December 2025.
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CH...
Internal Controls Over Rent Reasonableness - Significant Deficiency Condition: The Organization did not have a documented procedure supporting how rent reasonableness is documented and maintained in the tenant files to provide documentation of compliance with the criteria. Corrective Action Plan: CHP will be updating internal controls to include evidence of appropriate reviews and approvals of rent reasonableness.
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project...
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193 Questioned Costs: $1
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.
Management should implement a procedure requiring authorization and approval from Chief Financial Officer, Chief Executive Officer or Chief Operating Officer for all nonrecurring purchases prior to initiation of the purchase.
View Audit 372187 Questioned Costs: $1
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