Corrective Action Plans

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Develop and document formal policies and procedures for grant management, including repo1iing, monitoring, and compliance. Implement these policies and ensure that each office is using them correctly.
Develop and document formal policies and procedures for grant management, including repo1iing, monitoring, and compliance. Implement these policies and ensure that each office is using them correctly.
Procurement Policy will be included in the Employee Handbook and federal contracts will be reviewed by Grant Recipient to ensure all federal guidelines are met during the life of the grant. Communication between grant recipient, County Clerk, Treasurer and BOCC to make sure all guidelines are follow...
Procurement Policy will be included in the Employee Handbook and federal contracts will be reviewed by Grant Recipient to ensure all federal guidelines are met during the life of the grant. Communication between grant recipient, County Clerk, Treasurer and BOCC to make sure all guidelines are followed.
Policies and Procedures for Federal Programs will be included in the Employee Handbook. Each office will communicate with the County Clerk and Treasurer when federal funds have been awarded to ensure proper procedures are followed.
Policies and Procedures for Federal Programs will be included in the Employee Handbook. Each office will communicate with the County Clerk and Treasurer when federal funds have been awarded to ensure proper procedures are followed.
Finding 2024-005: Single Audit Reporting Package Not submitted on a timely manner – Repeat Finding – Material Weakness Condition: NACA did not submit its single audit reporting package within the required time frame. For purposes of a Single Audit, it’s due within nine months past the end of the fis...
Finding 2024-005: Single Audit Reporting Package Not submitted on a timely manner – Repeat Finding – Material Weakness Condition: NACA did not submit its single audit reporting package within the required time frame. For purposes of a Single Audit, it’s due within nine months past the end of the fiscal year. Corrective Action: Audit completion is planned, for 2025, to begin at the end of March 2026 for field work, with the completion of the audit, including the Single Audit, by May 31, 2026. The Single Audit will be filed no later than July 31, 2026. This is well within the due date. Name of Person Responsible: Walter McCullough, CFO Anticipated Date of Completion: Ongoing, FY 2025
Finding 2024-009: Reporting – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not maintain copies of performance-related reports submitted to the grantor for the Title V program. Corrective Action: Management is implementing a formal process t...
Finding 2024-009: Reporting – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not maintain copies of performance-related reports submitted to the grantor for the Title V program. Corrective Action: Management is implementing a formal process to retain all supporting documentation for performance-related reports submitted to grantors in accordance with Federal requirements. NACA is also hiring and training a Grant Director to strengthen oversight of grant reporting, compliance, and documentation requirements. As part of the monthly and grant reporting process, staff will ensure that copies of all submissions are saved. A review step will also be added to confirm that all required documentation has been retained prior to final submission. Management will continue to evaluate and adjust processes as needed to ensure compliance and completeness. Name of Person Responsible: Walter McCullough, CFO and finance staff Anticipated Date of Completion: May 31, 2026
Finding 2024-008: Cash Management – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not retain copies of cost reimbursement reports submitted to the grantor for the Urban Health Clinic, Substance Abuse Prevention, and Title V programs. Correct...
Finding 2024-008: Cash Management – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not retain copies of cost reimbursement reports submitted to the grantor for the Urban Health Clinic, Substance Abuse Prevention, and Title V programs. Corrective Action: Management is implementing a formal process to retain all cost reimbursement reports submitted to grantors in accordance with Federal record retention requirements. NACA is also hiring and training a Grant Director to strengthen oversight of grant reporting, reimbursement processes, and documentation requirements. This will include establishing a centralized and organized filing system, to ensure all submitted reimbursement reports are maintained and accessible. As part of the monthly reimbursement and grant reporting process, staff will ensure that copies of all submissions are saved and reconciled to the accounting records. A review step will also be added to confirm that all required documentation has been retained and properly organized prior to final submission. Management will continue to evaluate and adjust processes as needed to ensure compliance and completeness. Name of Person Responsible: Walter McCullough, CFO and finance staff Anticipated Date of Completion: May 31, 2026
Finding 2024-007: Procurement and Suspension/Debarment Documentation and Record Retention – Material Weakness Condition: NACA has written procurement policies that comply with Uniform Guidance; however, documentation evidencing compliance with procurement procedures and suspension and debarment requ...
Finding 2024-007: Procurement and Suspension/Debarment Documentation and Record Retention – Material Weakness Condition: NACA has written procurement policies that comply with Uniform Guidance; however, documentation evidencing compliance with procurement procedures and suspension and debarment requirements was not consistently retained. Corrective Action: Management will enhance implementation of existing procurement policies by ensuring that documentation supporting procurement decisions and suspension and debarment checks (e.g., SAM.gov verification) is consistently retained for applicable transactions. Procedures will be reinforced to ensure appropriate documentation is maintained for audit and monitoring purposes. Name of Person Responsible: Walter McCullough, CFO Anticipated Date of Completion: May 31, 2026
Finding 2024 -006: Overbilling of Indirect Costs – Material Weakness Condition: During the course of the audit, Baker Tilly determined that, for certain time periods, NACA applied an incorrect indirect cost rate, resulting in over billings to the funding source. Corrective Action: Along with the aud...
Finding 2024 -006: Overbilling of Indirect Costs – Material Weakness Condition: During the course of the audit, Baker Tilly determined that, for certain time periods, NACA applied an incorrect indirect cost rate, resulting in over billings to the funding source. Corrective Action: Along with the auditors and the process during the course, management disclosed and determined there was an overcharge of indirect costs. Currently, NACA is under a negotiated cost agreement. We have already disclosed the overbilling to I H S, who is our cognizant grantor, and plan is to disclose to other federal and local agencies. If needed, a payback plan will be established. Communication will be via email for documentation purposes. Name of Person Responsible: Walter McCullough, CFO Anticipated Date of Completion: April 30, 2026.
Views of responsible officials and planned corrective actions – Management concurs with the auditor’s finding. The Organization acknowledges that patients received sliding fee discounts that were inconsistent with the stated sliding fee discount categories under the Organization’s policy. All billin...
Views of responsible officials and planned corrective actions – Management concurs with the auditor’s finding. The Organization acknowledges that patients received sliding fee discounts that were inconsistent with the stated sliding fee discount categories under the Organization’s policy. All billing staff will receive retraining on the correct manual posting procedures for sliding fee scale adjustments after insurance payments, ensuring compliance with patient income verification and applicable percentage guidelines. We will also continue ongoing monitoring and review of accounts receiving sliding fee scale adjustments to ensure accurate and compliance application of the approved discount and percentages. Anticipated Completion Date – 90 days from audit issuance Responsible Contact Person – Donald Griffis, Business Analyst
UCM will develop and implement written procedures requiring that all financial reports submitted to federal awarding agencies or pass-through entities are prepared using actual expenditures recorded in UCM’s accounting system. Reported amounts will be reconciled to the general ledger and supported b...
UCM will develop and implement written procedures requiring that all financial reports submitted to federal awarding agencies or pass-through entities are prepared using actual expenditures recorded in UCM’s accounting system. Reported amounts will be reconciled to the general ledger and supported by appropriate documentation before submission, including general ledger detail, payroll records, accounts payable records, allocation schedules, invoices, receipts, proof of payment, and other records supporting the reported costs. UCM will implement a federal financial reporting checklist to document preparation, reconciliation, and review each report. The checklist will require verification that reported costs agree to actual expenditures, are recorded in the correct reporting period, are charged to the correct federal award, are supported by documentation, and are consistent with award terms and Uniform Guidance requirements. A qualified individual independent of the report preparation process will review and approve reports before submission, and evidence of review will be retained. Responsible for Corrective Action: Shruti Jha, Senior Director of Finance Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Independent Reviewer (CEO, Finance Committee Chair, or another qualified reviewer) Anticipated Completion Date: December 31, 2026
procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and ...
procedures to ensure payments are clearly identifiable by participant and reconciled to approved eligibility records before assistance is provided. Each payment will be supported by participant identification, eligibility approval, assistance type, approved amount, funding source, payment date, and supporting documentation. UCM has established TANF Eligibility Determination Guidelines, a List of Acceptable Documents, and an Assistance Agreement Form to support eligibility determinations and benefit payment documentation. Per VDSS guidance, once eligibility is established at the beginning of the program, a change in status during the participant’s stay does not disqualify the participant from receiving further services. Felony record documentation is not required in the participant file as felony record status is not part of the eligibility requirement per VDSS. Evidence of review and approval will be retained in the participant file. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Case Managers Shruti Jha, Senior Director of Finance Liya Tseye & Carmen Romero, Accountants Laura D’Ambrogi, Grants Manager Anticipated Completion Date: Substantially completed as of April 6, 2026. Ongoing payment review, eligibility monitoring, reconciliation, and supervisory review will continue during the program year.
UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibili...
UCM will strengthen internal controls over TANF eligibility determinations by formalizing written procedures that clearly identify the documentation required to support each eligibility criterion before assistance is provided. The procedures will define required documentation for financial eligibility, citizenship or qualified alien status, TANF benefit history, household composition, applicable legal eligibility requirements, and work participation requirements when applicable. UCM reviewed and discussed the findings with the auditor, Senior Director of Finance, and Chief Program Officer. UCM also reviewed the Virginia Department of Social Services post-training materials on TANF Employment Advancement Eligibility Determination Training, and clarified identified areas of the findings with the Virginia Department of Social Services as they relate to the subrecipient signed contract. UCM designed new Screening Guidelines for incoming program participants, including a documented supervisory review and approval process, which were completed on April 16, 2026. The new screening guidelines require participant files to include sufficient documentation supporting eligibility determinations and require supervisory review before assistance is provided. A supervisor or designated reviewer will verify that the participant file contains the required eligibility documentation, that eligibility criteria have been met, and that the assistance is consistent with TANF requirements, VDSS guidance, the subrecipient contract, and program guidelines. UCM reviewed and trained staff on the new eligibility screening guidelines, acceptable documents, and income requirements on April 28, 2026. Staff responsible for TANF eligibility determinations, case management, direct assistance, and grant compliance will continue to receive training as needed to ensure they understand TANF documentation requirements and maintain complete and accurate participant files. UCM will also periodically monitor participant files to confirm continued compliance and identify any additional training or process improvements needed. Responsible for Corrective Action: Gina Macanlalay, Director of Family Achievement Program Laura D’Ambrogi, Grants Manager Case Managers VDSS Program Consultant Anticipated Completion Date: Substantially completed as of April 28, 2026. Ongoing implementation, supervisory review, staff training, and monitoring will continue during the program year.
UCM will develop and implement comprehensive written policies and procedures addressing cost eligibility, documentation standards, and the requirement that only actual costs are charged to federal awards. The procedures will require costs to be supported by appropriate source documentation, such as ...
UCM will develop and implement comprehensive written policies and procedures addressing cost eligibility, documentation standards, and the requirement that only actual costs are charged to federal awards. The procedures will require costs to be supported by appropriate source documentation, such as invoices, receipts, payroll records, allocation schedules, contracts, approvals, proof of payment, and other relevant records. UCM will implement a review process to ensure costs charged to federal awards are based on actual expenditures recorded in the accounting system, properly supported, charged to the correct funding source, and consistent with Uniform Guidance requirements. Budgeted, estimated, or unsupported amounts will not be charged to federal awards unless specifically permitted by the award terms and adjusted to actual costs within the required reporting period. UCM will also strengthen controls over electronic signatures used in grant, payroll, expenditure, or approval documentation. Electronic signature procedures will require appropriate IT controls so that only the individual providing approval can select or apply their own name. UCM will review user access, system permissions, and approval workflows to ensure signatures are tied to the appropriate user and that evidence of approval is retained. Staff responsible for grant accounting, payroll allocation, accounts payable, electronic approval workflows, and federal award compliance will receive Uniform Guidance training and training on the updated documentation, actual cost, and electronic signature procedures. Responsible for Corrective Action: Cristina Schoendorf, Chief Program Officer Shruti Jha, Senior Director of Finance Deborah Ewell, Director of Human Resources Laura D’Ambrogi, Grants Manager IT Partner Anticipated Completion Date: December 31, 2026
UCM is implementing Insperity, a new Human Resource and Payroll software system, to improve the accuracy and documentation of time allocation, payroll processing, and benefit allocation across programs and funding sources, including the Family Achievement Program federal award. UCM will configure In...
UCM is implementing Insperity, a new Human Resource and Payroll software system, to improve the accuracy and documentation of time allocation, payroll processing, and benefit allocation across programs and funding sources, including the Family Achievement Program federal award. UCM will configure Insperity and related procedures to support time allocation by program, grant, or cost objective, supervisor approval, payroll allocation reporting, and retention of supporting documentation. In addition, UCM will develop and implement written policies and procedures addressing time and effort reporting, employee benefit allocations, payroll allocation methodology, review and approval requirements, and documentation retention standards. These procedures will require that employee benefits charged to the federal award are based on actual benefit costs incurred, rather than budgeted or estimated amounts, unless otherwise permitted by the award terms and adjusted to actual costs within the required reporting period. UCM will establish a review process to ensure payroll and benefit costs charged to the federal award are accurate, allowable, based on actual costs incurred, properly supported, and consistent with Uniform Guidance requirements. Staff responsible for grant accounting, payroll processing, and federal award compliance will receive Uniform Guidance training. Responsible for Corrective Action: Shruti Jha, Senior Director of Finance Deborah Ewell, Director of Human Resources Laura D’Ambrogi, Grants Manager Anticipated Completion Date: September 30, 2026
Finding 2024-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: In the prior fiscal year, Arctic Village Council (AVC) experienced delays in drawing down HUD funds due to staff transitions and turnover. While reimbursement wa...
Finding 2024-001 Lack of Internal Controls Over Cash Management Name of Contact Person: Galen Gilbert, First Chief Corrective Action Plan: In the prior fiscal year, Arctic Village Council (AVC) experienced delays in drawing down HUD funds due to staff transitions and turnover. While reimbursement was ultimately received, the funds were not deposited until after fiscal year-end, contributing to the reported cash management issue. To strengthen internal controls and avoid future delays, AVC will continue to follow its monthly reconciliation process to ensure that all grant expenditures are accurately aligned with drawdown activity and supported by eligible costs. In addition, AVC will explore establishing a line of credit (LOC) in FY2025 to help bridge timing gaps between expenditures and reimbursement cycles. This LOC would provide short-term liquidity support and help reduce reliance on general fund balances while awaiting federal reimbursements. Proposed Completion Date: September 30, 2025
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City implement formal procedures to verify and document suspension and debarment status for all vendors paid with federal funds. Explanation of disagreement with audit finding: There is...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the City implement formal procedures to verify and document suspension and debarment status for all vendors paid with federal funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will implement procedures to properly document controls. Name(s) of the contact person(s) responsible for corrective action: Glenda Delgado, Finance Director Planned completion date for corrective action plan: November 2025 If the Cognizant Agency has questions regarding this plan, please call Glenda Delgado, Finance Director at 401-432-7550.
Finding 1222573 (2024-004)
Material Weakness 2024
Life Academy will work to ensure that internal controls for federal awards are followed. Additionally, Life Academy has crafted a Policy and procedure manual that emphasis roles for various personnel within the district. Anticipated Implementation Date: Before October 1, 2025 Responsible Party: Chie...
Life Academy will work to ensure that internal controls for federal awards are followed. Additionally, Life Academy has crafted a Policy and procedure manual that emphasis roles for various personnel within the district. Anticipated Implementation Date: Before October 1, 2025 Responsible Party: Chief School Financial Officer, Federal Programs Director, Operations, and Superintendent.
Finding 1222572 (2024-003)
Material Weakness 2024
Life Academy has adopted policies and procedures to ensure compliance with Uniform Guidance Section 2 CFR, Part 200. The district only seeks reimbursement for federal expenditures; therefore, funds are not requested in advance of the expense. This process ensures drawn downs for federal disbursement...
Life Academy has adopted policies and procedures to ensure compliance with Uniform Guidance Section 2 CFR, Part 200. The district only seeks reimbursement for federal expenditures; therefore, funds are not requested in advance of the expense. This process ensures drawn downs for federal disbursements occur after the expense to prevent excessive cash on hand. Anticipated Implementation Date: Implemented on October of 2024 Responsible Party: Chief School Financial Officer and Superintendent
Finding 1222571 (2024-002)
Material Weakness 2024
Life Academy will work to complete the audit for the fiscal year no later than nine months after the end of the audit period.
Life Academy will work to complete the audit for the fiscal year no later than nine months after the end of the audit period.
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges noncompliance with federal reporting timelines.  Create a compliance calendar listing all federal reporting deadlines, including the Data Collection Form due date and interim milestones for audit completion.  Designat...
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges noncompliance with federal reporting timelines.  Create a compliance calendar listing all federal reporting deadlines, including the Data Collection Form due date and interim milestones for audit completion.  Designate outsourced finance team as the responsible official for preparing and submitting the Data Collection Form, with the CEO as backup, and require written confirmation of submission to management and the Finance Committee.  Incorporate a year-end compliance checklist into closing procedures to verify preparation and timely filing of the Data Collection Form.  Provide training to leadership and finance staff on federal reporting requirements and consequences of late submissions.
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges gaps in VOCA employee file documentation.  Implement a standardized checklist for VOCA and other grant-funded employees that includes required acknowledgements (nondiscrimination, drug-free workplace, confidentiality, ...
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges gaps in VOCA employee file documentation.  Implement a standardized checklist for VOCA and other grant-funded employees that includes required acknowledgements (nondiscrimination, drug-free workplace, confidentiality, and related forms).  Educate HR staff in auditing best practices, emphasizing complete and accurate employee files and the specific grant documentation required.  Schedule periodic reviews of VOCA-funded employee files (at least quarterly) to verify that all required documents are present and current, with results reported to management.
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges discrepancies in VOCA data metrics reported.  Utilize and document a consistent process and tools (such as Client Trackmanagement or database system) for effective tracking and reporting of all VOCA program metrics.  ...
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges discrepancies in VOCA data metrics reported.  Utilize and document a consistent process and tools (such as Client Trackmanagement or database system) for effective tracking and reporting of all VOCA program metrics.  Establish a routine for random and planned internal audits of reported metrics, comparing reports to source data to verify accuracy and completeness.  Provide training on proper reporting procedures, best audit practices, and data entry accuracy for all staff involved in VOCA data collection and reporting. Tracking and Documentation:  Organize all VOCA program reports by grant name, month, and year, with reports and supporting source documents maintained together and two signatures (Program Manager and Department Director) to confirm the process.  Ensure all staff sign off on VOCA-related training topics, with documentation saved in their personnel folder.  Conduct internal audits of VOCA performance data on a routine basis (monthly & quarterly) to ensure ongoing compliance and accuracy.
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges deficiencies in reconciliation of reimbursement claims. • Implement a standardized reimbursement reconciliation worksheet that ties each grant claim to the general ledger, payroll reports, and underlying invoices prior ...
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges deficiencies in reconciliation of reimbursement claims. • Implement a standardized reimbursement reconciliation worksheet that ties each grant claim to the general ledger, payroll reports, and underlying invoices prior to submission. • Require documented review and approval of each claim by the designated finance team member, confirming that claimed amounts are allowable, supported, and within the grant period. • Provide staff training on claim preparation, reconciliation, and documentation retention expectations.
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges weaknesses in payroll allowability and calculation accuracy. • Update written payroll procedures for grant-funded employees that define allowable and unallowable pay elements (including shift differentials) and specify ...
Views of Responsible Officials and Planned Corrective Actions: YWCA acknowledges weaknesses in payroll allowability and calculation accuracy. • Update written payroll procedures for grant-funded employees that define allowable and unallowable pay elements (including shift differentials) and specify documentation requirements. • Configure payroll and accounting systems to properly classify VOCAfunded positions and apply standard shift differential calculations, with automated checks where possible. • Require a secondary review of payroll registers and allocations for VOCAfunded staff before costs are included in reimbursement requests, with sign-off by designated finance team member. • Provide training to HR, payroll, and finance staff on VOCA grant requirements, federal cost principles, and internal review procedures.
Finding 2024-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part ...
Finding 2024-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
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