Corrective Action Plans

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Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...
Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.
Management deposited $619.17 on April 3, 2025 and $619.17 on April 10, 2025 to fully fund the reserve for replacement account.
Management deposited $619.17 on April 3, 2025 and $619.17 on April 10, 2025 to fully fund the reserve for replacement account.
View Audit 359677 Questioned Costs: $1
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This w...
The Capital District YMCA reviewed the vendor used for our project when the auditors brought this to our attention and we did not find any suspension or disbarment information. We will incorporate this vendor review into our process for all programs or activities related to Federal contracts. This will be done in conjunction with the procurement policy and be in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
The Capital District YMCA will develop and implement a written procurement policy in accordance with 2 CFR Section 200.318 and have it in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
The Capital District YMCA will develop and implement a written procurement policy in accordance with 2 CFR Section 200.318 and have it in place by July 31, 2025. The SVP/CFO Mary Maziejka will be responsible for development and implementation of the policy.
2025-001 Special Tests and Provisions - Sliding Fee Scale Discounts Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications o...
2025-001 Special Tests and Provisions - Sliding Fee Scale Discounts Recommendation: To help ensure that sliding fee scale (SFS) discounts are properly calculated and documented, the Center should perform random reviews of its SFS applications to detect and correct errors or incomplete applications on a timely basis. Corrective Action Taken: 1. Immediate Review and Correction Upon determination of the finding, we conducted a full review of the affected patient account. 2. Staff Training All Outreach and Eligibility staff have received refresher training on the proper application of the sl iding fee scale, including income verification processes and documentation standards. This training now occurs as part of onboarding and annually thereafter. 3. Policy and Procedure Review We reviewed our internal policies and procedures to ensure clear guidance on income documentation requirements, allowable income sources, and how to properly apply the sliding scale. 4. Double-Verification Process A second-level review has been instituted for all new patient applications and renewals involving sliding fee scale determinations. This ensures that income is correctly assessed, and the appropriate fee level is applied before any charges are finalized. 5. Audit and Monitoring A quarterly internal audit process has been implemented to review a random sample of sliding fee scale determinations for accuracy. Findings from these audits will be tracked, and any trends will be addressed through targeted training or process changes. Ongoing Commitment: We are committed to continuous improvement and will monitor the effectiveness of these corrective actions over the next year. Adjustments will be made as necessary to ensure sustained compliance and fairness in our billing practices. Our goal is to uphold transparency and affordability in patient care while maintaining full adherence to regulatory standards. Contact Person: Tamie Olson, Chief Financial Officer Completion Date: Fiscal year ending January 31, 2026
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and t...
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and the area support manager. Additional training reviews for specific compliance findings with all management staff.
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and t...
Action: Current Property manager and supervisor completed corrections and new HUD 50059A's for certifications corrected for March 31, 2025. Ongoing Action: Additional file reviews for all certifications, prior to and after completion, requiring the signatures of the reviewing Property manager and the area support manager. Additional training reviews for specific compliance findings with all management staff.
2025-002 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for two withdrawals from the Reserves for Replacement account totaling $2,500 during the year. Action taken: $2,000 has been returned to the Reserves for Replacement account. Contact person: Nan...
2025-002 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for two withdrawals from the Reserves for Replacement account totaling $2,500 during the year. Action taken: $2,000 has been returned to the Reserves for Replacement account. Contact person: Nancy Jordan Completion date: May 15, 2025 Explanation of Disagreement: Not applicable Repeat finding: No
2025-001 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for three withdrawals from the Residual Receipts account totaling $18,354 during the year. Action taken: $5,000 has been returned to the Residual Receipts account. Contact person: Nancy Jordan C...
2025-001 Reportable Condition — Compliance: Condition: The Organization did not receive HUD authorization for three withdrawals from the Residual Receipts account totaling $18,354 during the year. Action taken: $5,000 has been returned to the Residual Receipts account. Contact person: Nancy Jordan Completion date: May 15, 2025 Explanation of Disagreement: Not applicable Repeat finding: No
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure ...
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure that all resident files are maintained at the site for each resident of the Property in accordance with the HUD Handbook 4350.3. Management Response: Management agrees with the recommendation and will ensure that resident files are retained in accordance with the HUD Handbook 4350.3. The resident moved-out on June 13, 2024. No further action is required.
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying th...
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying the invoices approved by HUD and had not paid as of January 31, 2025. Recommendation: Management should ensure that HUD approved reserve for replacement withdrawals are used for the approved purposes. Management Response: Agree. The Corporation paid the remaining costs included in the HUD approved withdrawal on March 3, 2025. There is no further action required.
View Audit 355850 Questioned Costs: $1
The responsible official for the corrective action plan is Valerie Vallee, Vice President. The anticipated completion date is April 9, 2025. Response: Unpaid replacement reserve escrow from August 2024 was paid in April 2025.
The responsible official for the corrective action plan is Valerie Vallee, Vice President. The anticipated completion date is April 9, 2025. Response: Unpaid replacement reserve escrow from August 2024 was paid in April 2025.
Item 2024‐006 Reporting - Special Failure to submit the SF‐429 – Real Property Status Report and SF‐429‐A General Reporting reports accurately and timely results in noncompliance with the federal statute. To correct this, the agency will implement a formalized reporting procedure that outlines requi...
Item 2024‐006 Reporting - Special Failure to submit the SF‐429 – Real Property Status Report and SF‐429‐A General Reporting reports accurately and timely results in noncompliance with the federal statute. To correct this, the agency will implement a formalized reporting procedure that outlines required documentation, preparer and reviewer duties, and verification steps. A compliance calendar with automated reminders will be established, and dual-review sign-offs will be required for all submissions to ensure accuracy and completeness. To prevent recurrence, the agency will assign clear accountability for report preparation, review, and submission, supported by targeted staff training on federal real property reporting requirements. A centralized digital repository will be created for all real property documentation, ensuring consistent access and retention. The Finance Director will conduct quarterly compliance checks and report status updates to leadership, reinforcing oversight and ensuring sustained adherence to federal reporting standards. Responsible Personnel: Cynthia Cooper – Chief Finance Officer: Oversight, review, and compliance monitoring Sharon Jordan - Head Start Director: Accountability and reporting Estimated Date of Completion: December 2026
Finding 2024-005: Allowable Costs/Cost Principles Lack of proper review of underlying lease agreement for invoices Corrective Action Plan The lease agreement referenced in this finding originated in 2014 and involved copier equipment that had previously been returned. The matter has been fully resol...
Finding 2024-005: Allowable Costs/Cost Principles Lack of proper review of underlying lease agreement for invoices Corrective Action Plan The lease agreement referenced in this finding originated in 2014 and involved copier equipment that had previously been returned. The matter has been fully resolved with the copier provider, which refunded the applicable amount, and those funds were subsequently returned to the Office of Head Start in accordance with the instructions provided. The program also contacted OHS, followed the guidance received, and submitted all supporting documentation for review. Within the next 30 days, the program will strengthen its invoice review process by requiring verification of lease agreements and supporting documentation prior to payment approval and by ensuring all historical and current lease-related records are retained in a centralized location. To ensure long-term compliance, the program will implement strengthened internal controls within 60 days, including dual review of all leases-related invoices, periodic reconciliation of active lease agreements, and annual verification of contract status. Ongoing monitoring will be conducted by the Finance Officer and Head Start Director, who will provide quarterly updates on compliance and documentation accuracy. Responsible Personnel: Cynthia Cooper – Chief Finance Officer: Oversight, review, and compliance monitoring Sharon Jordan - Head Start Director: Accountability and reporting Estimated Date of Completion: December 2026
Finding 2024-004: Financial Reporting The club did not maintain proper documentation in support of financial reporting requirements for the two SF-425 reports that were tested. Corrective Action Plan The program will implement immediate corrective measures to strengthen federal financial reporting a...
Finding 2024-004: Financial Reporting The club did not maintain proper documentation in support of financial reporting requirements for the two SF-425 reports that were tested. Corrective Action Plan The program will implement immediate corrective measures to strengthen federal financial reporting and ensure full compliance with SF-425 documentation requirements. Within the first 30 days, supporting documentation for the SF-425 reports tested will be recreated and retained to the extent possible, and a standardized SF-425 Documentation Packet will be established to include all required backup materials. A designated staff member will be assigned responsibility for preparing and retaining all SF-425 support documentation, and finance staff will receive refresher training on federal reporting requirements and documentation standards. Between 30 and 60 days, the program will implement a Financial Reporting Documentation Policy requiring supporting schedules for each SF-425 line item, retention of all source documentation, and clear identification of preparers and reviewers. SF-425 preparation and documentation tasks will be integrated into the monthly and quarterly fiscal compliance calendar, and dual review and sign-off will be required for each submission to ensure accuracy and completeness. From 60 to 90 days, the program will strengthen reporting processes by implementing a SF-425 Preparation Checklist, establishing a centralized digital folder structure with restricted access and audit-ready program, cross-training additional staff to ensure continuity, and updating fiscal policies to reflect strengthened documentation and review procedures. Long-term oversight will include quarterly reporting compliance updates from the Finance Officer to the Head Start Director, Policy Council, and Executive Board; annual internal monitoring of SF-425 documentation packets; and maintenance of all federal reporting documentation for the required retention period under Uniform Guidance. Financial reporting procedures will be reviewed and updated annually. Full implementation will occur within 90 days, quarterly monitoring will remain ongoing, and annual policy review will occur each fiscal year. Evidence of completion will include completed SF-425 documentation packets, signed preparation and review checklists, updated fiscal policies and procedures, and quarterly compliance reports submitted to the Policy Council and Executive Board. Responsible Personnel: Cynthia Cooper – Chief Finance Officer: Oversight, review, and compliance monitoring Sharon Jordan - Head Start Director: Accountability and reporting Estimated Date of Completion: December 2026
Finding 2024-003: Property and Equipment Management (Repeat) The Inventory tracking sheet did not contain all required federal asset information and was not properly reconciled to property records. Corrective Action Plan The program will implement immediate corrective measures to strengthen property...
Finding 2024-003: Property and Equipment Management (Repeat) The Inventory tracking sheet did not contain all required federal asset information and was not properly reconciled to property records. Corrective Action Plan The program will implement immediate corrective measures to strengthen property and equipment management in accordance with 2 CFR 200.313(d)(1). The inventory tracking sheet has been updated to include all federally required data fields, (see attachment) followed by a full reconciliation of the revised spreadsheet to existing property records. Missing or incomplete asset information will be identified and corrected, with the Facilities Manager overseeing all updates and reconciliation activities. Property management inventory documentation will be integrated into the monthly and annual fiscal compliance calendar, and the spreadsheet provided will serve as the foundation for continued corrective work already underway. From 60 to 90 days, the program will conduct a complete physical inventory using the updated tracking spreadsheet, reconcile results to property records, document discrepancies, cross-train staff to ensure continuity, and update fiscal policies to reflect strengthened procedures and clarified roles. Long-term oversight will include annual physical inventories, and quarterly compliance updates from the Facilities Manager to the Finance Officer. Head Start Director, Policy Council, and Executive Board, and maintenance of audit-ready property records in a centralized location. Property management procedures will be reviewed annually and updated as needed. Physical inventory will be completed within 90 days, quarterly monitoring will continue, and annual physical inventories will be conducted every year. Evidence of completion will include the updated property management spreadsheet, reconciliation documentation, physical inventory results and reports, updated fiscal policies, and quarterly compliance reports submitted to the Policy Council and Executive Board. Responsible Personnel: Cynthia Cooper – Chief Finance Officer: Oversight, review, and compliance monitoring Sharon Jordan - Head Start Director: Accountability and reporting Estimated Date of Completion: December 2026
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. LYRIC will implement the following corrective actions: (1) develop and adopt a written procurement policy that requires SAM.gov exclusion verification for all covered transactions at or above $25,000,...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. LYRIC will implement the following corrective actions: (1) develop and adopt a written procurement policy that requires SAM.gov exclusion verification for all covered transactions at or above $25,000, as well as all subrecipient transactions regardless of amount; (2) create a standardized SAM.gov verification checklist requiring staff to print or save a screenshot of the SAM.gov search result and retain it in each vendor's contract file as documentation of verification; (3) designate the Contracts Manager as responsible for confirming that debarment documentation is completed and filed before any contract is executed; and (4) train all staff involved in procurement on suspension and debarment requirements under 2 CFR Part 180. However, please note that the appropriate Bids were held prior to the selection of the vendors and the vendors provided all the required validations before being contacted. Responsible Official and Position: Ana Rubio, Director of Finance, and Laura Chavez, Contracts Manager Expected Implementation Date: July 1, 2026
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. LYRIC will take the following corrective actions: (1) immediately correct the indirect cost rate applied to the HUD award and all future grant budgets to ensure it does not exceed the 10% rate; (2) wo...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. LYRIC will take the following corrective actions: (1) immediately correct the indirect cost rate applied to the HUD award and all future grant budgets to ensure it does not exceed the 10% rate; (2) work with HUD to address the $48,814 overcharge and determine the appropriate remedy, including offsetting other legitimate expenses against the overdrawn amount as necessary; (3) document the organization's elected indirect cost rate and methodology in each grant's budget file and award documentation; (4) evaluate whether to pursue a new NICRA through the cognizant federal agency if a rate above 10% is needed to accurately recover indirect costs with future grants; and (5) provide specific and targeted training to concerned staff on indirect cost rate rules, MTDC calculation, and Uniform Guidance compliance. Responsible Official and Position: Ana Rubio, Director of Finance, and Laura Chavez, Contracts Manager Expected Implementation Date: July 1, 2026
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. LYRIC will implement the following corrective actions: (1) document the start and end period of grant and performance for each future federal award in a centrally accessible grant file, and require Fi...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding. LYRIC will implement the following corrective actions: (1) document the start and end period of grant and performance for each future federal award in a centrally accessible grant file, and require Finance staff to reference these dates during all expense coding and reimbursement processing; (2) add a pre-submission checklist step requiring staff to confirm that all expenditure dates fall within the approved period of performance before any draw request is finalized; (3) assign supervisory review responsibility to the Finance or Grants Manager to provide a secondary check on period eligibility before submission; (4) work with HUD to assess the questioned costs and take appropriate corrective action to substitute other legitimate expenses as necessary; and (5) train finance and program staff on period of performance rules and the requirement that only costs incurred within the approved grant period may be charged to a federal award. Responsible Official and Position: Ana Rubio, Director of Finance, and Laura Chavez, Contracts Manager Expected Implementation Date: July 1, 2026
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding and treats accurate reimbursement of federal funds as a serious obligation. LYRIC will implement the following corrective actions: (1) create and maintain a detailed reimbursement tracking log recordin...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with this finding and treats accurate reimbursement of federal funds as a serious obligation. LYRIC will implement the following corrective actions: (1) create and maintain a detailed reimbursement tracking log recording each submitted draw by expense date, vendor, amount, and draw number, to be updated at the time of every submission; (2) require a second staff member to perform an independent review of each reimbursement request against the tracking log and general ledger prior to submission, specifically to identify potential duplicate charges or wrong coding of expenses; (3) work with HUD to address the $54,799 in duplicated amount to offset other legitimate expenses; and (4) explore whether LYRIC's accounting system can be configured to flag expenditures already coded to a prior reimbursement request, adding a system-level check to the manual review process. Responsible Official and Position: Ana Rubio, Director of Finance, and Laura Chavez, Contracts Manager Expected Implementation Date: July 1, 2026
Views of Responsible Officials and Planned Corrective Actions: Management accepts this finding. To prevent recurrence, LYRIC will: (1) assign a designated staff member and a contracts manager the responsibility for federal audit compliance monitoring, including tracking cumulative award expenditures...
Views of Responsible Officials and Planned Corrective Actions: Management accepts this finding. To prevent recurrence, LYRIC will: (1) assign a designated staff member and a contracts manager the responsibility for federal audit compliance monitoring, including tracking cumulative award expenditures throughout; (2) establish an annual federal expenditure calendar that flags when spending approaches the $750,000 threshold; (3) maintain a reporting timeline aligned with FAC submission deadlines, including the nine-month post-fiscal-year-end deadline; and (4) engage its audit firm at the start of each fiscal year to plan audit scope and timing, ensuring the Single Audit can be completed within the required timeframe. Uniform Guidance applicability training will be provided to staff as needed. Management also agrees with the non-submission of performance reports. LYRIC will take the following corrective actions: (1) develop a comprehensive grant reporting calendar for all active federal awards, identifying each required report type, submission deadline, and the staff member responsible for preparation and submission; (2) designate a program staff lead for the federal award reporting, with mandatory review by the Contracts Manager and Director of Finance prior to each submission; (3) implement an internal check-in to review upcoming reporting deadlines across all grants; and (4) submit any outstanding reports to the authorities as promptly as possible and proactively communicate with the assigned program officer regarding the delayed submissions to mitigate any compliance impact. Responsible Official and Position: Ana Rubio, Director of Finance, and Laura Chavez, Contracts Manager Expected Implementation Date: July 1, 2026
Finding 1236680 (2024-002)
Material Weakness 2024
Implementation of plan of action - Management has communicated with ALSDE and submitted a detailed spend-down plan to bring net cash resources under the 3-month limit. The spend-down plan was approved by ALSDE and the School is currently operating under that plan. The spend-down plan was revised by ...
Implementation of plan of action - Management has communicated with ALSDE and submitted a detailed spend-down plan to bring net cash resources under the 3-month limit. The spend-down plan was approved by ALSDE and the School is currently operating under that plan. The spend-down plan was revised by the School and reviewed and approved by ALSDE in conjunction with the FY 2025 financial statement submission. Implementation date - Anticipated completion August 4, 2025. Persons responsible for the implementation - The Board of Directors and Head of School.
We have implemented internal controls to ensure timely and accurate submissions of reports and proper reconciliation of reports to underlying records. Implementation date: __7/01/2026__
We have implemented internal controls to ensure timely and accurate submissions of reports and proper reconciliation of reports to underlying records. Implementation date: __7/01/2026__
We have implemented internal controls to ensure disbursements are properly reviewed and approved and all documentation and are retained on file based on the Center’s documentation retention policy. Implementation date: ___7/01/2026___
We have implemented internal controls to ensure disbursements are properly reviewed and approved and all documentation and are retained on file based on the Center’s documentation retention policy. Implementation date: ___7/01/2026___
We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: _June 16, 2026_
We have reviewed the sliding fee calculations calculated by the system and have implemented internal control procedures to ensure the discount fees are calculated and applied correctly. Implementation date: _June 16, 2026_
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