Corrective Action Plans

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Assistance Listing Number 14.181: Section 811 Supportive Housing for Persons with Disabilities. See the details of this finding for the late REAC submission in 2024-002 above.
Assistance Listing Number 14.181: Section 811 Supportive Housing for Persons with Disabilities. See the details of this finding for the late REAC submission in 2024-002 above.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING NO. 2024-004 Assistance Listing Number 14.181: Section 811 Supportive Housing for Persons with Disabilities See the details of this finding for segregation of duties and other designs of internal controls in 2024-001 above.
DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING NO. 2024-004 Assistance Listing Number 14.181: Section 811 Supportive Housing for Persons with Disabilities See the details of this finding for segregation of duties and other designs of internal controls in 2024-001 above.
Finding 2024-003, Significant Deficiency in Internal Control over Compliance. Condition: The property management failed to make the required monthly reserve deposits for the period of July 2023 to June 2024. Criteria: According to HUD Section 811 regulations, properties must make monthly reserve dep...
Finding 2024-003, Significant Deficiency in Internal Control over Compliance. Condition: The property management failed to make the required monthly reserve deposits for the period of July 2023 to June 2024. Criteria: According to HUD Section 811 regulations, properties must make monthly reserve deposits to ensure financial stability and ongoing maintenance. Cause: The failure was due to deficiencies in the internal controls within the management process related to the monthly deposits. Effect: The failure to make these deposits could jeopardize the financial health of the property and its ability to meet future maintenance needs. Recommendation: The auditor recommended that the property management implement internal controls to ensure monthly reserve deposits are made as required by HUD Section 811 regulations. Responsible Person: Brittany Colson, Manager Planned Action: The Project agrees with the finding and the auditor’s recommendations will be adopted. Anticipated completion date: The recommendation will be applied in fiscal year ending June 30, 2025.
Finding 2024-002, Significant Deficiency in Internal Control over Financial Reporting. Condition: The Project did not submit their financial information to H.U.D. by the required due date. Criteria: Submit the Project financial information by the required due date. Cause: Procedures are in place to ...
Finding 2024-002, Significant Deficiency in Internal Control over Financial Reporting. Condition: The Project did not submit their financial information to H.U.D. by the required due date. Criteria: Submit the Project financial information by the required due date. Cause: Procedures are in place to submit the required information by the required due date. However, the required information was not available for a timely submission. Effect: The REAC submission is late. Recommendation: The auditor recommended that the management and the Project’s governance review their procedures and begin the audit earlier to ensure the financial information is available for a timely submission. Responsible Person: Brittany Colson, Manager Planned Action: The Project agrees with the finding and the auditor’s recommendations will be adopted. Anticipated completion date: The recommendation will be applied in fiscal year ending June 30, 2025.
Finding 2024-001, Significant Deficiency in Internal Control over Financial Reporting. Condition: The design of the Project’s internal controls precludes certain segregation of duties and other designs of internal controls. Criteria: Proper design of the Project’s internal controls to include segreg...
Finding 2024-001, Significant Deficiency in Internal Control over Financial Reporting. Condition: The design of the Project’s internal controls precludes certain segregation of duties and other designs of internal controls. Criteria: Proper design of the Project’s internal controls to include segregation of duties and other designs of internal controls. Cause: The size of The Project’s accounting and administrative staff precludes certain segregation of duties and other designs of internal controls that would be preferred if the office staff were larger. Effect: The segregation of duties and other designs of internal controls are limited. Recommendation: The auditor recommended that management and Project governance review their procedures and develop processes to address deficiencies in the segregation of duties and other designs of internal controls. Increased involvement of the Board of Directors in the financial affairs of the Project would provide oversight and independent review functions, thereby lessening the severity of the deficiencies. Responsible Person: Brittany Colson, Manager Planned Action: The Project agrees with the finding and the auditor’s recommendations will be adopted. Anticipated completion date: The recommendation will be applied in fiscal year ending June 30, 2025.
Finding 2024-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.01...
Finding 2024-004 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster, Public and Indian Housing Program, Public Housing Capital Fund Program, and Coronavirus Relief Fund Assistance Listing Numbers: 14.871, 14.879, 14.850, 14.872, and 21.019 Material Noncompliance Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance Criteria: The Authority must maintain complete and accurate accounts and other records for the program in accordance with HUD compliance requirements. Condition: The Authority did not maintain complete and accurate accounts and other records in accordance with HUD compliance requirements regarding Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Eligibility, Reporting, and Special Tests and Provisions. Context: The Authority was unable to provide requested documentation at the time of audit to properly test the HUD compliance requirements. Known Questioned Costs: Unknown Cause: There is a material weakness in internal controls over compliance related to the maintenance of tenant files, wait lists, inspection reports and other records. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster and Public and Indian Housing Program are in material non- compliance with the compliance requirements of the program. Recommendation: We recommend that the Authority implement a process whereby Authority documents are stored and safeguarded to ensure compliance with the Uniform Guidance and the compliance supplement. View of Responsible Officials and Corrective Actions: The Authority experienced significant turnover in employees during the year and as a result certain source documents were misplaced or destroyed. Management agrees with the Auditors' finding and has hired a new Executive Director who will implement the required safeguards and ensure that the Authority follows its internal control over compliance processes and procedures related to the Housing Voucher Cluster, Public and Indian Housing Program and Public Housing Capital fund Program to remedy the aforementioned deficiencies. Bryant McClellan, CFO, will be responsible to implement this corrective action by December 31, 2025.
To improve the timeliness and accuracy of our quarterly and semi-annual reporting, Cayuga Centers has aligned reporting deadlines with internal reconciliation schedules. A reporting coordinator will be appointed to oversee submissions and ensure accuracy. Monthly reconciliations of qualifying costs ...
To improve the timeliness and accuracy of our quarterly and semi-annual reporting, Cayuga Centers has aligned reporting deadlines with internal reconciliation schedules. A reporting coordinator will be appointed to oversee submissions and ensure accuracy. Monthly reconciliations of qualifying costs and cash draws will support this process, and a reporting calendar with automated reminders will be implemented to keep all stakeholders on track.
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs ...
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs against program requirements and other relevant background documentation. For finding 2024-012, Cayuga will review relevant lease terms and program requirements. If, upon full evaluation, Cayuga Centers concurs that such costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. For steps to resolve the underlying control deficiency asserted or implied in this finding, please see Cayuga Centers’ response to Findings 2024-001 through 006 above.
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs ...
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs against program requirements and other relevant background documentation. For finding 2024-012, Cayuga will review relevant lease terms and program requirements. If, upon full evaluation, Cayuga Centers concurs that such costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. For steps to resolve the underlying control deficiency asserted or implied in this finding, please see Cayuga Centers’ response to Findings 2024-001 through 006 above.
As discussed above Cayuga Centers has engaged grants management advisors who will assist in evaluating this specific finding. To the extent that the finding merely asserts that indirect cost bases were improperly calculated in prior periods, please see Cayuga Centers’ response and actions steps with...
As discussed above Cayuga Centers has engaged grants management advisors who will assist in evaluating this specific finding. To the extent that the finding merely asserts that indirect cost bases were improperly calculated in prior periods, please see Cayuga Centers’ response and actions steps with respect to findings 2024-001 through 006. If, upon full evaluation, Cayuga Centers concurs that indirect costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs.
Cayuga Centers does not fully understand the scope of this asserted finding. It will, however, work with its auditors to fully assess this finding. As discussed above, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted findings. To the exte...
Cayuga Centers does not fully understand the scope of this asserted finding. It will, however, work with its auditors to fully assess this finding. As discussed above, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted findings. To the extent that the costs referenced in this finding are unallowable, Cayuga Centers will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. To the extent this finding asserts control failures, please see Cayuga Centers’ response to Findings 2024-005 and 006 above.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the drawdown process generally, Cayuga Centers has established a review protocol requiring that draws include only qualified expenditures incurred or expected within three business days. All draw requests require dual approval from both finance and program staff. A centralized draw request log is being maintained, including supporting documentation and reconciliation records. With respect to Finding 2024-008, Cayuga Centers does not entirely agree with the auditors’ assertion that accrued vacation expense was improperly included in draw requests. Under certain circumstances, costs of paid time off may be treated as incurred based on PTO earned, rather than PTO-paid. See 2 C.F.R. § 200.431(b). Cayuga Centers will further evaluate this asserted finding with the grants management advisors described above. To the extent there may be any compliance discrepancy, Cayuga Centers will take further appropriate action.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the drawdown process generally, Cayuga Centers has established a review protocol requiring that draws include only qualified expenditures incurred or expected within three business days. All draw requests require dual approval from both finance and program staff. A centralized draw request log is being maintained, including supporting documentation and reconciliation records. With respect to Finding 2024-008, Cayuga Centers does not entirely agree with the auditors’ assertion that accrued vacation expense was improperly included in draw requests. Under certain circumstances, costs of paid time off may be treated as incurred based on PTO earned, rather than PTO-paid. See 2 C.F.R. § 200.431(b). Cayuga Centers will further evaluate this asserted finding with the grants management advisors described above. To the extent there may be any compliance discrepancy, Cayuga Centers will take further appropriate action.
This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, ...
This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding in conjunction with Finding 2024-005 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. The new Finance Team leadership have reinstated use of the class system in our general ledger to allocate direct costs to specific programs and clearly separate non-reimbursable expenses. Monthly reconciliations will be performed to ensure qualifying costs align with cash draw requests. Accounting staff have or will receive targeted training on cost allocation principles and documentation standards to support this effort.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Cayuga Centers has also begun the process of working with its main federal funder regarding this item and will coordinate closely with that funder in res...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Cayuga Centers has also begun the process of working with its main federal funder regarding this item and will coordinate closely with that funder in resolving it. As an immediate action step, Cayuga Centers is reinforcing training for all grant management personnel, emphasizing the distinction between allowable and unallowable costs. The Training Department is developing a virtual curriculum to issue to all required staff. A pre-approval process was introduced for all grant-funded expenditures, and program managers will be required to certify compliance before expenses are submitted for reimbursement.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Evaluation of this finding and Cayuga Centers’ procurement policies will be completed no later than November 2025 and any improvements needed for complia...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Evaluation of this finding and Cayuga Centers’ procurement policies will be completed no later than November 2025 and any improvements needed for compliance or recommended as best practice will be adopted. As an initial action step, Cayuga Centers has developed a compliance checklist for all significant and recurring purchases. This checklist requires evidence of competitive bidding, vendor selection, and justification for sole-source procurement. Staff involved in purchasing have received, or will receive, training on federal and organizational procurement policies. The Compliance Department will conduct quarterly reviews of procurement records to ensure adherence to established procedures.
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.
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