Corrective Action Plans

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Strengthened internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implemented a detailed closing schedule and tracking process to monitor deadlines, beginning with mo...
Strengthened internal controls over year-end financial reporting to ensure timely completion of the audit by establishing a comprehensive audit timeline with milestone deadlines by February 28, 2026. Implemented a detailed closing schedule and tracking process to monitor deadlines, beginning with monthly financial close procedures and year-end close preparation by March 31, 2026. Ensured adequate staffing or external support during the financial statement preparation and audit process, including retention of qualified accounting consultant by April 30, 2026. Began conducting periodic reviews to confirm compliance with federal Single Audit submission deadlines, with Executive Director oversight of audit progress reports by May 31, 2026. In the process of prioritizing completion of the outstanding audit report for fiscal year 2025 with an aggressive timeline: 2025 audit by December 31, 2026. In the process of establishing year-round audit preparation procedures, including monthly reconciliations, quarterly financial reviews, and ongoing documentation organization to prevent delays.
Strengthened record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implemented procedures to maintain institutional knowledge during employee turn...
Strengthened record retention practices to ensure documentation of internal control activities is preserved in accordance with 2 CFR 200.334 (three years from submission of final expenditure report) by February 28, 2026. Implemented procedures to maintain institutional knowledge during employee turnover, including documented policies, cross-training, centralized recordkeeping, and formal transition protocols by March 31, 2026. Extended retention periods for documents supporting high-risk federal programs or key internal control activities beyond minimum requirements by April 30, 2026. Established a centralized electronic filing system with version control and backup procedures for all federal award documentation by May 31, 2026. Created detailed internal control documentation templates and ensured all control activities are evidenced in writing by June 30, 2026.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
Management concurs that there were staffing and turnover challenges for the Organization. Adequate policies and procedures are in place to ensure timeliness of data requested. Additionally, we will establish milestones to ensure future audits progress within the Uniform Guidance timeline.
2024-002 – Procurement, Suspension, and Debarment Condition: The District did not have an established policy or procurement protocol in place to ensure vendor verification through one of the three methods defined in federal compliance requirements. Cause: This condition appears to be the result of a...
2024-002 – Procurement, Suspension, and Debarment Condition: The District did not have an established policy or procurement protocol in place to ensure vendor verification through one of the three methods defined in federal compliance requirements. Cause: This condition appears to be the result of a lack of internal controls designed to ensure compliance with Uniform Guidance. Auditor Recommendation: We recommend that the District update their procurement policies and processes to ensure that suspension and debarment compliance requirements are being met and effective internal controls are in place. Plan of Action: The District updated its procurement policies and procedures to ensure compliance with federal suspension and debarment requirements under Uniform Guidance. The revised procurement policy establishes procedures requiring verification that vendors are not suspended or debarred prior to entering into contracts or making purchases using federal funds. The policy requires the Finance Department to verify vendor eligibility through one of the approved federal methods, including review of the System for Award Management (SAM.gov), obtaining vendor certifications regarding suspension and debarment status, or incorporating suspension and debarment verification language into applicable contracts. Documentation of the verification process will be maintained with procurement records. These procedures are designed to strengthen internal controls over procurement activities and ensure the District maintains compliance with both State and Federal procurement requirements. Date of implementaion: Corrective action was implemented in February 2026 when the District presented an updated Procurement Policy to the Board of Directors, which was formally approved. The revised policy includes procedures to ensure compliance with federal suspension and debarment requirements. Following Board approval, the Finance Department began implementing the updated procedures for vendor verification and maintaining documentation of suspension and debarment checks as part of procurement records. These procedures are now incorporated into the District's procurement processes to ensure ongoing complaicen with federal requirements.
Management acknowledges the finding and commits to taking corrective action. A thorough review of the factors contributing to the late filing will be conducted, and procedural enhancements will be implemented to ensure timely compliance with the submission requirements outlined in the Uniform Guidan...
Management acknowledges the finding and commits to taking corrective action. A thorough review of the factors contributing to the late filing will be conducted, and procedural enhancements will be implemented to ensure timely compliance with the submission requirements outlined in the Uniform Guidance. Management will also establish monitoring mechanisms to prevent future occurrences of late filings and ensure ongoing compliance
Condition During our testing, we noted that the Educational Foundation's written procurement policy did not incorporate all applicable Uniform Guidance procurement requirements. Specifically, the policy did not adequately address procurement methods and dollar thresholds, suspension and debarment ve...
Condition During our testing, we noted that the Educational Foundation's written procurement policy did not incorporate all applicable Uniform Guidance procurement requirements. Specifically, the policy did not adequately address procurement methods and dollar thresholds, suspension and debarment verification, and required contract provisions. As a result, the Association's written policy was not fully consistent with the requirements of 2 CFR Part 200 Corrective Action Plan Corrective Action Planned: Management acknowledges the auditor's recommendation regarding the enhancement of the Association's procurement policies to ensure full compliance with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR §§ 200.317–200.327). LeadingAge Michigan has initiated a comprehensive review of its existing procurement policies and procedures to ensure they fully incorporate all applicable federal procurement requirements. The revised policy will include provisions addressing procurement methods based on established dollar thresholds, competition requirements, documentation and record retention standards, contractor responsibility determinations, suspension and debarment verification, conflict of interest requirements, and all required federal contract provisions applicable to federally funded awards. Management will also establish standardized procurement documentation and review procedures to promote consistent application of the policy and to ensure compliance is adequately documented for all applicable purchases funded through federal awards. In addition, personnel responsible for procurement and grant administration will receive training on the updated procurement policy and the requirements of 2 CFR Part 200. This training will emphasize proper procurement planning, documentation, competitive purchasing requirements, and compliance with federal regulations to ensure consistent implementation throughout the organization. Management is committed to maintaining strong internal controls over federal awards and will periodically review procurement practices to ensure ongoing compliance with Uniform Guidance requirements. Name(s) of Contact Person(s) Responsible for Corrective Action: David Herbel, President and CEO Dalton Herbel, Vice President of Public Policy Kelly Price, Member Success Coordinator Anticipated Completion Date: 9/30/2026
The reporting for these has been updated and submitted. In 2024, I was not a part of the e-mail directing these to me - corrected and now processed timely.
The reporting for these has been updated and submitted. In 2024, I was not a part of the e-mail directing these to me - corrected and now processed timely.
Views and Responsible Officials and Planned Corrective Actions Empowered 4 Life Foundation appreciates the auditor’s recommendations and is committed to enhancing its financial management capacity to ensure timely and accurate compliance with grantor requirements, Uniform Guidance standards, and all...
Views and Responsible Officials and Planned Corrective Actions Empowered 4 Life Foundation appreciates the auditor’s recommendations and is committed to enhancing its financial management capacity to ensure timely and accurate compliance with grantor requirements, Uniform Guidance standards, and all applicable regulatory obligations. 1. Evaluation of Financial Management Capacity Since the 2023 audit, Management and the Board have begun a comprehensive review of the Empowered 4 Life Foundation’s current accounting and reporting structure. This assessment includes evaluating staffing levels, workload distribution, and the adequacy of existing financial oversight practices. The goal is to ensure that the Empowered 4 Life Foundation has the resources and expertise necessary to maintain strong financial stewardship. 2. Strengthening the Accounting and Reporting Function The Empowered 4 Life Foundation is exploring several options to enhance its financial management capacity, including: • Assigning dedicated personnel responsible for finance and accounting activities • Engaging qualified outsourced accounting support to supplement internal capacity • Reallocating administrative resources to ensure timely preparation of financial records, grant reports, and audit documentation These options are currently under Board review, and the Empowered 4 Life Foundation will implement the most effective combination of internal and external support to meet compliance requirements. 3. Establishment of a Structured Financial Closing and Reporting Calendar Management is developing a formal monthly and annual financial closing calendar aligned with grantor deadlines, Uniform Guidance requirements, and audit timelines. This calendar will outline key tasks, responsible parties, and due dates to ensure timely completion of all financial reporting obligations. 4. Implementation of Audit Documentation Procedures The Empowered 4 Life Foundation will implement procedures to ensure that all audit documentation is compiled, reviewed, and organized in advance of audit fieldwork. This includes establishing internal deadlines for preparing schedules, reconciliations, supporting documents, and grant compliance records. 5. Ongoing Monitoring and Improvement The Empowered 4 Life Foundation is committed to continuous improvement of its financial management systems. The Board and management will monitor the effectiveness of the enhanced accounting structure and make adjustments as needed to ensure ongoing compliance, accuracy, and operational efficiency. The Empowered 4 Life Foundation values the auditor’s guidance and will continue to strengthen its financial oversight practices to support transparency, accountability, and long term organizational sustainability. Personnel Responsible for the Implementation: Chief Executive Officer, Tonnie Turner Expected Date of Implementation: October 1, 2026
Name of auditee: The YWCA of Western New York, Inc. EIN: 16-0743243 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: July 1, 2023 - June 30, 2024 CAP prepared by: Michelle Sawyers msawyers@ywca-wny.org Finding 2024-001 The previous Agency leadership team did not identify that a Si...
Name of auditee: The YWCA of Western New York, Inc. EIN: 16-0743243 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: July 1, 2023 - June 30, 2024 CAP prepared by: Michelle Sawyers msawyers@ywca-wny.org Finding 2024-001 The previous Agency leadership team did not identify that a Single Audit was required for the fiscal year ending June 30, 2024. The current leadership team determined that the organization was subject to a Single Audit because it received federal funds exceeding the $750,000 threshold during that fiscal year. As a result, the current auditors, EFPR, were engaged to perform the required Single Audit. The Agency has implemented accounting procedures to ensure proper identification of federal expenditures and timely submission of the data collection form to the Federal Audit Clearinghouse.
The City will implement a new policy to verify vendors are not suspended or debarred.
The City will implement a new policy to verify vendors are not suspended or debarred.
Finding No. 2024-011: Procurement and Suspension and Debarment Lack of Documented Procurement Policy We incorporated a Procurement policy that established compliance with the Federal Government whereas, the Health Center will save all bids for three years after the completion of the project or the d...
Finding No. 2024-011: Procurement and Suspension and Debarment Lack of Documented Procurement Policy We incorporated a Procurement policy that established compliance with the Federal Government whereas, the Health Center will save all bids for three years after the completion of the project or the date after the final FFR is approved (whichever is later) in accordance with 45 CFR 75.361. The health center will provide, to the extent practical and economically feasible, consideration for procurement of materials, supplies, and services will be granted to small and minority businesses, women's business enterprises, and labor surplus area firms in accordance to 45 CFR 75.330. The health center is responsible for oversight of the operations of the federal award-supported activities. The health center must monitor its activities by completing the vendor evaluation form quarterly under federal awards to assure compliance with applicable federal requirements and performance expectations are being achieved in accordance to 45 CFR 75.342. The Procurement policy also takes into consideration the process for micro-purchases (not exceeding $10,000); small purchases ($10,000 to $250,000) large purchases (over $250,000); and sole source award determination and justification. We have also incorporated a policy that establishes compliance with Federal government Suspension & Debarment sections [45 CFR §75.327 and§75.335], SHC will do a check on all employees, providers, vendors, and contractors through www.SAM.gov to determine if they are suspended or debarred from receiving compensation from the Federal Government in such applicable instances.
Finding No. 2024-010: Lack of Management Oversight to Ensure Retention of Cash Disbursements and Expenses Approval The Health Center has moved to a cloud portal for submitting and processing invoices for approval and payment as well for maintaining vendor files. Under the cloud portal, any requests ...
Finding No. 2024-010: Lack of Management Oversight to Ensure Retention of Cash Disbursements and Expenses Approval The Health Center has moved to a cloud portal for submitting and processing invoices for approval and payment as well for maintaining vendor files. Under the cloud portal, any requests for payments cannot be processed without an invoice and or any other sufficient supporting documents. Approvals of invoices is now also reflected in the portal to indicate readiness for payment. The Health Center does not anticipate to charge expenses to the awards that are not in accordance with budgeted amounts as submitted to its funding sources.
Finding No. 2024-009: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time that is related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and ma...
Finding No. 2024-009: Lack of Management Oversight to Ensure Retention of Timesheets Grant timesheets are now being maintained with appropriate charging of time that is related programmatic or administrative functions. The timesheets are signed off by the employee and their related supervisor and maintained in the shared file for immediate availability and reference.
Finding No. 2024-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will rec...
Finding No. 2024-008: Inadequate Documentation and Records for Application of Sliding Fee Discounts We have incorporated a policy that establishes the basis for the sliding fee policy to assure affordable access to care for uninsured and underinsured patients of the organization. The policy will recognize a “full discount” for individuals and families with annual incomes at or below 100% FPL with only nominal fees charged, three levels of discount between 100% and 200%, and no discounts for copays for individuals and families earning over 200% FPL. This policy will be in accordance with Section 330(k)(3)(G) of the PHS Act and 42 CFR Part 51c.303(f) and 42 CFR Part 51c.303(u) which are incorporated herewith. We will charge a nominal fee to individuals and families with annual incomes at or below 100% of the Federal poverty level (FPL). Patients whose incomes are above 100% and at or below 200% of the FPL will be charged according to our sliding fee scale based on income and family size. Discounts will be provided to patients with incomes up to 200% of the FPL for medical visits. Discounts will be provided to patients with incomes up to 250% of the FPL for family planning visits. Staff will assess patients’ incomes based upon a sliding fee scale and no patient will be denied care based upon their inability to pay. The organization also has a policy of non-discrimination in the delivery of health care as stated in its Patient Bill of Rights. Also, the Board of Directors define the income and family size, and has defined the family size to be all parents, minors or guardians that are financially responsible for the household. The tracking and documentation of sliding fees is now maintained with the deposit record of each fee received in the shared file for immediate availability and reference.
Finding No. 2024-007: Inadequate System to Ensure Timely Filing and Review of Required Reports As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas the timely filing and review of required reports (e.g., Federal F...
Finding No. 2024-007: Inadequate System to Ensure Timely Filing and Review of Required Reports As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas the timely filing and review of required reports (e.g., Federal Financial Report (FFRs)) are now expected to be filed according to the prescribed deadline(s).
Finding 2024-006: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically des...
Finding 2024-006: Lack of Management Oversight over Drawdown Requests As the previous employees responsible for these functions did not perform them effectively, the organization now has such in place, whereas a drawdown process has been implemented. As the organization’s drawdowns are typically designated to cover payroll costs, this process now includes the following: • A drawdown allocation schedule for the employee’s making up the amount requested • A budget breakdown by department for the amounts making up the drawdown request • A supporting schedule and related invoices for amounts to be reimbursed (e.g., malpractice insurance, etc.) • A completed Standard Form (SF) 270 that tracks the applicable grant amounts previously drawdown that also specifies the amount to be currently drawn.
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in ac...
Views of Responsible Officials and Planned Corrective Actions: We acknowledge the finding related to the delayed submission of the Single Audit report and appreciate the recommendation provided. Management is committed to ensuring timely completion and submission of future Single Audit reports in accordance with the required deadlines. To address this, we will implement the following corrective actions: 1. Enhanced Internal Timeline: We will establish an internal deadline for audit-related documentation and review, allowing sufficient time for finalization before the official reporting deadline. 2. Increased Coordination: Management will work closely with auditors and key stakeholders throughout the audit process to ensure timely responses and resolution of outstanding items. 3. Resource Allocation: Additional internal resources will be dedicated to supporting the audit process, ensuring that necessary documentation and financial records are prepared in advance. 4. Regular Progress Monitoring: We will implement periodic check-ins during the audit period to track progress and address any potential delays proactively. We are confident that these measures will improve our ability to meet future reporting deadlines and enhance overall efficiency in the audit process.
2024-002 – Filing with the Federal Audit Clearinghouse Condition: Aging Services, Inc. (ASI) did not submit its audit report to the FAC within nine months from the year ending June 30, 2024. In conjunction with our FY2024 single audit, please see the ASI’s corrective action plan below: Management re...
2024-002 – Filing with the Federal Audit Clearinghouse Condition: Aging Services, Inc. (ASI) did not submit its audit report to the FAC within nine months from the year ending June 30, 2024. In conjunction with our FY2024 single audit, please see the ASI’s corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines to remain compliant with requirements. Management will make an effort to correct their timeliness and file within the appropriate deadlines going forward. Expected completion date: 6/30/2026
2024-001 – Material Difference Between Federal Expense Detail and Federal Expenses Reported Condition: During the audit, the detailed expenditure support for Special Programs for the Aging, Title III, Part C, Nutrition Services (“Title III C”), ALN 93.045 federal expenditures did not agree to the or...
2024-001 – Material Difference Between Federal Expense Detail and Federal Expenses Reported Condition: During the audit, the detailed expenditure support for Special Programs for the Aging, Title III, Part C, Nutrition Services (“Title III C”), ALN 93.045 federal expenditures did not agree to the original expenditures disclosed on the original SEFA. As a result, a journal entry in the amount of $34,005 was needed to reduce Title III C federal expenditures to agree the SEFA to the supporting expenditure detail. This deficiency is less severe than a material weakness, yet important enough to merit attention by those charged with governance. Accordingly, we consider this matter to be a significant deficiency. In conjunction with our FY2024 single audit, please see the ASI’s corrective action plan below: Management concurs with the finding. Management will implement procedures to reconcile grant expenditure detail to the general ledger, SEFA, and transmittal reports by program and Assistance Listing number prior to submission for audit. The reconciliation will be reviewed and approved by management, and any variances will be investigated and corrected timely Expected completion date: 6/30/2026
Finding 2024-002 Noncompliance with Federal and State Reporting Requirements Condition C4 did not submit its audited financial statements, SEFA and CYEFR and other required information to the Federal Audit Clearinghouse and GATA portal by the required due dates. Management Response Management concur...
Finding 2024-002 Noncompliance with Federal and State Reporting Requirements Condition C4 did not submit its audited financial statements, SEFA and CYEFR and other required information to the Federal Audit Clearinghouse and GATA portal by the required due dates. Management Response Management concurs with auditor’s finding and will implement the recommended corrective action. Person(s) responsible: Kerri Brown, CEO Date of Anticipated Completion Date: December 2026
Finding #2024-002 Deficiency - Internal Controls over Period-End Financial Closing Process of Limited Partnerships Corrective Action Planned ECHC, in its capacity as General Partner, has taken corrective action by terminating the prior property management company and engaging a new property manageme...
Finding #2024-002 Deficiency - Internal Controls over Period-End Financial Closing Process of Limited Partnerships Corrective Action Planned ECHC, in its capacity as General Partner, has taken corrective action by terminating the prior property management company and engaging a new property management company. ECHC will continue to execute and strengthen its oversight controls over the financial closing and reporting process for the Limited Partnerships to ensure complete, accurate, and timely financial information is provided and reviewed. The corrective action plan will include the following steps: 1. Transition to New Property Management Company o Complete on boarding of the new property management company, including communication of ECHC's expectations for financial reporting, internal controls, supporting documentation, and closing timelines. o Confirm that the new property management company understands the required format, content, and timing of monthly submissions. 2. Monthly Reporting Package Deadlines o Require the property management company to provide complete monthly financial reporting packages by an established deadline each month. o Reporting packages will include, as applicable, general ledger detail, trial balance, balance sheet, income statement, bank reconciliations, accounts receivable aging, accounts payable aging, tenant receivable support, cash activity, debt and escrow activity, and supporting documentation for significant or unusual transactions. o ECHC will monitor timely receipt of monthly reporting packages and follow up promptly on late or incomplete submissions. 3. Finance Department Review of General Ledger and Financial Reports o ECHC finance personnel will perform a timely monthly review of the general ledger and financial reports provided by the property management company. o The review will include evaluation of account balances, budget-to-actual fluctuations, unusual transactions, completeness of activity, and consistency with prior periods and known operating activity. o Identified issues will be communicated to the property management company for correction before the monthly close is finalized, where practicable. 4. Review of Key Reconciliations o ECHC will review key reconciliations prepared by the property management company, including bank reconciliations, tenant receivables, accounts payable, security deposits, escrow accounts, intercompany balances, debt balances, and other significant balance sheet accounts. o Reconciliations will be reviewed for completeness, accuracy, timeliness, and support for reconciling items. o Unresolved reconciling items will be tracked and followed up until resolution. 8. Ongoing Monitoring and Oversight o ECHC will monitor the new property management company's performance against established reporting deadlines and quality expectations. o Finance leadership will periodically evaluate whether oversight controls are operating effectively and whether additional controls are needed. o ECHC will maintain documentation of monthly reviews, reconciliations reviewed, issues identified, follow-up performed, and final resolution of exceptions. Management believes these corrective actions will strengthen the period-end financial closing process for the Limited Partnerships, improve the timeliness and accuracy of financial reporting, and reduce the need for post-closing audit adjustments.
Finding Number: 2024-004 Planned Corrective Action: The City and Auditor’s office will implement internal controls to verify any and all vendors doing business with the city are not suspended or debarred. We will utilize information provided from sam.gov and verify if any exclusions apply. We will d...
Finding Number: 2024-004 Planned Corrective Action: The City and Auditor’s office will implement internal controls to verify any and all vendors doing business with the city are not suspended or debarred. We will utilize information provided from sam.gov and verify if any exclusions apply. We will document and keep records on if there are any material changes to any of our vendors’ status. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Brian Elkins, City Auditor
Contact Person – Matt Bakke, Executive Director Corrective Action Plan – The Project will review its policies and procedures over selection from waiting list. Completion Date – 12/31/26
Contact Person – Matt Bakke, Executive Director Corrective Action Plan – The Project will review its policies and procedures over selection from waiting list. Completion Date – 12/31/26
Contact Person – Matt Bakke, Executive Director Corrective Action Plan – The Project will review its policies and procedures over documentation of periodic review of tenant files. Completion Date – 12/31/26
Contact Person – Matt Bakke, Executive Director Corrective Action Plan – The Project will review its policies and procedures over documentation of periodic review of tenant files. Completion Date – 12/31/26
Contact Person – Matt Bakke, Executive Director Corrective Action Plan – The Project will review its policies and procedures over monthly reconciliations. Completion Date – 12/31/26
Contact Person – Matt Bakke, Executive Director Corrective Action Plan – The Project will review its policies and procedures over monthly reconciliations. Completion Date – 12/31/26
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