Corrective Action Plans

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Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or...
Item: 2024-001 Assistance Listing Number: 93.914 Programs: HIV Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-through Agency: Maricopa County Department of Public Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR 200.405 - Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2025 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.
View Audit 363873 Questioned Costs: $1
Formula Grants for Rural Areas – Assistance Listing No. 20.509 Recommendation: We recommend the Organization revise its suspension and debarment policy to include process for retaining timestamp of search performed. Explanation of disagreement with audit finding: There is no disagreement with the a...
Formula Grants for Rural Areas – Assistance Listing No. 20.509 Recommendation: We recommend the Organization revise its suspension and debarment policy to include process for retaining timestamp of search performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will take the steps necessary to properly document timing of suspension and debarment search performed. Names of the contact persons responsible for corrective action: Rich Pavek, Executive Director, and Kris Burkey, Finance Manager Planned completion date for corrective action plan: Ongoing
Finding 572993 (2024-002)
Significant Deficiency 2024
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the approval of federal fund drawdown requests. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed all our internal controls to ensure all approvals are documented. The procedure has been updated to include preparing the draw documentation, entering the accounts receivable invoice into the accounting system, which now requires an approval for all accounts receivable invoices. Once the accounts receivable invoices are approved in the accounting system then a draw down can be requested in the payment management system. This new process to ensure the documented approval of federal fund drawdown's was implemented mid-year 2024, after the three selections in this finding were completed.
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categori...
Consolidated Health Centers Grant – Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization made changes to improve the process and procedure based on the 2023 audit finding, but they were not implemented until midyear 2024 based on the completion of the audit. It is expected that 100% improvement in findings would not take place with this late implementation. There was an improvement over the prior year, especially in the lack of documentation on file. The monthly audit process to spot check applications for accuracy and ensure complete documentation in the chart was also implemented mid-year in 2024.
To Government Officials: The Town of Branford, Connecticut respectfully submits the following corrective action plan for the year ended June 30, 2024. Significant Deficiency in Internal Control over Financial Reporting Recommendation: We recommend that the Town review its formal policies to ens...
To Government Officials: The Town of Branford, Connecticut respectfully submits the following corrective action plan for the year ended June 30, 2024. Significant Deficiency in Internal Control over Financial Reporting Recommendation: We recommend that the Town review its formal policies to ensure that they cover the year-end closing process and ensure that the Town can adjust and close out the general ledger timely, despite personnel changes and/or other extenuating circumstances. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Town has appointed an audit firm and anticipates scheduling field work to begin in early fall with the goal of publishing the FY 24-25 financial statements by the end of January 2026. While we recognize that the recommendation seeks for the Town to be immune from personnel changes and other extenuating circumstances it is also important to underscore that despite our best efforts this plan relies on all parties (Town, BOE and the auditor firm) having adequate resources in place throughout the process. Name(s) of the contact person(s) responsible for corrective action: James P. Finch; Kathryn H. LaBanca Planned completion date for corrective action plan: January 31, 2026
Recommendation: We recommend that the Organization establish controls to ensure the accuracy of the reporting of enrollee service days, as well as instituting a review process to catch any potential errors prior to submission. Management Response: The Organization has reviewed its procedure for ensu...
Recommendation: We recommend that the Organization establish controls to ensure the accuracy of the reporting of enrollee service days, as well as instituting a review process to catch any potential errors prior to submission. Management Response: The Organization has reviewed its procedure for ensuring the days of care recorded match the days of Service submitted for the monthly substantiation reports. We have addressed this matter in two ways. We have re-trained staff as to the requirements of the State of Michigan and how to calculate and record days of care for youth residing at the Ark. Additionally, we will have both our Compliance Officer and Data Analyst review the files and days of care tabulation to ensure accuracy in the submission of days of care to Michigan Department of Health and Human Services (“MDHHS”).
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditure...
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.
View Audit 363843 Questioned Costs: $1
We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct t...
We accept this finding as per 2 CFR 200.303, a formal documented review and approval process over the indirect cost calculations and online reimbursement requests was not reviewed or approved by someone other than the preparer prior to submittal to the grant agency. We have taken steps to correct the issue as of June 1, 2025. The Accounting Manager will send the monthly indirect cost allocation report to the Executive Director to review and approve prior to beginning any month-end billing process so if corrections are needed, they can be made prior to reimbursement requests being sent to the grant agency. We have also implemented a new month-end process as of June 1, 2025, for the Accounting Manager to provide a detailed GL report to each Program Manager to review and approve program expenses for the given month prior to any billing requests being submitted to the grant agency.
We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospect...
We accept this finding that we could not provide adequate verification or documented dates when an entity is being checked through the Sam.gov system prior to entering into a contract as defined in 2 CFR section 180.995. We have taken steps to correct the issue as of June 1, 2025. All new prospective contractors will be entered into the Sam system and scanned for debarment prior to contracting with them by the Program Manager. In addition, we are in the process of updating our vendor agreements to include language so a vendor can attest they are not debarred from doing business with the federal government.
Identification Number: 2024-001 Finding: Procurement, Suspension and Debarment Corrective Actions Taken or Planned: The Armed Services YMCA (ASYMCA) acknowledges the control deficiency identified in the area of procurement policy and is actively addressing it to ensure full compliance with 2 CFR § ...
Identification Number: 2024-001 Finding: Procurement, Suspension and Debarment Corrective Actions Taken or Planned: The Armed Services YMCA (ASYMCA) acknowledges the control deficiency identified in the area of procurement policy and is actively addressing it to ensure full compliance with 2 CFR § 200.318 (formerly referenced as 2 CFR 300.218), which governs procurement standards for non-federal entities receiving federal awards. 1. Policy Development and Alignment with Federal Regulations ASYMCA Finance is currently compiling and formalizing procurement procedures in accordance with 2 CFR § 200.318. This initiative will result in a comprehensive, board-approved procurement policy that ensures compliance with federal requirements and strengthens internal controls. 2. Existing Policies and Controls ASYMCA already maintains consistent, documented, and approved policies in several key areas of procurement and financial management, including: • Authority of Responsibility: Delegation of authority for designating funds and obligating ASYMCA for purchases, including spending thresholds and approved personnel. • Procurement Standards: General procurement principles and internal controls. • Professional Services and Consulting Agreements • Purchase of Capital Items • Signature Authority • Legal Review • Unbudgeted Expenditures • Record Retention • Policy Enforcement and Consequences • Procedures for Invoicing, Payment Processing, and Reimbursements (Travel and Non-Travel) • Requesting New Vendors • Competition: Requirements for full and open competition in vendor selection.   3. Areas for Expansion and Integration To ensure full compliance with federal procurement standards, ASYMCA will expand its current policies to include the following areas: • Conflict of Interest: Clear guidelines to prevent personal or organizational conflicts in procurement decisions. • Methods of Procurement: Defined procedures for micro-purchases, small purchases, sealed bids, competitive proposals, and non-competitive proposals. • Purchase/License of Technology or Software: Standards for evaluating and acquiring digital tools and platforms. • Indirect Cost: Clarification of treatment and allocation of indirect costs in procurement. • Methods of Procurement (as per federal thresholds) • Contracting with Small and Minority Businesses and Women’s Business Enterprises • Contract Cost and Price Analysis • Federal Awarding Agency Requirements 4. Implementation Timeline ASYMCA is committed to finalizing, approving, and implementing the updated procurement policy the end of the 2025 reporting period. This will include: • Internal review and legal vetting (if necessary) • Board and/or Audit Committee approval • Staff training and dissemination of the policy • Integration into operational procedures for all federally funded and non-federally funded projects Conclusion ASYMCA is committed to maintaining the highest standards of accountability, transparency, and regulatory compliance. The actions outlined above demonstrate a proactive and structured approach to addressing the control deficiency and ensuring that all procurement activities are conducted in accordance with applicable federal regulations. Anticipated completion date: December 31, 2025 Responsible Contact Person: Laura Tate-Smith, Chief Financial Officer
Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified i...
Finding: 2024-002 Material Weakness in Internal Control Over Compliance and Material Noncompliance U.S. Department of Housing and Urban Development Section 8 Housing Choice Vouchers 14.871 - IA125V08001 for FY24 Housing Voucher Cluster Reporting Finding Summary: Three (3) instances were identified in which the City did not use accurate financial information or retain evidence to document the individual who reviewed the Voucher Management System (VMS) reports prior to submission. Responsible Individual: Diana Steiner, Finance Director Corrective Action Plan: We agree with the auditor’s recommendation and staff will have asecond person review the reports. Anticipated Completion Date: By the completion of the ACFR for the fiscal year ending June 30, 2025.
Since the Agency began receiving the Notice of Awards under the new entity in May 2024, we continue to submit the SF-270 in a timely manner for the awarding agency's approval, in accordance with our Standard Operating Procedures (SOPs) and as required by regulations.Proposed Completion Date: Decembe...
Since the Agency began receiving the Notice of Awards under the new entity in May 2024, we continue to submit the SF-270 in a timely manner for the awarding agency's approval, in accordance with our Standard Operating Procedures (SOPs) and as required by regulations.Proposed Completion Date: December 31, 2025
The O􀆯ice is sending the 270 monthly in compliance with applicable regulations and as established in our SOP since October 2024, the date the grantee gave us the approval for submitting all the 270. Proposed Completion Date: December 31, 2025
The O􀆯ice is sending the 270 monthly in compliance with applicable regulations and as established in our SOP since October 2024, the date the grantee gave us the approval for submitting all the 270. Proposed Completion Date: December 31, 2025
Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold requi...
Management plans to develop proper written policies and procedures that will ensure timely submission of the audit package and data collection form to the Federal Audit Clearinghouse within the required timeline during years in which the District incurs federal expenditures above the threshold required by Uniform Guidance.
Finding 572966 (2024-004)
Significant Deficiency 2024
The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies.
The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies.
Finding 572965 (2024-003)
Significant Deficiency 2024
The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies.
The City of Harrington, Delaware will review the State’s procurement process to satisfy the compliance requirements for the program. The City of Harrington, Delaware will also put procedures in place to check and review each bidder as part of the Federal suspension and debarment policies.
The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...
The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Leslie Miller, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.
Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, D...
Corrective Action Plan: PMS will coordinate with the Audit Team to schedule a walkthrough of the Federal Clearinghouse submission process within the first week after Board approval of the Audit, to ensure timely filing. Persons Responsible: Kent Mosbrucker, Vice President of Finance; Denise Cantu, Director of Finance. Estimated Completion Date: May 15, 2025
Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Au...
Corrective Action Plan: Targeted training will be implemented to ensure full compliance with the sliding scale requirements. A new income calculation section has been added to patient intake forms, and monthly audits will be conducted to ensure accuracy and continuous improvement throughout 2025. Audits by location will be carried out by CBO staff and financial analysts, with results shared with administrators and CARs for accountability. Clinics showing minimal improvement will receive additional training. Two mandatory sliding fee scale training sessions will be schedules for all CARs, accounts receivable staff, and administrators. Persons Responsible: Steven Hansen, President & CEO; Peral Lujan, Central Billig Office Director Estimated Completion Date: December 31, 2025
Finding 572934 (2024-001)
Material Weakness 2024
FINDING 2024-001 Finding Subject: 20.205 Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Commissioner Ron Jarman, Auditor Tammy Justice Contact Phone Number and Email Address: 765.745.0013, rjarman@rushcounty.in.gov; 765.932.2077, auditor@rushcounty....
FINDING 2024-001 Finding Subject: 20.205 Highway Planning and Construction - Procurement Contact Person Responsible for Corrective Action: Commissioner Ron Jarman, Auditor Tammy Justice Contact Phone Number and Email Address: 765.745.0013, rjarman@rushcounty.in.gov; 765.932.2077, auditor@rushcounty.in.gov Views of Responsible Officials: Rush County concurs with the finding. Description of Corrective Action Plan: The Commissioners will create a Procurement, Suspension & Debarment Policy with all necessary requirements. Anticipated Completion Date: September 2025
2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporti...
2024-001 Reporting - Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number 21.027 Grant Period - Year Ended June 30, 2024 Condition Found The City failed to submit the annual report in a timely manner. We consider this to be an instance of non-compliance relating to the Reporting Compliance Requirement. Corrective Action Plan The employee responsible for this negligence no longer works for the City. The City will endeavor to comply with all reporting requirements for our Federal Grants and monies received. Responsible Person for Corrective Action Plan Gregory Donovan, Director of Finance (SLFRF) Tenille Rose Martin, Grants Manager (SS4A) Elliot Liebson, Director of Planning (FEMA) Gary Bainter, Asst. Fire Chief (FEMA) Implementation Date of Corrective Action Plan January 1, 2025
Finding 572658 (2024-003)
Material Weakness 2024
Finding 2024-003 – Subrecipient Monitoring Corrective Action Planned In 2024, management finalized revisions to the reports used to complete subrecipient risk assessments. Corrective actions have been implemented as of January 1, 2025 and the reports and process are functioning as intended and asses...
Finding 2024-003 – Subrecipient Monitoring Corrective Action Planned In 2024, management finalized revisions to the reports used to complete subrecipient risk assessments. Corrective actions have been implemented as of January 1, 2025 and the reports and process are functioning as intended and assessments are current. Control processes for subrecipients monitoring checklists have been modified to ensure complete and timely documentation is retained. Persons Responsible for Corrective Action Susan Norby, Division Chair - Research Finance Completion Date January 1, 2025
Finding 572657 (2024-002)
Significant Deficiency 2024
Finding 2024-002 – Cash Management Corrective Action Planned In 2024, management finalized revisions to the reports used to monitor subrecipient payments. Corrective actions have been implemented as of March 31, 2025 and the reports and monitoring process are functioning as intended and all reviews ...
Finding 2024-002 – Cash Management Corrective Action Planned In 2024, management finalized revisions to the reports used to monitor subrecipient payments. Corrective actions have been implemented as of March 31, 2025 and the reports and monitoring process are functioning as intended and all reviews are current. Persons Responsible for Corrective Action Susan Norby, Division Chair - Research Finance Completion Date March 31, 2025
The Housing Authority takes the recommendation from the audit regarding CFP. All CFPs after 2021 have been designated 25% to operating. CFP 21 was changed with permission from the Portfolio Manager at the time and the annual plan included this money to go to operating. All future designations in ...
The Housing Authority takes the recommendation from the audit regarding CFP. All CFPs after 2021 have been designated 25% to operating. CFP 21 was changed with permission from the Portfolio Manager at the time and the annual plan included this money to go to operating. All future designations in EPIC will show the amount to go to operating. However, the HA is not currently able to access CFP 21 in EPIC to edit it – it is locked.
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Mercy Apartments agrees with the audito...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Mercy Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
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