Corrective Action Plans

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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
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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.
To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that inc...
To help maintain compliance with the Organization’s sliding fee discount program and related policy, we recommend the Organization strengthen its internal controls by implementing the following: 1. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 2. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences in order to maintain continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign-off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Management agrees with the finding and will implement the recommendations above and maintain consistency with their internal monitoring procedures moving forward.
Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monit...
Isler recommended LCOG implement procedures to:  Formally document the determination of whether entities receiving federal funds are subrecipients or contractors prior to entering into agreements and preparing the SEFA, using the criteria in 2 CFR 200.331.  Develop and implement a risk-based monitoring plan for all identified subrecipients, ensuring that required monitoring activities (including review of reports and Single Audits, where applicable) are performed and documented throughout the period of performance.  Ensure the SEFA accurately reflects subrecipient relationships and amounts passed through.  This monitoring plan has already been implemented.
Isler recommended LCOG establish and implement formal, documented procedures for verifying that vendors are not suspended or debarred before entering into covered transactions paid with federal funds. These procedures should specify the method of verification (e.g., checking SAM.gov) and require ret...
Isler recommended LCOG establish and implement formal, documented procedures for verifying that vendors are not suspended or debarred before entering into covered transactions paid with federal funds. These procedures should specify the method of verification (e.g., checking SAM.gov) and require retention of evidence (e.g., dated printouts or screenshots of the search results) within the procurement or vendor files. This has already been implemented as part of the procurement process.
The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers ...
The Town will take immediate steps to further ensure that grant funds, especially those that include federal funds, will be maintained separately in a separate bank account when grants require such actions for compliance. The grant funds will be tracked separately in their own funds or cost centers using the new due-to due-from procedures. In addition, our staff is currently researching a variety of software programs in order to strengthen our in-house grant management procedures to maintain full compliance. The Town will also consider hiring additional personnel and/or soliciting the services of a professional grant manager to further assist with future grant opportunities, particularly those involving grant funds.
Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Feder...
Finding Number: 2024-001 Finding Name: Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Finding Summary: Criteria or Specific Requirement - Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition - The annual Federal Financial Report was not submitted timely and required performance reporting was not completed during the year. Questioned Costs - N/A Context - The Federal Financial Report for the reporting period end September 29, 2024 was due December 28, 2024, however, this was not submitted until February 25, 2025. Additionally, two (2) performance reports were due during the year, however, neither were completed. The first was for the period September 30, 2023 - March 31, 2024 and was due April 30, 2024, and the second was for the period April 1, 2024 - September 30, 2024 and was due October 30, 2024. Effect - The Company did not comply with federal reporting requirements. Cause - Management turnover caused uncertainty in assigned responsibilities, including this reporting requirement. Identification as a Repeat Finding - N/A Recommendation - The Company should review reporting requirements in grant award documents for all federal awards to ensure compliance. Client Planned Action: Benson Hospital agrees to the finding. The issue was identified in February of 2025 and the required reporting was completed and submitted. Going forward we have established a protocol by which reports for such Congressional Funding shall be submitted timely. Client Responsible Party: Mark Nellis, CFO; (520) 586-1873 Completion Date: February 22, 2025
September 25, 2025 Person responsible: Steve Kadin, Executive Vice President Fiscal Year Ended November 30, 2024 Section III – Federal Awards Findings and Questioned Costs Item 2024 – 001 Federal Assistance Listing Number: 14.181 Supportive Housing for Persons with Disabilities Condition Surplus cas...
September 25, 2025 Person responsible: Steve Kadin, Executive Vice President Fiscal Year Ended November 30, 2024 Section III – Federal Awards Findings and Questioned Costs Item 2024 – 001 Federal Assistance Listing Number: 14.181 Supportive Housing for Persons with Disabilities Condition Surplus cash was not deposited into the residual receipts account within 60 days following the end of the fiscal year. Views of Responsible Officials and Corrective Action The Project was planning on the capital improvements in the fiscal year 2024, but it did not happen as planned. Management will deposit the excess cash to the residual receipts account and obtain HUD approval for the future fund release for capital projects. Management will ensure that the residual receipts account is properly funded in the future.
Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate...
Effective immediately, the Chief Financial Analyst has established a new schedule for monthly financial statements at Westward Heights Care Center. Monthly financial statements will be completed and provided to the Administrator by approximately the 20th of each month. This schedule ensures adequate time to prepare quarterly reports for submission to the USDA. Once the quarterly financials are finalized, the USDA report will be submitted no later than the last day of the month. This plan will also be added to the calendar with reminders set for the Administor to ensure timely review and submission.
Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assess...
Audit Finding Reference: 2024-001 Description of Finding: The audit revealed that grant expenditures were incurred outside the authorized performance period, resulting in non-compliance with grant regulations and potential cost disallowance. Planned Corrective Action • Conduct a comprehensive assessment of existing procedures to identify gaps that led to noncompliance with grant regulations. • Ensure timely submission of grant applications. • Implement enhanced oversight and monitoring processes for all grant-related expenditures to ensure alignment with policy 2 CFR 200.1. • Maintain detailed documentation of all award dates and expenditures to provide a clear compliance record. • Ensure all documentation is easily accessible and systematically organized for audit purposes. • Ensure pre-award costs are allowable only to the extent they would have been allowable if incurred after the effective date and only with written approval from the Federal awarding agency (as per 2 CFR 200.458). • Establish a process for obtaining and documenting written approval for pre-award costs. • Provide comprehensive training on compliance with Uniform Grant Guidance to all relevant staff. • Review and update policies and procedures related to grant expenditures regularly to ensure they are current and compliant with federal regulations. • Assign accountability for monitoring and reporting compliance to specific roles within the organization. The Business Manager, Elizabeth Bouchard, will be responsible for implementing this plan beginning with the Fiscal Year 2026 grant cycle. As of September 2025, non-compliance issues have been identified and addressed, documentation has been maintained to track award dates, and training has been provided to designated roles within the District. In addition, procedures to maintain detailed documentation of all award dates and expenditures to ensure a clear compliance record have been shared with all District Administrators utilizing grant funds.
View Audit 370226 Questioned Costs: $1
Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.
Management has implemented procedures internally to track HUD filing deadlines and monitor and submit the REAC FDS timely. Management has ensured multiple individuals within the organization have appropriate access to HUD systems to ensure appropriate coverage is available as needed in the future.
Finding 1159572 (2024-002)
Material Weakness 2024
Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.
Finding 2024-002: Transit Grants. Federal Award Numbers: 113057, 113061, 113052, 113093 Response: Toole County on behalf of Northern Transit Interlocal will implement and set up different expenditure and revenue codes to identify the grants and the expenditure of the grant funds.
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