Corrective Action Plans

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Item 2025.002 - Reporting Recommendation The Organization should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the reports are accurate. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire ...
Item 2025.002 - Reporting Recommendation The Organization should establish controls to ensure all accounting records are analyzed and proper support is available in order to ensure that the reports are accurate. Repeat Finding Not a repeat finding. Action Taken The Health Center has engaged Cambire Consulting to assist in the restructure of the grant department and workflow. In addition, the Health Center converted GL accounting and grant tracking to Sage lntacct. The updated grant reporting and tracking will include workpaper for reconciliation and supporting documents for reporting.
Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Heal...
Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Health Center converted the payroll system from Paycom to Paylocity which has capacity for grant hours tracking. We should have compliance in three months after implementation. The first pay date using Paylocity will be 7/2/2026 covering the pay period from 6/14/2026 to 6/27/2026. In addition, The Health Center's new GL system, Sage lntacct, also has grant accounting capability. With these two systems conversions, we should be able to track time and effort compliance.
Finding: 2025-002 Condition Found: The Organization did not have adequately designed internal controls to ensure compliance with Federal suspension and debarment requirements. Specifically, the Organization did not perform SAM.gov exclusion screenings for all contractors. SAM.gov checks were perform...
Finding: 2025-002 Condition Found: The Organization did not have adequately designed internal controls to ensure compliance with Federal suspension and debarment requirements. Specifically, the Organization did not perform SAM.gov exclusion screenings for all contractors. SAM.gov checks were performed only for employees, rather than being performed for all applicable vendors whose yearly expenditures charged to the grant met or exceeded $25,000. As a result, the Organization’s exclusion screening process was not consistently applied to all vendors who met the expenditure threshold. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: On May 7, 2026, Little Rivers Health Care completed a comprehensive review of all vendors to identify those meeting the federal suspension and debarment screening threshold, with no results. This review identified no excluded or debarred vendors and included all vendors associated with business conducted during 2025. In addition, searches conducted for periods prior to 2025, which included vendors utilized during 2025, did not identify any excluded parties. While the Organization inadvertently failed to perform the required vendor screenings during 2025, the retrospective review, together with the 2026 screening process, demonstrated that none of the applicable vendors were suspended, debarred, or otherwise excluded from participation in federal programs during the period under review. Recognizing the oversight in 2025 and to ensure ongoing compliance, the Organization established a formal vendor exclusion monitoring process consisting of a four-member review team. While the review process itself is relatively straightforward, the team was intentionally designed with redundancy to ensure continuity during periods of staff absence, turnover, or organizational transition. This approach provides multiple levels of oversight and helps ensure that the control remains effective over time. The review team will conduct SAM.gov exclusion screenings and validation reviews twice annually, during May and November of each year, for all vendors meeting applicable federal requirements. Meetings have been scheduled indefinitely with no planned end date. The next scheduled review dates are November 10, 2026, May 11, 2027, and November 9, 2027. Documentation of completed reviews and any required follow-up actions will be maintained as part of the Organization's compliance records. Anticipated Completion Date: May 7, 2026 (Corrective action completed). Ongoing semiannual SAM.gov exclusion screening reviews will continue indefinitely each May and November.
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly appli...
Finding: 2025-001 Condition Found: Through testing a statistically valid sample of 25 individual patient balances, we noted one instance in which the sliding fee discount applied was inconsistent with the Organization's policy. Specifically, a contracted third-party billing company incorrectly applied a sliding fee discount to a patient account, resulting in a discount that was not consistent with the Organization's sliding fee discount policy. Individual(s) Responsible for Corrective Action: Andrew Barter, CEO Planned Corrective Action: The identified error resulted from a contracted third-party billing company applying a sliding fee discount that was inconsistent with Little Rivers Health Care's Sliding Fee Discount Program policy. Upon identification of the finding, the account was reviewed and corrected to ensure the patient received the appropriate discount. To prevent future occurrences, Little Rivers Health Care re-instituted its monthly monitoring and review procedures in May 2026. These monitoring activities had been conducted consistently through the fall of 2025 and include periodic audits of patient accounts receiving sliding fee discounts, verification of discount calculations, and oversight of third-party billing activities. Findings from these reviews are documented, and corrective action is taken promptly when discrepancies are identified. In addition, the contracted billing company has been reminded of the organization's sliding fee discount requirements and expectations for compliance. To provide ongoing oversight and validation of compliance with the Sliding Fee Discount Program, Little Rivers Health Care has also implemented quarterly review meetings involving the Billing Manager, Controller, and Chief Executive Officer. These meetings have been formally scheduled, with the first occurrence set for July 20, 2026. The quarterly reviews will evaluate monitoring results, validate adherence to policy requirements, identify trends or potential risks, and ensure continuous compliance with program requirements. Anticipated Completion Date: May 20, 2026 (Corrective action completed), for reinstatement of monthly monitoring procedures. Quarterly compliance review meetings with the Billing Manager, Controller, and CEO are scheduled to commence on July 20, 2026, and will continue on an ongoing basis as part of the Organization's continuous compliance monitoring process.
Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staff...
Authority Response and Planned Corrective Action Plan: The Authority accepts the recommendation of the auditor and has initiated corrective actions to strengthen compliance with Housing Quality Standards (HQS) inspection requirements and related abatement procedures. Management identified that staffing turnover and transition-related training gaps contributed to delays in the timely processing and enforcement of failed inspection reinspections and landlord abatements during the audit period. In response, the Authority has implemented enhanced monitoring and supervisory review procedures over failed inspections and reinspection timelines to ensure compliance with HUD requirements. Management has reinforced staff training related to HQS enforcement, reinspection tracking, and Housing Assistance Payment (HAP) abatement procedures. In addition, the Authority is utilizing system generated tracking reports and management oversight tools to identify failed inspections approaching required corrective action deadlines and to ensure timely follow-up and enforcement actions are completed. The Authority believes these corrective measures will strengthen internal controls over compliance and help ensure continued adherence to HUD Housing Quality Standards requirements and related special tests and provisions compliance requirements. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.
Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Vo...
Authority's Response and Planned Corrective Plan: The Authority accepts the auditor’s recommendation. Management acknowledges the importance of maintaining complete and readily available tenant file documentation to support eligibility determinations and ongoing program compliance for the Housing Voucher Cluster. The documents noted as unavailable during the audit relate to file maintenance and documentation retention. Management does not believe the exceptions indicate that the sampled households were ineligible for assistance; however, the Authority recognizes that required documentation must be consistently maintained and available for audit review. In response, the Authority will implement a corrective action plan that includes increased supervisory review of tenant files, enhanced file completion checklists, periodic internal quality control reviews, and additional staff training on required eligibility documentation, including consent forms, lead-based paint documentation, HAP contracts, and tenancy addenda. The Authority will also strengthen monitoring procedures to ensure missing or incomplete documents are identified and corrected timely. Management will assign responsibility for periodic file review to Housing Choice Voucher leadership and will document follow-up actions taken. These procedures are intended to improve internal controls over tenant file maintenance and ensure continued compliance with HUD requirements, Uniform Guidance, and the applicable compliance supplement. Isaiah Norris, Vice President of the Housing Choice Vouchers Program, is responsible for ensuring the deficiencies have been rectified by September 30, 2026.
Finding 2025-001 - Section 8 Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance & Material Weakness Management Response and Corrective Action Plan The Southern Nevada Regional Housing Authority (SNRHA) agrees with the audit finding and recommendation. During the audit per...
Finding 2025-001 - Section 8 Tenant Files - Eligibility- Internal Control over Tenant Files - Noncompliance & Material Weakness Management Response and Corrective Action Plan The Southern Nevada Regional Housing Authority (SNRHA) agrees with the audit finding and recommendation. During the audit period, the Agency was finalizing its transition from paper files to electronic records while simultaneously establishing a dedicated Quality Control (QC) Unit. These organizational and process changes contributed to inconsistencies in file documentation, income verification procedures, and compliance monitoring. Management notes that compliance improved during the audit period, with the overall tenant file error rate decreasing from 32% in 2024 to 28.3% in 2025 and income-related errors decreasing from 21% to 11.7%. While these improvements demonstrate significant progress, SNRHA recognizes the need to further strengthen internal controls to ensure full compliance with HUD requirements and reduce the risk of future errors. The Housing Authority respectfully submits this Corrective Action Plan (CAP) in response to Finding 2025-001 concerning deficiencies in Section 8 tenant file eligibility determinations and internal controls over tenant files, identified as both noncompliance and a material weakness. Corrective Action Plan: Staffing Enhancements • One (1) Housing Programs Supervisor (Compliance) to oversee quality control, audit readiness, policy implementation, and compliance monitoring. • Two (2) Senior Occupancy Specialists (SOS) to assist with file reviews, staff mentoring, and compliance guidance. • One (1) Office Assistant (OA) to support administrative processes, document management, and workflow efficiency. These staffing enhancements will improve internal controls through increased supervision, workload distribution, and technical assistance. Target Completion Date: September 30, 2026. Quality Control (QC) Procedures • 100% QC review of all provisional (new-hires) staff files. • 100% QC review of all new admissions, lease-ups, and contract executions. • 25% monthly QC review of files processed by non-provisional staff. • Quarterly SEMAP review for overall key performance indicators • Use standardized QC checklists aligned with HUD regulations, HOTMA requirements, SEMAP indicators, and annual audit standards. • Track eligibility transactions, QC findings, corrective actions, and retraining efforts through a centralized Smartsheet system. • Issue monthly individual and departmental compliance scorecards. • Provide coaching and retraining for staff exceeding a 5% monthly error rate. Target Completion Date: Implemented and ongoing. Training and Professional Development The Authority will strengthen staff competency through structured training initiatives: • Eighteen (18) staff members will complete the Nan McKay HCV Rent Calculation Training with HOTMA requirements in July 2026 • Updated Standard Operating Procedures (SOPs) will be finalized and staff trained on: o Annual and interim reexaminations o Portability o Terminations o Moves and contracts • Staff will receive training on: o Accurate system data entry and validation procedures • The entire department will complete monthly assigned ASPIRE trainings, aligned with: o Eligibility requirements o QC findings and trends o SEMAP indicators and audit findings. • Senior Occupancy Specialists (SOS) will provide ongoing one-on-one technical assistance and timely follow-up on error corrections. Internal Controls and Process Improvements The Authority will enhance internal controls through: • Standardized workflows aligned with updated SOPs • Increased supervisory oversight of eligibility determinations • Integration of QC findings into continuous process improvements • Strengthened documentation practices to ensure audit compliance • Improved segregation of duties where applicable • Mandatory verification that EIV reports are generated, reviewed, and retained in tenant files prior to certification completion. • Verification of utility allowance calculations using the Authority's Board-approved Utility Allowance Schedule. • Monitoring inspection due dates through Yardi and management dashboards. • Reestablishment of inspection due dates within Yardi and monthly monitoring of inspection batching reports Target Completion Date: September 30, 2026 Monitoring and Oversight The Compliance Supervisor will oversee the implementation of this plan and: • Monitor QC processes and staff performance. • Analyze trends in error rates and compliance deficiencies. • Report progress to Compliance & Training Administrator. Monthly reviews of QC data will be conducted to identify systemic issues and adjust training and procedures as needed to sustain compliance. Person(s) Responsible: Rosa Elaine Garcia, Director of Housing Programs, in assistance with Compliance & Training Administrator, Housing Programs Supervisor (Compliance) and Training and Development Specialist
Non-compliance with Cash Management Requirements of the Capital Fund Program Corrective Action With the exception of Capital Fund Program grant authorizations budged for Public Housing Program operating assistance, the Authority will expend the unexpended Capital Fund Program grant proceeds held pri...
Non-compliance with Cash Management Requirements of the Capital Fund Program Corrective Action With the exception of Capital Fund Program grant authorizations budged for Public Housing Program operating assistance, the Authority will expend the unexpended Capital Fund Program grant proceeds held prior to drawing down additional funding from Capital Fund Program grants. Jebidiah Jackson, Executive Director, has assumed the responsibility of executing this corrective action as of August 1, 2026.
Insufficient Cash and Deficit of Unrestricted Net Position Corrective Action The Authority will analyze and evaluate charges and allocations to the Section 8 Housing Choice Voucher Program and budget administrative and applicable operating expenses of the Program within HUD’s administrative funding ...
Insufficient Cash and Deficit of Unrestricted Net Position Corrective Action The Authority will analyze and evaluate charges and allocations to the Section 8 Housing Choice Voucher Program and budget administrative and applicable operating expenses of the Program within HUD’s administrative funding limits. Additionally, the Authority will abstain from advancing Public Housing Program assets to the Section 8 Housing Choice Voucher Program. Jebidiah Jackson, Executive Director, has assumed the responsibility of executing this corrective action as of August 1, 2026.
Finding: Procurement, Suspension & Debarment: Congressional Grants - One procurement transaction for a building construction contract which covers 100% of the major program expenditures was tested. We noted that the expenditures of the major program were for valid allowable activities and costs howe...
Finding: Procurement, Suspension & Debarment: Congressional Grants - One procurement transaction for a building construction contract which covers 100% of the major program expenditures was tested. We noted that the expenditures of the major program were for valid allowable activities and costs however, we noted that the procurement, suspension and debarment requirements for a procurement transaction over the simplified acquisition threshold were not followed including, not obtaining competitive bids, missing cost/price analysis, and selecting the contractor primarily on qualifications but without a valid noncompetitive justification. Also, the suspension and debarment search was not conducted. valid. Management is in agreement with this finding. Below is the corrective action plan Views of Responsible Officials and Corrective Action Plan: Management acknowledges that procurement procedures did not fully comply with federal requirements for procurements exceeding the simplified acquisition threshold. Specifically, required elements such as competitive bidding, cost/price analysis, formal justification for noncompetitive procurement, and suspension and debarment verification were not consistently performed or documented. To address this matter, management will implement the following corrective actions: • Formalized Procurement Policy Update: Update and formalize procurement policies to align with federal grant requirements, including specific guidance for procurements exceeding the simplified acquisition threshold. • Competitive Procurement Procedures: Require documented competitive bidding or proposals for all applicable procurements unless a valid and documented sole-source or noncompetitive justification is approved in advance. • Cost/Price Analysis Requirement: Implement a standard requirement to perform and document cost or price analysis for all significant procurement transactions. • Suspension and Debarment Verification: Require documented verification (e.g., SAM.gov search) that all contractors are not suspended or debarred prior to contract award. • Enhanced Review and Oversight: Implement a secondary review control to ensure all procurement documentation is complete and compliant prior to contract execution and payment. • Training and Compliance Awareness: Provide training to relevant personnel on federal procurement requirements, including documentation standards and compliance expectations. Responsible Official Warren McLean Completion Date: The project was completed on December 30, 2025. Mortenson is the largest contractor in Minnesota, and the 5th largest contractor in the United States. They completed a very complex commercial kitchen, NEON Collective Kitchens, a 25,000 square foot facility, one of the 5 largest commercial kitchens in the country. Going forward, we will adhere to the corrective action plan that we outlined above.
Finding: Reporting: Congressional Grants - The Organization's federal award agreement requires SF-425 Federal Financial Report and a performance report to be filed annually. The Organization did not file these reports in 2025 as required. Views of Responsible Officials and Planned Corrective Actions...
Finding: Reporting: Congressional Grants - The Organization's federal award agreement requires SF-425 Federal Financial Report and a performance report to be filed annually. The Organization did not file these reports in 2025 as required. Views of Responsible Officials and Planned Corrective Actions: Management is in agreement with this finding Below is the corrective action plan Management acknowledges that required grant reporting, including the SF-425 Federal Financial Report and annual performance report, was not submitted in accordance with the federal award agreement. This was due to a breakdown in tracking reporting deadlines and responsibilities. To address this matter, management will implement the following corrective actions: • Centralized Grant Compliance Tracking: Establish a comprehensive reporting calendar that includes all federal grant reporting requirements, due dates, and assigned responsible parties. • Assignment of Accountability: Designate a specific individual responsible for monitoring compliance with all grant reporting requirements and ensuring timely submission of required reports. • Formalized Review and Submission Process: Implement a standardized process requiring preparation, supervisory review, and documented approval of all grant-related reports prior to submission. • Periodic Compliance Monitoring: Conduct periodic (e.g., quarterly) reviews of grant agreements to confirm all reporting requirements are identified, tracked, and fulfilled. • Training and Awareness: Provide training to relevant personnel on federal grant compliance requirements, including reporting obligations and applicable deadlines. Responsible Official: Warren McLean Completion Date: June 30, 2026
Persons responsible for corrective action: Patience Teboe, Grants Administrator Corrective action planned: A) During the initial kickoff meeting for all new grants, the Grants Department will identify and document all reporting requirements, deadlines, and compliance obligations associated with the ...
Persons responsible for corrective action: Patience Teboe, Grants Administrator Corrective action planned: A) During the initial kickoff meeting for all new grants, the Grants Department will identify and document all reporting requirements, deadlines, and compliance obligations associated with the grant award. B) The Grants Department will enter all reporting deadlines into the grant management calendar system. Automated email notifications will be generated to provide timely reminders to the responsible operational manager and their direct supervisor prior to reporting due dates. C) Operational managers will be required to submit all grant reports electronically to their direct supervisor, or designated approver, for review prior to submission to the funding agency. D) The reviewing supervisor or designated approver will provide documented electronic approval (email approval will serve as evidence) to both the operational manager and the Grants Department. The Grants Department will maintain the approval documentation and update the grant management calendar to reflect completion of the reporting requirement. E) Any required report that has not received documented approval and been returned to the Grants Department at least five (5) business days prior to the reporting deadline will be escalated to the appropriate Executive-level leader and the Chief Financial Officer (CFO) for immediate follow-up. Implementation date: July 1, 2026 If you have any questions regarding the Tribe's Corrective Action Plan, please contact Chief Financial Officer, Greg Gunderson at 402-315-2760 ext. 4116 or ggunderson@poncatribe-ne.gov.
Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services ...
Persons responsible for corrective action: Keith Morrow, Health Services Chief Executive Officer Corrective action planned: Developed and implemented process by which Business Services staff in Health Services review documents provided by non-Ponca Native Americans upon initial request for services and on an annual basis to follow to confirm and verify their capacity to receive health services from the Ponca Tribe. Steps have been taken to see the staff verifying are independent from those who initially collect such documents. Additionally, confirmed such process is consistent with existing verification review of Ponca members requesting services. Implementation date: December 1, 2025.
Audit Finding Reference: 2025-003 Improve Controls over Period of Performance Planned Corrective Action: The District has strengthened its grant management and closeout procedures to ensure that all expenditures charged to federal awards are incurred, processed, and paid within the applicable period...
Audit Finding Reference: 2025-003 Improve Controls over Period of Performance Planned Corrective Action: The District has strengthened its grant management and closeout procedures to ensure that all expenditures charged to federal awards are incurred, processed, and paid within the applicable period of performance. Specifically, the District will: 1. Implement a formal grant closeout checklist that includes a review of all open purchase orders, encumbrances, unpaid invoices, and outstanding obligations prior to submission of final expenditure reports. 2. Require reconciliation of grant expenditures between the Grants Office, Special Education Department, and Business Office before final grant reports are submitted. 3. Establish periodic reviews of open encumbrances throughout the year to identify outstanding obligations and ensure timely processing of invoices. 4. Designate backup personnel and document grant management procedures to ensure continuity during staffing transitions or vacancies. 5. Require supervisory review and approval of all grant closeout documentation to verify that all allowable expenditures have been recorded and reported appropriately. 6. Provide training to personnel responsible for grant administration and financial reporting regarding federal period-of-performance requirements and grant closeout procedures. Planned Implementation Date of Corrective Action: The revised grant monitoring and closeout procedures have been implemented for all active federal grants and will be fully incoiporated into the District's grant management process beginning with the current fiscal year. Person Responsible for Corrective Action: Grants Manager Signature Derek Pinto, Assistant Superintendent of Finance
Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of...
Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of all employees whose compensation is funded, in whole or in part, by federal awards. 2. C.ompletion of required semi-annual certifications or periodic personnel activity reports, as applicable, in accordance with Uniform Guidance requirements. 3. Review and approval of certifications bysupervisory personnel to ensure accuracy and completeness. 4. C.entralized maintenance of all certifications by the Grants Office to ensure records are readily available for audit and monitoring purposes. 5. Development of a compliance calendar with established due dates and reminder notifications for required certifications. 6. Quarterly monitoring bythe Business Office to verifythat all required certifications have been completed, reviewed, and retained. Planned Implementation Date of Corrective Action: The District has begun implementing these procedures and will have the revised process fully operational by 6/30/2026. All required certifications for the current fiscal year will be collected and maintained going forward. Person Responsible for Corrective Action: Grants Manager, Funds Analyst, Deputy Chief Financial Officer Signature Derek Pinto, Assistant Superintendent of Finance
Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedure...
Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedures to clearly identify when federal procurement requirements apply in addition to state and local procurement regulations. 2. Develop and implement a federal procurement checklist that must be completed prior to the award of any contract funded in whole or in part with federal grant funds. 3. Work with the Law Department to establish standardized contract templates containing all required federal contract provisions, including the Byrd Anti-Lobbying Amendment when applicable. 4. Require a secondary review bythe Business Office or Grants Management personnel before contract execution to verify compliance with Uniform Guidance procurement standards and required contract clauses. 5. Provide annual training to Business Office staff, grant managers, and other personnel involved in procurement activities regarding federal procurement requirements and contract provisions. 6. Conduct periodic internal reviews of federally funded procurement transactions to ensure ongoing compliance. Planned Implementation Date of Corrective Action: The revised procedures, procurement checklist, and standardized contract templates will be implemented by7 /1/2026. Training will be completed for applicable staff during the current fiscal year and prior to the initiation of future federally funded procurements. Person Responsible for Corrective Action: Assistant Superintendent of Finance Derek Pinto, Assistant Superintendent of Finance
Audit Finding Reference: 2025-004 Maintain Approved Rate Support for Employee Pay Rates and Time and Effort Support Planned Corrective Action: The District will strengthen internal controls over payroll costs charged to federal programs by implementing the following corrective measures: 1. Identify ...
Audit Finding Reference: 2025-004 Maintain Approved Rate Support for Employee Pay Rates and Time and Effort Support Planned Corrective Action: The District will strengthen internal controls over payroll costs charged to federal programs by implementing the following corrective measures: 1. Identify all employees whose salaries and wages are charged, in whole or in part, to the Child Nutrition Cluster and other federal awards. 2. Implement a formal process requiring completion of appropriate time and effort certifications in accordance with Uniform Guidance requirements and District policy. 3. Establish procedures to ensure certifications are completed in a timely manner, signed by employees and/or supervisors as required, and maintained in a centralized location. 4. Develop a compliance tracking system to monitor the collection and retention of required documentation throughout the year. 5. Conduct periodic reviews of payroll allocations to verify that payroll charges are supported by appropriate documentation and accurately reflect the work performed. 6. Provide annual training to Child Nutrition, Payroll, Human Resources, and Business Office personnel regarding federal time and effort documentation requirements and record retention responsibilities. Planned Implementation Date of Corrective Action: The District has implemented procedures to identify all federally funded employees and will require completion and retention of all applicable time and effort documentation beginning immediately and for all future reporting periods. Person Responsible for Corrective Action: HR Generalist for Cafeteria Derek Pinto, Assistant Superintendent of Finance
District management will adopt sound accounting policies and establish and maintain internal control that will initiate, authorize, record, process, and report transactions consistent with management's assertions embodied in the financial statements and that will safeguard District assets.
District management will adopt sound accounting policies and establish and maintain internal control that will initiate, authorize, record, process, and report transactions consistent with management's assertions embodied in the financial statements and that will safeguard District assets.
Corrective Actions to Be Implemented: The organization is moving from MIP Fund Accounting to QuickBooks online Advanced which will remove the multi-step data entry process currently used for time capture and payroll processing. Simultaneously, we are implementing Hourtimesheet, a Defense Contract Au...
Corrective Actions to Be Implemented: The organization is moving from MIP Fund Accounting to QuickBooks online Advanced which will remove the multi-step data entry process currently used for time capture and payroll processing. Simultaneously, we are implementing Hourtimesheet, a Defense Contract Audit Agency (DCAA) compliant time tracking system which does not allow time entries outside of each employee assigned grant allocations. It has a native integration with Quickbooks and is the gold standard for government contract compliance. • QuickBooks Online Advanced anticipated completion: June 1, 2026 • Hourtimesheet anticipated completion: September 1, 2026 Responsible Parties: Brandi Senters, Finance Director, will be responsible for implementation, with oversight from the Executive Director, Erin Broussard.
Finding 1218757 (2025-002)
Material Weakness 2025
Corrective Action Plan: Effective January 2026, Pact management implemented a new process that strengthens the internal controls over the FFATA reporting to ensure the required reports are submitted within the required timeframe. The monthly report being run to capture those subaward actions that re...
Corrective Action Plan: Effective January 2026, Pact management implemented a new process that strengthens the internal controls over the FFATA reporting to ensure the required reports are submitted within the required timeframe. The monthly report being run to capture those subaward actions that require FFATA reporting has been changed to encompass 45 days to ensure that no late entries are missed when the reporting is done.
Finding 1218756 (2025-001)
Material Weakness 2025
Corrective Action Plan: Misuse of Funds – Vehicle: Pact updated its Global Vehicle Policy effective November 1, 2025. The updated Global Vehicle Policy reinforces Pact’s zero-tolerance policy. No new reports of vehicle misuse have been received since November 2025, and all the reported cases of misu...
Corrective Action Plan: Misuse of Funds – Vehicle: Pact updated its Global Vehicle Policy effective November 1, 2025. The updated Global Vehicle Policy reinforces Pact’s zero-tolerance policy. No new reports of vehicle misuse have been received since November 2025, and all the reported cases of misuse occurred prior to November 1. Pact’s updated policy complies with all applicable laws and regulations, including the organization’s internal Code of Conduct, while aligning with the objectives and scope of work for the project. Pact’s guidelines specify roles and responsibilities and role assignments; identify authorized places to obtain fuel; where to store vehicle keys; where to park vehicles; and require individuals to enter detailed records regarding the use of the vehicle into a log. Misuse of Funds – Payroll: In alignment with Pact’s core principle of continuous quality improvement, and following substantiation of the misuse in one country office, Pact developed and implemented a corrective action plan. This plan included a comprehensive quality review of existing controls to identify and address any procedural gaps in the timesheet systems to ensure the timesheet systems have a functional auditable approval trail. We have reinforced, including in Senior Management Team meetings with staff, and other trainings supervisors’ responsibility to review and verify hours worked for their staff.
Subject: Response to Financial Statement Finding 2025-01 We appreciate the opportunity to respond to the financial statement finding titled "2025-01 Material Weakness in Internal Control Over Financial Reporting and the Preparation of the Schedule of Expenditures of Federal Awards" identified in the...
Subject: Response to Financial Statement Finding 2025-01 We appreciate the opportunity to respond to the financial statement finding titled "2025-01 Material Weakness in Internal Control Over Financial Reporting and the Preparation of the Schedule of Expenditures of Federal Awards" identified in the audit report dated September 30, 2025. Finding Summary: A material weakness was identified in internal control over financial reporting and the preparation of the Schedule of Expenditures of Federal Awards (SEFA). During the audit, a prior period adjustment of $1,821,000 was required to correct beginning net position in the Plantation Yacht Harbor Marina Fund. Additionally, for the fiscal year ended September 30, 2024, certain reimbursable federal grant expenditures were not properly matched with related revenue and receivables and were not included in the SEFA. These issues indicate that controls were not sufficient to ensure all transactions were accurately identified, recorded, and reported in accordance with generally accepted accounting principles and Uniform Guidance requirements. Management Response: Management acknowledges the material weakness in internal control over financial reporting and SEFA preparation. The identified condition resulted from incomplete identification and reconciliation of grant-related activity during fiscal year 2024, which led to the omission of reimbursable expenditures and related revenues from both the financial statements and the SEFA. Upon discovery, management recorded a prior period adjustment of $1,821,000 to correct beginning net position in the Plantation Yacht Harbor Marina Fund. The related grant expenditures have been properly included in the SEFA for the fiscal year ended September 30, 2025. Management agrees with the auditor’s recommendation and recognizes the need to strengthen internal controls surrounding the identification, reconciliation, and reporting of federal grant activity. Corrective Action Plan: To address this finding and strengthen internal controls, the Village has implemented and will continue to implement the following actions: Centralized Grant Tracking The Village has established a comprehensive grant tracking log to monitor all federal and state awards, including expenditures, reimbursement status, and SEFA reporting requirements. Enhanced SEFA Preparation Controls Year-end financial reporting procedures have been strengthened to include a formalized SEFA preparation and review process. This process includes reconciliation of the grant tracking log to the general ledger and a secondary review to ensure completeness and accuracy. Improved Coordination and Training Communication between the Finance Department and grant program managers has been enhanced to ensure timely identification of grant activity. Additional training on Uniform Guidance requirements and SEFA reporting has been provided to relevant staff. These control enhancements are designed to ensure that all reimbursable grant expenditures are properly identified, recorded, and reported in both the financial statements and the SEFA. Conclusion: Management has taken corrective action to address the identified material weakness and has implemented additional controls to improve the accuracy and completeness of financial reporting and SEFA preparation. Management believes these measures will effectively mitigate the risk of similar issues occurring in the future and will continue to monitor and refine these processes to ensure ongoing compliance with applicable accounting and federal reporting requirements
Finding 2025-002 Condition: Two vendors were awarded a contract without a competitive procurement process. The school did not maintain any documentation in the files regarding why a competitive procurement process was not performed. Corrective Action Planned: Southbridge Public Schools is actively c...
Finding 2025-002 Condition: Two vendors were awarded a contract without a competitive procurement process. The school did not maintain any documentation in the files regarding why a competitive procurement process was not performed. Corrective Action Planned: Southbridge Public Schools is actively creating procedures for all procurements in compliance with Massachusetts General Laws and Federal Regulations. This procedure will be in place for any procurements utilizing federal grant funding. Anticipated Completion Date: July 31, 2026 Contact: Matthew Robidoux – Business Manager
Finding 2025-001 Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: Southbridge Public Schools will be creating and implementing procedures for time and effort certifications. The procedure will include use of the form distributed by the Mas...
Finding 2025-001 Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: Southbridge Public Schools will be creating and implementing procedures for time and effort certifications. The procedure will include use of the form distributed by the Massachusetts Department of Elementary and Secondary Education for employees who are paid by a grant and require a time and effort certification. Anticipated Completion Date: July 31, 2026 Contact: Matthew Robidoux – Business Manager
Condition Holyoke Gas & Electric (HG&E) calculated indirect costs using an incorrect total direct cost base rather than the modified total direct costs required by the grant agreement and 2 C.F.R. §200.414(f). Indirect cost was calculated based on total cost, including construction and material. Cor...
Condition Holyoke Gas & Electric (HG&E) calculated indirect costs using an incorrect total direct cost base rather than the modified total direct costs required by the grant agreement and 2 C.F.R. §200.414(f). Indirect cost was calculated based on total cost, including construction and material. Corrective Action Plan Corrective Action Planned: By December 25, 2026, HG&E will implement a formal grant administration policy that clearly defines roles and responsibilities and establishes a comprehensive framework for effective grant management. In addition, HG&E will ensure that all questions related to indirect costs and other compliance requirements are confirmed in writing. HG&E believes this approach will significantly reduce the risk of future reporting errors. Names of Contact Persons Responsible for Corrective Action: Brooke McMahon – 413-536-9318 Bill Sullivan - 413-536-9523 99 Suffolk Street Holyoke, MA 01040 Anticipated Completion Date: The Corrective Action Plan will be implemented by December 31, 2026
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