Corrective Action Plans

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If we receive federal funds in the future, we will stay abreast of current and changing policies and procedures.
If we receive federal funds in the future, we will stay abreast of current and changing policies and procedures.
If we receive federal funds in the future, we will stay abreast of current and changing policies and procedures.
If we receive federal funds in the future, we will stay abreast of current and changing policies and procedures.
The Village will implement procedures to ensure that qualified vendors who receive over $25,000 of federal funds have not been suspended or debarred.
The Village will implement procedures to ensure that qualified vendors who receive over $25,000 of federal funds have not been suspended or debarred.
The Organization recognizes four drawdowns for supplies were budgeted estimates and that incurred supplies costs were subsequently more than the estimates. Cash management procedures were corrected in June 2025 to include only incurred supplies expenses in drawdown requests
The Organization recognizes four drawdowns for supplies were budgeted estimates and that incurred supplies costs were subsequently more than the estimates. Cash management procedures were corrected in June 2025 to include only incurred supplies expenses in drawdown requests
Condition: NIST Recovery Reports were prepared without evidence of a secondary review or approval by an individual independent of the preparer and knowledgeable of grant requirements. Planned Corrective Action: The Controller will prepare the monthly NIST Recovery Report and submit the report to the...
Condition: NIST Recovery Reports were prepared without evidence of a secondary review or approval by an individual independent of the preparer and knowledgeable of grant requirements. Planned Corrective Action: The Controller will prepare the monthly NIST Recovery Report and submit the report to the Vice President of Operations for review and approval. The Vice President of Operations will provide documented evidence of the review and approval to the Controller. Upon receipt of the documented evidence of review, the Controller will request that the Vice President of Operations initiate the recovery of the monthly NIST reimbursement amount. Contact person responsible for corrective action: Alan Kowalewski Anticipated Completion Date: 08/20/2026
Description of Corrective Action Plan: For any future projects funded with federal money, the City will ensure the federal procurement standards are followed. Anticipated Completion Date: Immediately, will be considered for any future procurements done with federal funds.
Description of Corrective Action Plan: For any future projects funded with federal money, the City will ensure the federal procurement standards are followed. Anticipated Completion Date: Immediately, will be considered for any future procurements done with federal funds.
Condition: During testing of subrecipient payments, we identified 15 instances in which payments to subrecipients were made more than 30 calendar days after receipt of a complete and approved invoice. Planned Corrective Action: During the audit period, the organization experienced delays in processi...
Condition: During testing of subrecipient payments, we identified 15 instances in which payments to subrecipients were made more than 30 calendar days after receipt of a complete and approved invoice. Planned Corrective Action: During the audit period, the organization experienced delays in processing certain subrecipient invoices. As a result, some subrecipients were not paid in accordance with the requirements of 2 CFR 200.305(b)(3). To address this finding, management has implemented the following corrective actions: Revised internal procedures to ensure payments are made within 30 calendar days of the approval of subrecipient invoices, regardless of when reimbursement is received from the federal awarding agency. Implemented a weekly aging report to identify subrecipient invoices approaching payment due dates and to ensure timely resolution. Provided additional training to the program, finance and the management teams on federal payment requirements and internal procedures. Established periodic management reviews to monitor compliance with payment timeliness requirements and identify process improvements as needed. Management fully implemented all corrective actions as of June 30, 2026. Contact person responsible for corrective action: Nancy Cummins, Controller Anticipated Completion Date: June 30, 2026
The City of Mt. Pleasant agrees with the finding identified and respectfully submits the following Corrective Action Plan for the year ending December 31, 2025. The City does not have written policies and procedures regarding federal awards required by 2CFR200. This includes procurement standards, i...
The City of Mt. Pleasant agrees with the finding identified and respectfully submits the following Corrective Action Plan for the year ending December 31, 2025. The City does not have written policies and procedures regarding federal awards required by 2CFR200. This includes procurement standards, including bidding procedures and review of vendor suspention and debarment. Implementation and monitoring - The City has verbally discussed and trained the current staff with the required procedures to ensure compliance with the 2CFR 200 requirements, including the verification of the vendor through SAM.gov as soon as this finding was known to the staff. The City has updated the written policies and procedures to ensure the inclusion of the requirements surrounding federal awards as required by 2CFR 200 and provided them to the staff in December 2025. This update included procurement standards, bidding procedures, and the review of the vendors through SAM.gov. It will be the responsibility of the Division Heads, City Manager and Fiannce Director to ensure the policies and procedures are being adhered to. If anyone has questions about the plan, please contact Lauren Pavlowski at 989-779-5376.
Finding 1237735 (2025-001)
Material Weakness 2025
CORRECTIVE ACTION PLAN Reference Number: 2025-001 – Internal Control over Federal Financial Reporting Name of Contact Person: Connie Franks , CEO A blue and black logo Description automatically generated Corrective Action: Corrective Action Plan Proposed Completion Date: September 23, 2025 Context a...
CORRECTIVE ACTION PLAN Reference Number: 2025-001 – Internal Control over Federal Financial Reporting Name of Contact Person: Connie Franks , CEO A blue and black logo Description automatically generated Corrective Action: Corrective Action Plan Proposed Completion Date: September 23, 2025 Context and Status of Correction Hanna’s House acknowledges the finding regarding the untimely submission of two quarterly SF-425 Federal Financial Reports. The two late reports identified in the 2025 audit occurred before the corrective actions established in response to the 2024 audit finding (2024-001) were implemented. As of September 23, 2025, Hanna’s House implemented additional procedures to improve the monitoring and tracking of federal reporting deadlines, strengthen oversight, and support the timely submission of required federal reports. These corrective actions were previously documented in Hanna’s House’s response to the 2024 audit finding. Although the prior finding included both SF-PPR and SF-425 reporting deficiencies, the corrective actions address the underlying reporting and monitoring requirements applicable to both programmatic and financial reporting. The procedures below have been implemented and remain in place. A. Reporting Responsibility and Accountability Hanna’s House has assigned responsibility for tracking federal reporting requirements, preparing required reports, and ensuring timely submission through the applicable federal reporting systems. Primary and backup staff have been assigned to provide continuity and accountability for reporting requirements, including during staff absences or transitions. Finance personnel are responsible for preparing and submitting the required SF-425 Federal Financial Reports, with executive leadership providing oversight. B. Reporting Calendar and Deadline Monitoring Hanna’s House established a federal reporting calendar to help ensure all required reporting deadlines are identified and monitored. The calendar: Includes quarterly and annual federal reporting deadlines based on the applicable Notices of Award. Establishes internal deadlines for report preparation, review, and submission. Includes automated reminders 30, 14, and 7 days before each reporting deadline. Is reviewed regularly by Finance and leadership to identify upcoming deadlines and address any potential issues in advance. C. Review and Oversight Hanna’s House has also established a review process to provide additional oversight of federal reporting. Under this process: Designated staff prepare the required reports and review the information for accuracy and completeness. Finance and executive leadership review reports prior to submission. Upcoming reporting deadlines are monitored and communicated to the appropriate staff. Quarterly compliance reviews are conducted to confirm that required reports have been completed and submitted timely. D. Ongoing Monitoring The reporting calendar, automated reminders, and supervisory review process provide ongoing monitoring of federal reporting requirements. Since these procedures were implemented, Hanna’s House has maintained timely submission of its required federal reports. This subsequent reporting history provides evidence that the corrective actions implemented in response to the prior-year finding have been effective. Hanna’s House will continue to monitor federal reporting deadlines and review compliance as part of its regular grant management process. Implementation Date and Current Status The corrective actions addressing Finding 2025-001 were implemented effective September 2025 in response to the prior-year audit finding. The two late SF-425 submissions identified in the 2025 audit occurred before these corrective actions were implemented. Since implementation, Hanna’s House has submitted its required federal reports timely, and the corrective procedures remain in place. Management considers the corrective actions associated with Finding 2025-001 fully implemented. Hanna’s House will continue to monitor the reporting process to ensure the procedures remain effective and federal reporting requirements continue to be met. Personnel Responsible for Implementation and Ongoing Oversight Connie Franks, Chief Executive Officer Corrective Action Implementation Date: September 23, 2025 Current Status: Corrective actions fully implemented.
Finding Number 2025-003: Matching – Significant Deficiency in Internal Control over Compliance and Noncompliance Corrective Action: Management will update its matching procedures to require staff to verify that each cost is allowable under the applicable grant before including it in the matching poo...
Finding Number 2025-003: Matching – Significant Deficiency in Internal Control over Compliance and Noncompliance Corrective Action: Management will update its matching procedures to require staff to verify that each cost is allowable under the applicable grant before including it in the matching pool. The procedures will specifically exclude unrecovered indirect costs from CoC Program match unless HUD provides prior written approval. Grant accounting staff will retain support for each matching cost, and a supervisor will review and approve the matching schedule before submission. Any ineligible costs identified will be removed and corrected. Name of Responsible Individual(s): Jason Brenier and Judy Bokhari Anticipated Completion Date: December 2026
Finding Number 2025-002: Period of Performance – Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action: Management will update its grant allocation procedures to require staff to verify and document that costs were incurred within the applicable grant period ...
Finding Number 2025-002: Period of Performance – Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action: Management will update its grant allocation procedures to require staff to verify and document that costs were incurred within the applicable grant period before charging them to an award. The accounting system will be used to track grant periods, retain allocation support, and flag costs charged outside the applicable period. A supervisor will review allocations and resolve exceptions before claims are submitted. Any costs charged to the wrong period will be corrected. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, Luz Gonzales-Toscano Anticipated Completion Date: December 2026
Finding Number 2025-001: Special Tests and Provisions – Significant Deficiency in Internal Control Over Compliance Corrective Action: Management will further enhance its rental assistance procedures to require a documented rent reasonableness determination before a participant moves in and before an...
Finding Number 2025-001: Special Tests and Provisions – Significant Deficiency in Internal Control Over Compliance Corrective Action: Management will further enhance its rental assistance procedures to require a documented rent reasonableness determination before a participant moves in and before any change in rent or lease terms is charged to the program. The determination will be supported by comparable rental information and retained with the lease, amendments, rent notices, and other documentation supporting the approved rent amount. Program staff will use a standardized checklist to confirm that the determination and required lease documents are complete before approving initial assistance or a rent change. A supervisor will review and sign the checklist. Management will also review rent reasonableness at least annually for participants whose rent has not changed during the preceding year and retain the results in the participant file. Management will train applicable staff on the revised procedures and periodically review a sample of files to confirm that determinations are timely, adequately supported, and retained. Identified gaps will be corrected and addressed through follow-up training as needed. Name of Responsible Individual(s): Jason Brenier, Judy Bokhari, Luz Gonzales-Toscano and Thu Huynh-Vien Anticipated Completion Date: December 2026
Management agrees with the finding and will implement additional review procedures to ensure tenant files are complete and rent calculations are accurate. The Authority will provide additional training to the staff performing these duties.
Management agrees with the finding and will implement additional review procedures to ensure tenant files are complete and rent calculations are accurate. The Authority will provide additional training to the staff performing these duties.
Condition: Program expenses are approved via budget documents and during program director meetings. Recommendation: Any expenses that are associated with a federal grant should be approved by the appropriate program manager on an individual basis as incurred. Action taken: All expenses are now appro...
Condition: Program expenses are approved via budget documents and during program director meetings. Recommendation: Any expenses that are associated with a federal grant should be approved by the appropriate program manager on an individual basis as incurred. Action taken: All expenses are now approved by the appropriate supervisor on an individual basis as incurred. Company credit card purchases: As of June 2025, the organization is utilizing an online credit card reporting system that requires supervisors to review and approve purchases. Check requests, mileage and personal expenses: As of September 2025, the organization is requiring that all requests go to the supervisor, which are then reviewed and forwarded to bookkeeping, together with an approval statement, for processing.
Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend that management implement and maintain procedures to ensure rent reasonableness determinations are performed, documented, and retained for all units receiving rental assistance prior to the first lease payment, on an annu...
Continuum of Care – Assistance Listing No. 14.267 Recommendation: We recommend that management implement and maintain procedures to ensure rent reasonableness determinations are performed, documented, and retained for all units receiving rental assistance prior to the first lease payment, on an annual basis, and if rental rates charged for the same unit are increased. Such documentation should be maintained in participant files and preserved in accordance with federal record retention requirements to support compliance with HUD regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization acknowledges that rent reasonableness assessments were not performed and documented during the period under audit. To address this issue, the Organization will implement procedures requiring completion and documentation of a rent reasonableness review prior to approving rental assistance payments. Additionally, the Organization will maintain supporting documentation in participant files and conduct periodic reviews to ensure compliance with HUD rent reasonableness requirements. Name(s) of the contact person(s) responsible for corrective action: Jennifer Reason, COO Planned completion date for corrective action plan: 8/1/2026 If the US Department of Housing and Urban Development has questions regarding this plan, please call Ben Pinon at 615-256-8195 ext. 125.
Recommendation: We recommend that management implement and maintain procedures to ensure documented review and approval of employee timecards, payroll costs charged to federal programs and ensure compliance with federal requirements. Explanation of disagreement with audit finding: There is no disagr...
Recommendation: We recommend that management implement and maintain procedures to ensure documented review and approval of employee timecards, payroll costs charged to federal programs and ensure compliance with federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the transition to a new payroll system, documentation evidencing management’s review and approval of employee timecards was not retained. Nashville Safe Haven Family Shelter, Inc will work with their payroll service provider to ensure that payroll records, including evidence of timecard review and approval, are appropriately retained and accessible, including during any future system transitions. Name(s) of the contact person(s) responsible for corrective action: Jennifer Reason, COO Planned completion date for corrective action plan: 8/1/2026
The County will continue to ensure that suspension and debarment assessments are performed.
The County will continue to ensure that suspension and debarment assessments are performed.
Action taken in response to finding: The County will review the subrecipient monitoring requirements and work with the County Auditor to develop a formal policy that includes internal controls, monitoring procedures, and documentation requirements.
Action taken in response to finding: The County will review the subrecipient monitoring requirements and work with the County Auditor to develop a formal policy that includes internal controls, monitoring procedures, and documentation requirements.
Finding 2025-003: Late Refunds- Student Financial Assistance Cluster - Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: The Department of Education requires that all refunds be made within 45 days of a student’s withdrawal (34 CFR 668.22, 685.306). Condition: Sikic...
Finding 2025-003: Late Refunds- Student Financial Assistance Cluster - Federal Direct Student Loans -ALN # 84.268 - Year Ended December 31, 2025 Criteria: The Department of Education requires that all refunds be made within 45 days of a student’s withdrawal (34 CFR 668.22, 685.306). Condition: Sikich tested four drop students in our sample and noted two late refunds. This finding is considered to be a material weakness and an instance of noncompliance. This finding was not a repeat finding. Recommendation: We recommend the College increase controls over monitoring drop students and paying refunds. Responsible Person: Dr. Jessica Fritz, Bridgette McGuire, Denise Land, DJ Kramer, Derrick Phillips Corrective Action Plan: DRCOM has implemented increased controls over the R2T4 process through increased and timely communication between various departments involved in the drop process and LOA’s. These departments are the Academic Dean, Registrar, Financial Aid, IT, and Student Accounts Implementation Date: 08/01/2026
Finding 2025-002: Financial Responsibility - Student Financial Assistance Cluster - Federal Direct Student Loans - ALN # 84.268 - Year Ended December 31, 2025 Criteria: An accredited school that participates in Federal programs authorized by Title IV of the Higher Education Act of 1965 is required t...
Finding 2025-002: Financial Responsibility - Student Financial Assistance Cluster - Federal Direct Student Loans - ALN # 84.268 - Year Ended December 31, 2025 Criteria: An accredited school that participates in Federal programs authorized by Title IV of the Higher Education Act of 1965 is required to demonstrate minimum standards of financial responsibility set forth by the U.S. Department of Education (DOE). Condition: The College did not meet the minimum Composite Score set forth by the U.S. Department of Education for the year ended December 31, 2025. We consider this finding to be a material weakness and an instance of noncompliance. This finding is repeated and was reported in the prior year as Finding 2024-002. Recommendation: The College needs to monitor its financial responsibility ratios throughout the year. Responsible Person: Dorian G. Kramer, DJ Kramer, Jennifer Hogan Corrective Action Plan: The college continues to monitor its financial responsibility ratios through the aforementioned financial accountability plans. As well, DRCOM has continued to improve its financial soundness through 2026 through multiple approaches, including a professional third-party assessment and plan implementation for increasing admissions, restructuring of debt, donor recruitment, hiring of a new clinic manager to increase income in the student clinic, and exploring other revenue streams for the college Implementation Date: Overall plan has been in place since 08/2024, with a reassessment of all strategies at the beginning of each semester.
CORRECTIVE ACTION PLAN September 25, 2026 U.S. Department of Health and Human Services Park DuValle Community Health Center, Inc. respectively submits the following corrective action plan for the yearended December 31, 2025. Name and address of independent public accounting firm: Blue & Co., LLC 265...
CORRECTIVE ACTION PLAN September 25, 2026 U.S. Department of Health and Human Services Park DuValle Community Health Center, Inc. respectively submits the following corrective action plan for the yearended December 31, 2025. Name and address of independent public accounting firm: Blue & Co., LLC 2650 Eastpoint Pkwy., Suite 300 Louisville, Kentucky 40223 Audit period: December 31, 2025. The findings from the schedule of findings and questioned costs for the year ended December 31, 2025, are discussed below. The findings are numbered consistently with the numbers assigned in the Schedule. FINDINGS - FINANCIAL STATEMENT AUDIT 2025-001 Condition: During our audit procedures, we noted that bank reconciliations were not performed as part of close procedures. The absence of bank reconciliations increases the risk that cash could be materially misstated. Action: Management will implement policies and procedures by December 31, 2026, to ensure proper reconciliation of bank accounts. FINDINGS- FEDERAL AWARD PROGRAM AUDITS 2025-002 Condition: Sliding fee scale: There were several instances noted where the incorrect sliding fee discount was given to patients based on their verified incomes and household sizes, as well as instances in which patients were not evaluated for sliding fee discounts based on patient income and family size. Action: Managementwill implement internal control procedures by December 31, 2026, to ensure that sliding fee discounts are properly applied and posted to patient accounts for eligible encounters and that patients are evaluated for eligibility for sliding fee discounts.
Following the NSC security breach and incorrect institution linking, the College worked with NSC to restore the correct connection, which was resolved in November 2023. The Registrar redeveloped reporting queries and resumed accurate submissions in June 2024. Enhanced processes now allow files to be...
Following the NSC security breach and incorrect institution linking, the College worked with NSC to restore the correct connection, which was resolved in November 2023. The Registrar redeveloped reporting queries and resumed accurate submissions in June 2024. Enhanced processes now allow files to be reviewed, corrected, and finalized within approximately one week, and all reporting was brought current by the end of 2025.
All federally funded monies will be reported and spent as indicated in the agreement.
All federally funded monies will be reported and spent as indicated in the agreement.
Finding 1237664 (2025-001)
Material Weakness 2025
2025 CORRECTIVE ACTION PLAN July 21, 2026 Beacon, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Blue & Co., LLC 720 E Pete Rose Way, Suite 100 Cincinnati, OH 45202 Audit period: January 01,...
2025 CORRECTIVE ACTION PLAN July 21, 2026 Beacon, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Blue & Co., LLC 720 E Pete Rose Way, Suite 100 Cincinnati, OH 45202 Audit period: January 01, 2025 - December 31, 2025 Beacon, Inc.’s response to the findings from the December 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Financial Statement Findings 2025-001 Finding: Preparation of Financial Statements Management’s response: Management concurs with the above finding and, accordingly, has engaged the auditors to assist with the preparation of the 2025 year-end external financial statements. Action planned: Engagement of the auditors to assist with the preparation of the 2025 year-end external financial statements. Management is currently reviewing the procedures and controls in place to address the preparation and review of external year-end financial statements and will revise and enhance as warranted. Implementation Date: Ongoing Responsible Person: Rev Forrest Gilmore, Executive Director
2025-002 – ALN 10.415 – Rural Rental Housing Loan – Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Erika Turner, Executive Director Projected Com...
2025-002 – ALN 10.415 – Rural Rental Housing Loan – Reporting Management acknowledged the finding and will follow the Auditor's recommendations as listed in the Schedule of Findings and Questioned Costs. Person Responsible for Correction of Finding: Ms. Erika Turner, Executive Director Projected Completion Date: December 31, 2026
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