Corrective Action Plans

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Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps...
Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps to strengthen oversight and ensure future compliance. Knowledgeable personnel are now in place and have been made fully aware of all federal reporting requirements and deadlines. Management is actively developing formalized policies and procedures governing federal reporting, including a centralized compliance calendar, documented workflows, defined roles and responsibilities, and an internal review process prior to submission. These measures will be implemented by the first quarter of 2026.
Management concurs with this finding. The missed submission was caused by inadequate tracking mechanisms and insufficient procedural formalization under prior leadership. New personnel are now assigned responsibility for compliance and reporting, and management has completed a full review of all rep...
Management concurs with this finding. The missed submission was caused by inadequate tracking mechanisms and insufficient procedural formalization under prior leadership. New personnel are now assigned responsibility for compliance and reporting, and management has completed a full review of all reporting obligations across federal awards. Management is in the process of developing standardized grant reporting procedures, enhanced tracking tools, and formal internal review controls to ensure timely and accurate submissions going forward. These procedures will be implemented by the first quarter of 2026.
After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, r...
After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. The Outsourced CFO will ensure that the Organization submits timely single audit data collection and reporting package to the Federal Audit Clearinghouse. 22
The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With...
The Organization recognizes the financial statement finding identified and we have taken corrective actions to ensure the accuracy of our financial controls and procedures moving forward. After the fiscal year ended in 2024, there has been a change in leadership within our financial department. With this transition, adjustments have been made to the financial procedures and controls to address potential lapses in the closing process. The Organization has revised the way it records, reconciles, and review financial entries. These changes were necessary to ensure proper U.S. GAAP practices were in place. These updates include accurately accruing accounts payable and accounts receivable, to ensure revenue and expenses are recognized in the proper period. We have also implemented a proper review process of the financial statements and any adjustments that are required to finalize them. The Organization believes it have fully addressed and corrected all procedures that led to this finding.
Notre Dame Health System ceased operation prior to the date of this report. Accordingly, mnagement is unable to take corrective action or implement further internal control improvements related to this finding.
Notre Dame Health System ceased operation prior to the date of this report. Accordingly, mnagement is unable to take corrective action or implement further internal control improvements related to this finding.
View Audit 372473 Questioned Costs: $1
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal ...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal year (FY) 2023. Management has made clearing this backlog its highest priority. The schedule is to complete and file the FY 2023 package by fall 2025 and the FY 2024 package shortly thereafter, at which point CUAHSI expects to return to on-time Federal Audit Clearinghouse filings. Recent upgrades to the accounting system, the hiring of in-house finance staff, and revised closing procedures are designed to streamline and accelerate future audit preparation so that all subsequent audits are filed by the required deadlines. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339) 221-5400 • Email: msabino@cuahsi.org Projected Completion Date: 2026-09-30
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: CUAHSI acknowledges that incomplete documentation was available to show subrecipient-monitoring procedures were followed for FY 2023 wi...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: CUAHSI acknowledges that incomplete documentation was available to show subrecipient-monitoring procedures were followed for FY 2023 within the required timeframe. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI now follows a written Subrecipient Monitoring Policy that specifies the duties of the Director of Finance, Staff Accountant, and Principal Investigator. Monitoring of active subawards began in May 2023. The subaward monitoring process was updated on September 21 2023 and further refined in spring 2024. All subrecipients from FY 2020–2023 have been retroactively certified, and timely reviews were in place for awards from FY 2024 onward. Management performs a mid-year check to confirm that monitoring records are complete, adequate, and securely stored. Name of Contact Person: • Jordan S Read, Chief Executive Officer • Telephone: (339)933-4660 • Email: jread@cuahsi.org Projected Completion Date: NA; is complete
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Vendor status for 2023 recipients was retroactively evaluated by CUAHSI staff and certified by management during calendar year 2024. Re...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Vendor status for 2023 recipients was retroactively evaluated by CUAHSI staff and certified by management during calendar year 2024. Records were organized and filed in a secure, centralized document management system. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI considers this finding closed, as current practices comply with established policies and procedures. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339)221-5400 • Email: msabino@cuahsi.org Projected Completion Date: NA; is complete
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Certain 2023 draws were processed as advances outside grant guidelines, although these draws were properly recorded as advances payable...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: Certain 2023 draws were processed as advances outside grant guidelines, although these draws were properly recorded as advances payable in the accounting records. Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI considers this finding resolved. A written drawdown procedure is now in place, requiring two-tier preparation and review, and, for working-capital advances, written approval from the prime funder. When the non-compliance was identified, CUAHSI suspended all NSF draws (late March 2023) until new controls were implemented. On 15 June 2023, CUAHSI completed its first draw under the revised policy. Name of Contact Person: • Jordan S Read, Chief Executive Officer • Telephone: (339)933-4660 • Email: jread@cuahsi.org Projected Completion Date: NA; is complete
Implement a tracking system (spreadsheet or database) to monitor completion of home visits and conferences for all enrolled children. Train teachers and family service staff on the requirements and proper documentation procedures for home visits and parent-teacher conferences. Conduct monthly review...
Implement a tracking system (spreadsheet or database) to monitor completion of home visits and conferences for all enrolled children. Train teachers and family service staff on the requirements and proper documentation procedures for home visits and parent-teacher conferences. Conduct monthly reviews to ensure compliance
Confirm the specific reporting periods and deadlines for all DHHS grants, including ARP and CRRSA grants. Ensure semiannual SF-425 reports are submitted within the deadlines outlined in the grant agreements, and annual SF-425 reports for ARP and CRRSA grants Maintain documentation of submission date...
Confirm the specific reporting periods and deadlines for all DHHS grants, including ARP and CRRSA grants. Ensure semiannual SF-425 reports are submitted within the deadlines outlined in the grant agreements, and annual SF-425 reports for ARP and CRRSA grants Maintain documentation of submission dates and retain copies of all reports for audit and compliance purposes. Establish an internal calendar and reminder system to track future SF-425 reporting deadlines to prevent delays.
Finding 2023-005 Assistance Listings: 93.567 & 93.576 Issue: Timely submission of Single Audit We respectfully acknowledge the Single Audit was not submitted timely. We were in a period of growth and building an in-house finance team. Prior to 2024, an outside consulting team performed the accountin...
Finding 2023-005 Assistance Listings: 93.567 & 93.576 Issue: Timely submission of Single Audit We respectfully acknowledge the Single Audit was not submitted timely. We were in a period of growth and building an in-house finance team. Prior to 2024, an outside consulting team performed the accounting function. The basic financial statements were delayed, and this caused the Single Audit for December 31, 2023, reporting deadline to be delayed. Corrective Actions We put in place an internal finance team, a CFO, an Accountant and a Consultant to operate effectively and to meet reporting deadlines. Responsible Official: Renee Carroll, CFO Implementation Date: August 14, 2025
Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review a...
Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review and note interpreter use. 3. File Accountability – Physical files labeled with responsible case manager; cross-checked during audits. 4. Compliance Reviews – Compliance Coordinator conducts quarterly file audits. Responsible Official: Javid Siddiqi, Director of Immigration Services Implementation Date: Completed January 2025; quarterly monitoring ongoing.
Finding 2023-003 Assistance Listings: 93.567 & 93.576 Issue: Two reports were resubmitted after the deadline due to formatting problems. Corrective Actions 1. Clarification Provided – Original submissions were on time; errors arose from incompatible file formats. 2. Two-Step Review – Reports prepare...
Finding 2023-003 Assistance Listings: 93.567 & 93.576 Issue: Two reports were resubmitted after the deadline due to formatting problems. Corrective Actions 1. Clarification Provided – Original submissions were on time; errors arose from incompatible file formats. 2. Two-Step Review – Reports prepared by Compliance Coordinator, then sequentially reviewed by Director of Immigration Services and CEO. 3. Submission Log – Central log with due dates, submission confirmations, and file-format checks. 4. Quarterly Spot-Checks – Compliance Coordinator tests report files on recipient software. Responsible Officials: Javid Siddiqi (Director), Rachel Kornfeld (CEO) Implementation Date: Process in place since August 2023.
Finding 2023-002 Assistance Listings: 93.567 & 93.576 Issue: Inadequate timekeeping allocation procedures. We respectfully acknowledge the finding inadequate allocation procedures, and we offer the following clarifications. Corrective Actions 1. Payroll System Upgrade – Implementing UKG with grant a...
Finding 2023-002 Assistance Listings: 93.567 & 93.576 Issue: Inadequate timekeeping allocation procedures. We respectfully acknowledge the finding inadequate allocation procedures, and we offer the following clarifications. Corrective Actions 1. Payroll System Upgrade – Implementing UKG with grant allocation fields (configuration underway). 2. Manager Review Cycle – Monthly allocation reports auto-sent to managers; signed approvals returned to Accounting. 3. CFO Review & Sign-off – CFO verifies and finalizes allocations before posting to FundEZ. 4. Written Policies – Comprehensive timekeeping and allocation manual (draft completed; final issue by July 15 2025). Responsible Official: Renee Carroll, CFO Target Completion: System live and policies finalized by July 30, 2025.
Finding 2023-001 Assistance Listings: 93.567 & 93.576 Issue: Expense allocations lacked sufficient grant-level detail. We respectfully agree with your finding of deficiency in internal controls and are working through the process to correct this. Root Cause Rapid program expansion outpaced existing ...
Finding 2023-001 Assistance Listings: 93.567 & 93.576 Issue: Expense allocations lacked sufficient grant-level detail. We respectfully agree with your finding of deficiency in internal controls and are working through the process to correct this. Root Cause Rapid program expansion outpaced existing finance capacity and procedures. Corrective Actions 1. Finance Team Expansion – Hired full-time CFO, staff accountant, and external consultant (Jan 2025). 2. Policy & Procedure Overhaul – New written procedures (completed Mar 2025) referencing 2 CFR 200 Subpart E. 3. Tri-System Documentation – All expenses now recorded and cross-referenced in FundEZ (accounting), Apricot (program), and a reconciliation workbook. 4. Monthly Reconciliations – Accounting staff prepare grant-by-grant reconciliations; Program Director and CFO jointly sign off during month-end close. Responsible Official: Renee Carroll, CFO Implementation Date: Fully operational as of January 2025; monthly review ongoing.
FA 2024-001 Improve Controls over Equipment Compliance Requirement: Equipment and Real Property Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of E...
FA 2024-001 Improve Controls over Equipment Compliance Requirement: Equipment and Real Property Management Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Agriculture Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: 10.553 - School Breakfast Program 10.555 - National School Lunch Program Federal Award Number: 235GA32N1199 Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund COVID-19 - 84.425W - American Rescue Plan Elementary and Secondary School Emergency Relief Fund - Homeless Children and Youth Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021) S425U210012 (Year: 2021), S425W210011 (Year: 2021) Questioned Costs: None identified Prior Year Finding: FA 2022-001, FA 2021-001, FA 2020-001, FA 2019-003, FA 2018-002, FA 2017-004 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over equipment and real property management as it relates to the Child Nutrition Cluster and Elementary and Secondary School Emergency Relief Fund programs. Corrective Action Plans: Management has strengthened controls over equipment to ensure that the records are complete, accurate and r reflect all required information. We are in the process of developing a physical inventory list of equipment. The inventory listing will have all identifying information such as an item description, an identifying number, the source of funding, the title holder, the acquisition date, the cost, the percentage of federal participation in the project costs, the location of the equipment, the use and condition of the equipment, and any ultimate disposal data for each piece of equipment. A complete physical inventory will be performed each year and reconciled with the equipment listing. Estimated Completion Date: 12/31/2025 Contact Person: Christopher Stephens, Chief Financial Officer Telephone: 229-268-4761 Email: christopher.stephens@dooly.k12.ga.us
Corrective Action Taken: A qualified CFO has been hired and controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: A qualified CFO has been hired and controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
See table on page 25.
See table on page 25.
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice a...
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.
View Audit 372196 Questioned Costs: $1
2023-001 RESERVE ACCOUNT FUNDING Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2023 Award Numbers: Various CFDA Number: 10.415 Criteria: The Project’s reserve account must be fully funded and maintained in a separate bank account. Condition: During our au...
2023-001 RESERVE ACCOUNT FUNDING Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2023 Award Numbers: Various CFDA Number: 10.415 Criteria: The Project’s reserve account must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserves, it was not fully funded. Cause: Yearly budgeted transfers were not made to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account
Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of d...
Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of debt service by ten years, we began funding it in order to meet that requirement by the end of fiscal year 2023, which we did, and we have maintained the required funding since then. Contact person responsible for corrective action: Eric Draime, CFO Anticipated Completion Date: 6/30/2023
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2024.
View Audit 372174 Questioned Costs: $1
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2024.
View Audit 372174 Questioned Costs: $1
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2024.
View Audit 372174 Questioned Costs: $1
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