Corrective Action Plans

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The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.
The Accountant prepares reimbursement requests and the Contracted Controller reviews and approves reimbursement before submission is submitted.
SHN annually runs all vendors through Verify Comply to ensure there are no vendors who are suspended or disbarred. Before a new vendor is paid, the vendor is ran through Verify Comply to ensure there is no suspension and debarment, and the paperwork is retained with the Vendor’s W-9.
SHN annually runs all vendors through Verify Comply to ensure there are no vendors who are suspended or disbarred. Before a new vendor is paid, the vendor is ran through Verify Comply to ensure there is no suspension and debarment, and the paperwork is retained with the Vendor’s W-9.
SHN will draft a “Federal Grants Management Policy Manual” and implements related procedures which will be in compliance with Uniform Guidance (2 CFR 200.320) for micro-purchases. As of April 2025, there is a Procurement Policy in place and contracted vendors and staff are required to follow the pol...
SHN will draft a “Federal Grants Management Policy Manual” and implements related procedures which will be in compliance with Uniform Guidance (2 CFR 200.320) for micro-purchases. As of April 2025, there is a Procurement Policy in place and contracted vendors and staff are required to follow the policy. For food purchases that are in relation to federal funding, due to multiple smaller purchases, the requester must obtain 3 quotes and complete a spreadsheet indicating why the vendor was selected. It is then approved by the Director of Operations to move forward with the purchase.
View Audit 370389 Questioned Costs: $1
The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.
The Programs and Partnership Team has developed a Standard Operating Procedure to ensure all team members are following requirements for eligibility and properly documenting that eligibility was obtained.
The City will ensure that federal procurement is properly followed by educating our staff on federal processes and thresholds. Any and all federal procurement will need to be approved by the City Administrator prior to contracts being approved. Add language to bid docs that all contractors must prov...
The City will ensure that federal procurement is properly followed by educating our staff on federal processes and thresholds. Any and all federal procurement will need to be approved by the City Administrator prior to contracts being approved. Add language to bid docs that all contractors must provide a "debarment check" at the time of bid opening. We will also assign staff to check SAM for the debarment or suspension of contractors, as a second measure of assurance. We will add language to our updated Administrative Policy for Purchasing and Contracting. These measures should strengthen our internal controls to verify that all contractors who are paid more than $25,000 in federal funding are in good standing and not suspended or debarred.
2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.
2024-003 The City charged costs that were incurred prior to the beginning of the period of performance of the grant. Helen Tomic, Long Range Planning Manager December 31, 2025 The City will implement control procedure to prevent the charging of costs before the period of performance.
View Audit 370339 Questioned Costs: $1
2024-002 The City did not submit the required Program Reports for all four quarters of 2024. Stephen Fricker, Director of Finance December 31, 2025 The City will implement additional control procedures to ensure all reports are filed in a timely manner.
2024-002 The City did not submit the required Program Reports for all four quarters of 2024. Stephen Fricker, Director of Finance December 31, 2025 The City will implement additional control procedures to ensure all reports are filed in a timely manner.
PAX has established policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed in a timely manner. The primary deliverable will be timely audit completion and submission.
PAX has established policies, procedures, and controls to ensure that future submissions of Uniform Guidance reports are filed in a timely manner. The primary deliverable will be timely audit completion and submission.
Based upon current auditor’s recommendation, PAX has revised its effort verification reporting system. The previous system recommended by the last auditor was launched in FY23, however, current auditor points out the need to track all efforts rather than only the federal grants in order to provide s...
Based upon current auditor’s recommendation, PAX has revised its effort verification reporting system. The previous system recommended by the last auditor was launched in FY23, however, current auditor points out the need to track all efforts rather than only the federal grants in order to provide support for the full effort of each employee. Our latest revised system will accurately capture 100% of the effort spent by each employee on specific grants, other programs, and general and administrative functions, ensuring complete documentation of allocation of wages and salaries to the respective federal awards.
Management will continue to request invoices from vendors in a timely manner. In the event a vendor fails to provide such invoice management will make reasonably estimate of expense to be accrued at year-end.
Management will continue to request invoices from vendors in a timely manner. In the event a vendor fails to provide such invoice management will make reasonably estimate of expense to be accrued at year-end.
Management will review retroactive calculations to ensure decimal point variances are identified prior to disbursement as in this case $35.104 vs $35.14
Management will review retroactive calculations to ensure decimal point variances are identified prior to disbursement as in this case $35.104 vs $35.14
SCRANTON PRIMARY HEALTH CARE CENTER INC IN THE FUTURE YEAR FILINGS OF THE DATA COLLECTION FORM AND REPORTING PACKAGE WILL OBTAIN AND COMPILE ON A TIMELY BASIS TO ALLOW THE REPORT TO BE FILED NO LATER THAN NINE MONTHS AFTER THE END OF THE AUDIT PERIOD OR EXTENDED PERIOD ALLOWED BY THE OFFICE OF MANAG...
SCRANTON PRIMARY HEALTH CARE CENTER INC IN THE FUTURE YEAR FILINGS OF THE DATA COLLECTION FORM AND REPORTING PACKAGE WILL OBTAIN AND COMPILE ON A TIMELY BASIS TO ALLOW THE REPORT TO BE FILED NO LATER THAN NINE MONTHS AFTER THE END OF THE AUDIT PERIOD OR EXTENDED PERIOD ALLOWED BY THE OFFICE OF MANAGEMENT AND BUDGET.
Comments on findings and recommendations The organization agrees with the finding and the auditor’s recommendation. Actions taken or planned The organization reinstated the practice of preparing monthly financial statements to be reviewed by management and those charged with governance. Completion d...
Comments on findings and recommendations The organization agrees with the finding and the auditor’s recommendation. Actions taken or planned The organization reinstated the practice of preparing monthly financial statements to be reviewed by management and those charged with governance. Completion date September 30, 2024
Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creati...
Management acknowledges the issue but offers the following context: The occurrence was due to a significant and unexpected increase in client volume at OASIS following the relocation of a CAN case manager out of state. This transition resulted in a number of clients being redirected to OASIS, creating a temporary strain on resources. The few instances of noncompliance noted in the finding were missed during this influx. Management is actively reviewing intake procedures to ensure capacity adjustments are made in response to future changes in referral patterns.
AOOS will work with its fiscal agent to strengthen oversight and establish compensating controls during staff vacancies to ensure proper review of reports. In addition, AOOS will re-establish and implement policies that require management review and documentation of all reports prior to submission t...
AOOS will work with its fiscal agent to strengthen oversight and establish compensating controls during staff vacancies to ensure proper review of reports. In addition, AOOS will re-establish and implement policies that require management review and documentation of all reports prior to submission to granting agencies, thereby ensuring accuracy, accountability, and compliance with federal requirements. Completion Date: September 30, 2026 Responsible Person: Sheyna Wisdom, Executive Director, AOOS
To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness...
To address the identified deficiency, SAAMS will revise its payroll procedures to require that all payroll batch reports consistently include employee name, program charged, amounts charged to each program, hours, and pay rate. A standardized reporting format will be developed to ensure completeness and consistency of information. In addition, SAAMS will update its policies to clearly describe the review objectives and responsibilities of staff conducting payroll reviews. Training will be provided to relevant staff to ensure proper understanding and execution of the updated procedures. These measures will ensure payroll reviews are accurate, effective, and aligned with best practices. Completion Date: September 30, 2026 Responsible Person: Dr. Wei Ying Wong, CEO, SAAMS
SEE CORRECTIVE ACTION PLAN FOR CHART/TABLE
SEE CORRECTIVE ACTION PLAN FOR CHART/TABLE
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. C...
Corrective Action Plan Identifying Number: 2024-003 Finding: The Agency did not properly allocate indirect costs during the fiscal period in which the corresponding direct costs were incurred, resulting in an indirect cost rate exceeding the de minimis rate for a portion of the 2024 fiscal period. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with Uniform Guidance requirements for indirect costs, the following actions will be implemented: 1. Establish Written Indirect Cost Procedures – Develop and document procedures to ensure indirect costs are consistently calculated at the approved de minimis rate per the federal grant award on total direct costs during the performance period. 2. Implement Pre-Posting Review – Require a supervisory review of indirect cost calculations before charges are recorded to the general ledger and before grant reimbursements are submitted. We have implemented new procedures to ensure that indirect costs are included in each invoice for reimbursement. 3. Staff Training – Provide training for grants and finance staff on indirect cost requirements, the proper application of the de minimis rate, and reconciliation processes in accordance with 2 CFR 200.414(f). 4. Quarterly Reconciliations – Implement quarterly reconciliations of indirect costs applied to grants to confirm rates are applied correctly and consistently throughout the fiscal year. 5. Continuity Controls – Assign responsibility for indirect cost oversight to both a primary and a backup staff member to ensure consistency during periods of management turnover. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • New procedures: June 15, 2025 • Written procedures in place: December 31, 2025 • Staff training completed: January 31, 2026 • Supervisory review and reconciliations implemented: Beginning with January 2026 close
View Audit 370280 Questioned Costs: $1
Corrective Action Plan Identifying Number: 2024-002 Finding: The Agency did not verify that one particular vendor was not suspended or debarred when it entered into a contract with the vendor who received $25,000 or more in federal grant funds. Corrective Actions Taken or Planned: 1. Review of Vendo...
Corrective Action Plan Identifying Number: 2024-002 Finding: The Agency did not verify that one particular vendor was not suspended or debarred when it entered into a contract with the vendor who received $25,000 or more in federal grant funds. Corrective Actions Taken or Planned: 1. Review of Vendor Requirement Checks a formal review will be implement to review the procurement contract reviews and verification performed prior to any expenditures related to the contract are performed. 2. Training and Vendor Requirement Checks- Provide training to all procurement staff on federal grant compliance requirements, including performance and documentation of the suspension/debarment verification via SAM.gov prior to entering into a contract. 3. Ongoing Monitoring – The VP of Finance will provide updates to senior leadership and the Finance Committee. Contact Person Responsible for Corrective Action: Gino Taylor, Vice President of People, Culture, & Equity Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: ● Written procedures in place: September 30, 2025 ● Staff training completed: October 31, 2025 ● Audit completion: December 31, 2025
Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or ...
Corrective Action Plan Identifying Number: 2024-001 Finding: Expenditure was identified for one invoice with a 2023 service period that was improperly recorded, and reimbursed, as an expenditure in 2024, indicating improper expense recognition in accordance with US GAAP. Corrective Actions Taken or Planned: The Agency concurs with the finding. To correct the cause and ensure compliance with 2 CFR 200.403(e), the following actions will be implemented: 1. Establish Written Cutoff Procedures – Formal written procedures will be developed for reviewing service dates and supporting documentation prior to posting expenditures in the general ledger. These procedures will specifically address Uniform Guidance period-of-performance requirements. 2. Implement Supervisory Review – All expenditures charged to federal awards will undergo supervisory review at period-end. The review will confirm that expenses are recorded in the proper performance period before submission for reimbursement. Effective June 2025, the Vice President of Finance and the Controller performed a retrospective review of 2024 expenses to confirm that they were allocated to the correct reporting period. This supervisory review has continued into the current reporting period with no exceptions noted. 3. Staff Training – Grants and finance staff will receive focused training on Uniform Guidance cost principles, proper expenditure cutoff, and documentation standards to ensure consistent application. Staff training will include review of the finding and leadership will highlight the importance of verifying the correct reporting period for each entry. 4. Continuity Controls – To address turnover risk, responsibility for cutoff procedures will be assigned to both a primary and a backup staff member to provide coverage and reduce errors caused by staff changes. 5. Ongoing Monitoring – The VP of Finance will review quarterly grant compliance checklists and provide updates to senior leadership and the Finance Committee. Contact Person Responsible for Corrective Action: Fred Timberlake, Vice President of Finance Isha Martin, Controller/Grant Finance Manager Anticipated Completion Date: • Management supervisory review procedures: June 15, 2025 • Written cutoff procedures in place: December 31, 2025 • Staff training completed: January 31, 2026
View Audit 370280 Questioned Costs: $1
Finding 2024-001 Program Federal Assistance Listing and Title: 10.766 Community Facilities Loans and Grants Award Numbers: Unknown Federal Grantor: U.S. Department of Agriculture Pass-Through Agency: N/A Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal a...
Finding 2024-001 Program Federal Assistance Listing and Title: 10.766 Community Facilities Loans and Grants Award Numbers: Unknown Federal Grantor: U.S. Department of Agriculture Pass-Through Agency: N/A Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with federal laws, regulations and program compliance requirements. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and deposits of loan and reserve payments, which should be reviewed and approved by a responsible party other than the original preparer. Condition/Context: There was not a review/approval performed of the annual reserve deposit tested and its entry for the loan. The sample was not statistically valid. Cause: There are not controls in place for a review and approval process of journal entries and deposits for the loan and reserve payments. Effect: Accounting software and/or reports could contain errors. Recommendation: The fire department should review its internal control procedures to ensure there is proper review and approval processes over completeness and accuracy of deposits and reserve payments, including documentation of that review. Corrective Action Plan: Controls for review and approval of journal entries and deposits Corrective Action Planned: The control deficiency has been discussed with the Department’s management and we acknowledge our responsibility for a review and approval process. The Board was aware that this condition existed and realizes that the concentration of duties and responsibilities in a limited number of individuals is not desirable from a control point of view. The Department is onboarding a Business Manager in a new position that will allow more segregation of duties. The Department has met with our Accountant to prioritize those duties that are important for segregation of accounting responsibilities. Name(s) of Contact Person(s) Responsible for Corrective Action: Jenny Minter Anticipated Completion Date: December 31, 2025
Management concurs with the findings and is working to ensure all employees adhere to control procedures and compliance requirements set by HUD. For finding 2024-002, the Organization has transferred the funds into an interest-bearing account.
Management concurs with the findings and is working to ensure all employees adhere to control procedures and compliance requirements set by HUD. For finding 2024-002, the Organization has transferred the funds into an interest-bearing account.
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