Corrective Action Plans

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Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.
Corrective Action Plan: The Hospital is currently working on a plan to file all audit reports for the subsequent fiscal year ended September 30, 2025, before their required reporting due date of June 30, 2026.
The county will implement a formal reconciliation process between grant tracking spreadsheets and the General Ledger. This reconciliation will be performed at minimum quarterly (when most grants are submitted) and shall include: 1. Documented Comparison: A side-by-side verification of total expendit...
The county will implement a formal reconciliation process between grant tracking spreadsheets and the General Ledger. This reconciliation will be performed at minimum quarterly (when most grants are submitted) and shall include: 1. Documented Comparison: A side-by-side verification of total expenditures and revenues per grant on amounts reported within the general ledger and amounts included on subsidiary tracking spreadsheets. This verification (crosswalk) should include specific general ledger account numbers used for tracking revenues and expenditures. 2. Supervisory Review: Reconciliations should be reviewed and signed off by a person independent of the spreadsheet preparation 3. System Integration: In January 2025, the County implemented a new ERP software system, which offers a grant module and features to identify grant items to help eliminate reliance on manual “shadow” systems or spreadsheets.
Finding Number: 2024-003 Planned Corrective Action: Medina County acknowledges the deficiencies identified related to procurement documentation and suspension and debarment compliance under the Federal Transit Cluster. To address these issues, the County has implemented the following corrective acti...
Finding Number: 2024-003 Planned Corrective Action: Medina County acknowledges the deficiencies identified related to procurement documentation and suspension and debarment compliance under the Federal Transit Cluster. To address these issues, the County has implemented the following corrective actions: 1. Suspension and Debarment Verification Controls Effective immediately, prior to execution of any covered transaction funded in whole or in part with federal funds that is expected to equal or exceed $25,000, the Transit Department will verify vendor eligibility by performing a search of the System for Award Management (SAM.gov). Evidence of the SAM search, including the date performed and results, will be retained in the procurement file. In addition, all federally funded procurement contracts will include a standard suspension and debarment certification clause, or alternatively, a signed vendor certification will be obtained and retained when applicable. 2. Standardized Procurement Documentation The County will implement a standardized procurement checklist to be completed for all Transit procurements. This checklist will require documentation of: o The rationale for the method of procurement o The basis for contractor selection or rejection o The selection of contract type o The basis for contract price Completed checklists and supporting documentation will be maintained as part of the official procurement file in accordance with 2 CFR § 200.318 and the Medina County Transit Purchasing Policies and Procedures Manual. 3. Supervisory Review and Oversight The Transit Director, or designee, will perform a documented supervisory review of each procurement file prior to contract execution to ensure all required federal and County documentation is complete. No procurement will proceed without evidence of this review. 4. Training and Accountability Staff involved in Transit procurement activities will receive refresher training on federal procurement requirements, including suspension and debarment and procurement documentation standards. Compliance with these procedures will be monitored on an ongoing basis. Anticipated Completion Date: Implemented immediately and fully operational by March 31, 2026 Responsible Contact Person: Shannon Rine, Transit Director
2023-007 Material Weakness: See finding 2024-007. Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to better establish policies and procedures to ensure compliance with the grant requisition processes. Management’s response: The Authority has ...
2023-007 Material Weakness: See finding 2024-007. Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to better establish policies and procedures to ensure compliance with the grant requisition processes. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management is evaluating its processes and procedures related to grant requisitions and is planning on implementing procedures to ensure grants are requisitioned in the future. Additionally, management plant to work with its newly hired fee accountant in the future to ensure grant funds are properly requisitioned.
2023-005 Material Weakness: See finding 2024-005. Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Managem...
2023-005 Material Weakness: See finding 2024-005. Recommendation: We recommend that management of the Authority review the deadlines for FDS submission and the financial statement submission and work with the newly retained fee accountant to ensure that these deadlines are met in the future. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its submissions were not timely. Management engaged the services of a fee-accountant subsequent to year-end who will assist with these submission going forward. In order to submit and ensure integrity of the unaudited financial statements, the bank accounts reconciliations needed to be completed and account analysis performed. Management will continue to prioritize and remediate outstanding compliance obligations and develop a compliance catch-up plan to ensure timely account reconciliation and account analysis in the future. The fee accountant was not re-engaged to perform bank reconciliations and account analysis for the year ended June 30, 2025 until after June 30, 2025 year end. As a result, management expects this to be a repeat finding in the June 30, 2025 audit.
2023-006 Significant Deficiency: See finding 2024-006. Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Management’s response: The Authority has had some staff turnover over the past several year...
2023-006 Significant Deficiency: See finding 2024-006. Recommendation: We recommend that management of the Authority work with its newly retained fee accountant to prepare an operating budget by AMP location. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that its budget was not prepare by AMP location. Management engaged the services of a fee-accountant subsequent to year-end who will assist with the budgeting process in the future. The fee engaged was just recently re-engaged subsequent to June 30, 2025 year end. Management is aware that general best practice is to have a budget adopted by the board prior to the beginning of each fiscal year, however since the fee accountant was retained after the beginning of the 2025-2026 fiscal year, the 2025-2026 budget will not be prepared and adopted by the board on a timely basis.
2024-004 Significant Deficiency: See finding 2024-004. Recommendation: We recommend that management of the Authority review its processes for closing out all fully-expended grants with HUD to ensure that, in the future, when grants are fully expended, the close-out process begins shortly thereafter....
2024-004 Significant Deficiency: See finding 2024-004. Recommendation: We recommend that management of the Authority review its processes for closing out all fully-expended grants with HUD to ensure that, in the future, when grants are fully expended, the close-out process begins shortly thereafter. Management’s response: The Authority has had some staff turnover over the past several years. A new executive director and a new account clerk were both hired within the past several years. Management was aware that several older grants were still shown as “open” and that the close-out procedures would have to be implemented at some point. Management is evaluating its processes and procedures related to closing out grants and is planning on implementing procedures to ensure grants are properly closed. Management plans on working with the newly hired fee accountant in the future to assist with the close out of grants that have been fully expended.
I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should retain documentation to support complet...
I. Procurement, Suspension and Debarment Evidence of controls over Suspension and Debarment Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should retain documentation to support completeness and accuracy of the vendor list submitted for screening and the results obtained to support the screening process to ensure that no suspended or debarred vendors are utilized by the Corporation prior to entering into transactions. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation will formalize the system of record and end-to-end data flow, implement monthly reconciliations to confirm the completeness of the vendor population submitted for screening, and introduce data validation checks to ensure the accuracy of key vendor information. Supporting documentation will be centrally maintained to evidence control execution, and related policies and procedures will be updated with targeted training to promote consistent and sustainable application. Collectively, these enhancements are designed to mitigate the risk of engaging with suspended or debarred vendors. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Allison Dennison, Director, Compliance Operations, Allison.Dennison@umm.edu
I. Procurement, Suspension and Debarment Incomplete Federal Requirements within Procurement Policies Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its procurement policy ...
I. Procurement, Suspension and Debarment Incomplete Federal Requirements within Procurement Policies Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its procurement policy to include the provisions required by the Uniform Guidance for purchasing goods and/or services with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA, Corporate Financial Reporting and Legal drafted a procurement policy for federal awards. The policy is under review by other relevant stakeholders across UMMS. Anticipated Completion Date – August 31, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: Manageme...
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Evidence of Review and Approval of the Reported Expenditures Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: Management should reassess the design of its controls to ensure documentation is retained that evidences the review and approval of expenditures submitted to the Department of Treasury for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. ORSPA and Corporate Financial Reporting are developing standard operating procedures for the required review and reconciliation of grant expenditures per the accounting system to the financial submissions to the granting agency, including requirements for maintaining evidence of the review(s). Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and i...
Other finding – SEFA Preparation Preparation of Schedule of Expenditures of Federal Awards Assistance Listing 21.027 – COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Federal Agencies: Department of Treasury Recommendation: The Corporation should update its policies and procedures and internal controls to ensure accurate reporting of the Schedule as required by the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation established a centralized UMMS Office for Research and Sponsored Programs Administration (ORSPA) department in December 2025. The ORSPA department created a standard pre-award approval process for all sponsored proposals prior to submission or award acceptance. The pre-award approval process applies to all federal, state, local, private and commercial funding opportunities across all UMMS entities and covers new, renewal, resubmission and supplemental proposals. The establishment of a central intake process through one department, for all grants across the Corporation, enhances the controls to ensure complete and accurate reporting of the Schedule as required by the Uniform Guidance. Additionally, ORSPA and Corporate Financial Reporting implemented the following controls to ensure all expenditures of federal awards are included on the Schedule. These controls include:  Reconciliation of the grants from the pre-award approval process to the grants tagged in the accounting system;  Use of a specific grant identifier within the accounting system to track expenditures and revenue recognition and tag grants as federal, state or private funded;  Comparison of grant expenditures per the accounting system to the grant agreement;  Comparison of grant expenditures per the accounting system to the financial reporting submissions made to the federal agencies;  Certification from legal entity Finance Executives that the draft Schedule is complete and accurate;  Comparison of the prior year Schedule to the current year Schedule with further investigation around changes in grants and agencies included, and significant changes in the expenditures. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corpora...
H. Period of Performance Timely Payment of Financial Obligations Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: As the grant period has ended, we recommend that the Corporation works with the funding agency to remedy the period of performance noncompliance. In addition, we recommend that the Corporation reassess the design of its period of performance controls to identify where enhancement or additional controls are needed over liquidation of financial obligations subsequent to the end of a grant award. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue to educate all grant managers on (1) the reporting capabilities within the system that can be utilized in the execution of monitoring payment status on individual invoices that have been submitted to granting agencies for reimbursement, and (2) the requirement to use their grant specific general ledger coding when orders are placed with vendors that are set up under the Corporation’s group purchasing process. For the specific vendor noted in Finding 2024-003, a grant number input field has been added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants and the monitoring of payment of those expenditures. The use of the accurate grant general ledger coding by grant managers when orders are placed will reduce the time between placement of order and payment of the invoice. The grant manager responsible for oversight of BHSB grants will work with BHSB to remedy the period of performance noncompliance noted in Finding 2024-003. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: M...
C. Cash Management; L. Reporting Evidence and Review and Approval of the Reported Expenditures and Timely Report Submission Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should reassess the design of its controls to ensure submissions to BHSB are made timely within the required 15-day period and that documentation is retained that evidences the review and approval of expenditures submitted to BHSB for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on capabilities within the system that can be utilized in the execution of review and approval of grant expenditures prior to timely submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as to retain their review and approval evidence. Additionally, management is developing standard operating procedures and policies that include the requirements for compliance and internal controls for federal grants. The policies will acknowledge that for controls to be designed and operate effectively, there must always be a segregation of duties between the preparer of the control vs. reviewer and that clear documentation must be retained to evidence the execution of the controls. Anticipated Completion Date – June 30, 2027 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management shou...
A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles Review and Approval of Purchase Orders Assistance Listing 93.959: Block Grants for Substance Use Prevention, Treatment, and Recovery Services Federal Agency: Department of Health and Human Services Recommendation: Management should obtain documentation that evidences the review and approval of expenditures submitted to Behavioral Health System Baltimore (BHSB). Explanation of disagreement with audit finding: There is no disagreement with the finding and recommendation. Action planned/taken in response to finding: The Corporation went live on its new ERP system in April 2024. Since go-live, management has continued to optimize the system and find ways to strengthen our internal controls, including automating certain processes. Management will continue educating grant managers on system capabilities that can be utilized in the execution of review and approval of grant expenditures prior to submission to the relevant granting agencies for reimbursement. Centralized repositories have been set up for grant managers to extract specific monthly financial reports for use in the execution of their controls, as well as retain their review and approval evidence. For the specific vendor noted in Finding 2024-001, a grant input field was added to the group purchasing orders to allow for enhanced tracking and review of expenditures associated with grants. Additionally, management worked with the vendor to ensure the requisition and approval configuration is properly maintained to prevent an approver from approving their own requisitions. Anticipated Completion Date – June 30, 2026 Name(s) of the contact person(s) responsible for corrective action: Jeff Chadwick, Financial Reporting Director, jeff.chadwick@umm.edu
The Organization will develop and implement written procurement policies and procedures that comply with Uniform Guidance and ensure consistent application across all procurement activities.
The Organization will develop and implement written procurement policies and procedures that comply with Uniform Guidance and ensure consistent application across all procurement activities.
The Organization has engaged an audit firm to complete the 2024 audit and is implementing procedures to ensure the Single Audit is completed and submitted in a timely manner in future years.
The Organization has engaged an audit firm to complete the 2024 audit and is implementing procedures to ensure the Single Audit is completed and submitted in a timely manner in future years.
Beginning in 2024, the Organization transitioned its time-tracking process to QuickBooks Time, which integrates directly with its accounting system. In addition, the Organization will formally document all future pay rate authorizations in writing, including approvals by the employee and the applica...
Beginning in 2024, the Organization transitioned its time-tracking process to QuickBooks Time, which integrates directly with its accounting system. In addition, the Organization will formally document all future pay rate authorizations in writing, including approvals by the employee and the applicable manager or supervisor. This documentation will be retained in each employee’s personnel file to substantiate authorized pay rates going forward.
The Organization will implement procedures to ensure a physical inventory of all federally funded fixed assets is performed at least every two years and reconciled to the fixed asset records. Newly acquired fixed assets will be tagged upon purchase, and written policies will be updated to assign res...
The Organization will implement procedures to ensure a physical inventory of all federally funded fixed assets is performed at least every two years and reconciled to the fixed asset records. Newly acquired fixed assets will be tagged upon purchase, and written policies will be updated to assign responsibility and ensure ongoing compliance.
The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accor...
The Morgan County Economic Development Office acknowledges the status and final reports for the CDBG and Home grant programs must be submitted by the required due dates. The office will actively monitor all deadlines and ensure that all reports are completed and submitted in a timely manner in accordance with those requirements.
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Manag...
Finding: The Organization did not have adequate and effective controls over compliance in place as it relates to activities allowed or unallowed and allowable costs. We noted Instances where payroll and non-payroll related expenditures did not have documentation of review. Corrective Response: Management is committed to strengthening how we track and allocate hours to grant-funded projects to ensure full compliance with 2 CFR 200.430. Going forward, the organization will implement a time study approach to support the allocation of personnel costs to federal grants. Employees working across multiple funding sources will participate in periodic time studies designed to reasonably estimate the distribution of their time based on actual activities performed. The results of these time studies will be used as the basis for allocating payroll costs to the appropriate grants, and will be supported by documentation and supervisory review. We will also implement consistent tools and processes to ensure allocations are applied systematically across all funding sources. On a monthly basis, the finance team will review and reconcile payroll allocations to ensure they align with the established methodology. In addition, we will provide training and ongoing oversight to reinforce compliance and prevent similar Issues In the future.
Finding 2024-04 Schedule of Expenditures of Federal Awards. Management concurs with the finding. IHS will be working with the new outside CPA firm to develop a grant bridging report beginning FY2025/26.
Finding 2024-04 Schedule of Expenditures of Federal Awards. Management concurs with the finding. IHS will be working with the new outside CPA firm to develop a grant bridging report beginning FY2025/26.
Finding 2024-03 Filing of Single Audit Reports. Management concurs with the finding. Beginning July 1, 2025, IHS will be transitioning some of its financial reporting and audit support functions to an outside CPA firm specializing in nonprofit services. It is anticipated that this transition will he...
Finding 2024-03 Filing of Single Audit Reports. Management concurs with the finding. Beginning July 1, 2025, IHS will be transitioning some of its financial reporting and audit support functions to an outside CPA firm specializing in nonprofit services. It is anticipated that this transition will help assist in meeting the single audit filing deadline.
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recogniti...
Finding 2024-01 Internal Control Over Financial Reporting: Revenue Recognition. Management concurs with the finding. Innovative Health Solutions (IHS) began full implementation of GAAP reporting in FY2024/25. The Fiscal Policy Manual was updated during FY2024/25 to incorporate GAAP revenue recognition criteria for various revenue streams. IHS will continue to review and refine its accounting policies and procedures as it transitions some of its financial reporting and audit support functions to a new outside CPA firm specializing in nonprofit services beginning July 1, 2025.
Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Unifor...
Finding reference: 2024-007 - 93.137 – Community Programs to Improve Minority Health Grant Program Material Weakness and Noncompliance over Subrecipient Monitoring Recommendation: Program management should revise subaward agreements to specifically note the requirements and regulations of the Uniform Guidance, as noted in Section 200.331(a). Additionally, program management should develop standardized procedures for selecting and granting subawards. These procedures should be formalized and maintained for future reference. Brief minutes of progress meetings should be taken to show that monitoring is taking place. All reporting by the subrecipient should be reviewed by management of the program. Action taken: The HHS Department will outline the selection process within the Notice of Funding Availability. Furthermore, a monitoring schedule will be created and program staff are required to review all reports submitted by the subrecipient.
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