Corrective Action Plans

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93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend management continue to strengthen review cont...
93.224/93.527 - Consolidated Health Centers (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, Public Housing Primary Care, and School Based Health Centers); (HHS Community Health Center Program) Recommendation: We recommend management continue to strengthen review controls over the setup, maintenance, and application of sliding fee discount schedules, including periodic monitoring procedures to identify and promptly correct exceptions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management has established a system of review and documentation of an internal audit that is conducted monthly to ensure slides are being applied properly. Name(s) of the contact person(s) responsible for corrective action: Jolene Joseph Planned completion date for corrective action plan: December 31, 2025
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Michael A. Watkins, Auditor Contact Phone Number and Email Address: 812-385-4927 / mwatkins@gibsoncounty-in.gov Views of Responsible Officials:...
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Michael A. Watkins, Auditor Contact Phone Number and Email Address: 812-385-4927 / mwatkins@gibsoncounty-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Deputy Auditor will prepare the report using the financial information available in LOW, and the Auditor will review and approve it before submitting it to the U.S. Treasury. Moving forward, the County Auditor will strengthen internal control procedures to ensure compliance with 2 CFR 200.303. These improvements will include protocols for communicating with the U.S. Treasury whenever system issues arise that could affect timely or accurate reporting. Anticipated Completion Date: January 1, 2027
FINDING 2025-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Michael A. Watkins Contact Phone Number and Email Address: 812-385-4927 / mwatkins@gibsoncounty-in.gov Views of Responsible Offi...
FINDING 2025-001 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Michael A. Watkins Contact Phone Number and Email Address: 812-385-4927 / mwatkins@gibsoncounty-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The County recognizes that a vendor's absence from the SAM.gov registry does not guarantee compliance and requires formal verification. To resolve this issue immediately, the County Auditor's office will perform a look-back review on SAM.gov for all vendors currently paid with SLFRF funds to ensure their eligibility during our contract periods. Going forward, for any expenditure involving federal grant funds, county staff will be required to obtain the vendor's Unique Entity Identifier (UEI) and print a copy of the SAM.gov exclusion search report. This verification step must be completed and documented before we execute any new contracts or approve claim payments. Additionally, the County Attorney will prepare a standard certification addendum. We will require our multi-year vendors to sign this form to certify their continuous eligibility through the end of the SLFRF grant performance period. Anticipated Completion Date: September 1, 2026
The corrective action plan for the internal control material weakness, timely reporting (2025-003), is summarized as follows: Corrective Action Planned: The previous auditor was not responsive and the organization had to engage with a new auditor. Going forward, the League has a process in place for...
The corrective action plan for the internal control material weakness, timely reporting (2025-003), is summarized as follows: Corrective Action Planned: The previous auditor was not responsive and the organization had to engage with a new auditor. Going forward, the League has a process in place for timely audit completion and submission. Anticipated Completion Date: End of audit process, September 2026. Responsible: Management and Board of Directors.
The corrective action plan for the internal control material weakness, noncompliance with Uniform Audit Guidance Subpart E-Cost Principles (2025-002), is summarized as follows: Corrective Action Planned: Management respectfully disagrees with the finding that indirect costs were double charged. The ...
The corrective action plan for the internal control material weakness, noncompliance with Uniform Audit Guidance Subpart E-Cost Principles (2025-002), is summarized as follows: Corrective Action Planned: Management respectfully disagrees with the finding that indirect costs were double charged. The Organization uses the Direct Allocation Method described in Appendix IV to 2 CPR Part 200. Under this method, joint costs are allocated directly to benefiting programs and activities using allocation bases designed to reflect the relative benefits received. General administrative and general expenses are treated as indirect costs. The Organization also elected to use the de minimis indirect cost rate permitted by 2 CPR§ 200.414(f). Management believes the costs allocated directly to the federal award and the costs recovered through application of the de minimis rate represent separate cost categories and that no individual cost was charged to the award both directly and indirectly. Management's allocation methodology and resulting charges were also reviewed and approved by the grantor, and management relied on that approval in determining that its treatment was acceptable. Although management disagrees with the finding, the Organization will review and enhance its written cost-allocation procedures to more clearly identify: • Costs charged directly to each federal award; • Joint costs allocated under the Direct Allocation Method; • General administrative costs treated as indirect costs; and • Controls designed to ensure that costs charged directly are not also recovered through another allocation or reimbursement method. Management will also retain documentation supporting the allocation bases used, the calculation and application of the de minimis rate, and relevant grantor approvals and communications. Anticipated Completion Date: Responsible: Management and Board of Directors.
The corrective action plan for the internal control material weakness, financial statement reorting (2025-0001), is summarized as follows: Corrective Action Planned: The League of Human Dignity elected not to consolidate all related organizations. After considering the nature of the organizations, t...
The corrective action plan for the internal control material weakness, financial statement reorting (2025-0001), is summarized as follows: Corrective Action Planned: The League of Human Dignity elected not to consolidate all related organizations. After considering the nature of the organizations, the needs of financial statement users, and the cost of preparing consolidated financial statements, management elected to continue presenting stand-alone financial statements. Management believes the stand-alone financial statements provide clearer information regarding the League's financial position and activities and has maintained sufficient financial information to evaluate the effect of the entities not consolidated. Management understands that this treatment represents a departure from generally accepted principles. Management and the Board will reevaluate this decision annually, including the relationships among the organizxations, the financial significance of the related entities, and the applicable financial reporting requirements. Anticipated Completion Date: Continuous. Responsible: Management and Board of Directors.
2025-002 – Allowable Activities and Costs Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Management concurs with the finding. To strengthen internal controls o...
2025-002 – Allowable Activities and Costs Federal Agency: U.S. Department of Veterans Affairs Federal Program: 64.033 Supportive Services for Veteran Affairs Responsible Official Jason Gilbert, Chief Executive Officer Plan Detail Management concurs with the finding. To strengthen internal controls over payroll time distribution, the Organization will implement the following corrective actions:  Complete a comprehensive review and cleanup of employee labor allocation records, remove outdated grants, inactive labor allocations, and legacy program assignments.  Review employee labor allocations whenever an employee is hired, changes position, or changes funding sources to ensure the labor allocation reflects current program assignments.  Supervisors will be instructed to review employee timesheets for both hours worked and program allocation accuracy before approving timecards.  Periodically perform reconciliations between labor allocation reports, payroll registers, personnel assignments and the general ledger to verify that payroll documentation and accounting records remain consistent.  Monitor payroll service provider system updates and promptly address any future reporting discrepancies with the vendor. Management expects these actions to strengthen controls over payroll documentation and reduce the risk of payroll costs being supported by inaccurate time distribution records. Anticipated Completion Date April 2026
Finding 2025-002: Significant Deficiency – Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to ass...
Finding 2025-002: Significant Deficiency – Audit Completion and Submission to the Federal Government Compliance Area: Reporting (L) Based on the finding in the fiscal year 2023 audited financial report, the county commissioners set aside $100,000 in their budget to hire or contract with a CPA to assist with audit preparation. This was in addition to $30,000 set aside in the county treasurer’s budget for audit consulting. The county commissioners hired an individual in September 2024. That individual left employment with the county in November 2024 and the position was not refilled through the end of fiscal year 2025. The remainder of the FY2024 audit preparation was completed in-house. Due to reductions in revenue and budget constraints, both the $100,000 allocation for a new employee and the $30,000 for consulting services were cut from the commissioners’ and treasurer’s budgets for FY2025, so the county is continuing to pivot audit preparation responsibilities and expanding the number of in-house employees working on different facets of the preparation. The finance staff has become somewhat more stable and have grown in their knowledge of county finances. We are utilizing multiple different staff members on parallel tasks with oversight and assistance from the county treasurer and clerk. We are confident that the audit preparation for FY2026 will be completed months earlier. James A Anderson Fremont County Treasurer
IGLESIA CRISTIANA (DISCÍPULOS DE CRISTO) EN PUERTO RICO, INC. CORRECTIVE ACTION PLAN For the year ended December 31, 2025 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and ...
IGLESIA CRISTIANA (DISCÍPULOS DE CRISTO) EN PUERTO RICO, INC. CORRECTIVE ACTION PLAN For the year ended December 31, 2025 Audit Report: Reports on Compliance and Internal Control in Accordance with Government Auditing Standards and 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards Audit Period: January 1, 2025 – December 31, 2025 Principal Executive: Rvda. Hilda E. Robles Florán, General Pastor Contact Person: Mr. Luis F. Sierra Galíndez, Administrative Assistant Phone: (787)761-4335 AUDIT FINDINGS Section III – Major Federal Award Program Findings and Questioned Costs Finding Reference Number: 2025-001 Program: Disaster Grants – Public Assistance (Presidentially Declared Disaster) (ALN 97.036) Compliance Requirement: Procurement and Suspension and Debarment (I) Type of Finding: Significant Deficiency in Internal Controls (SD), Instance of Noncompliance (NC) Corrective Action Plan Management concurs with the findings. The required Builder’s Risk Insurance Coverage was obtained after the condition was identified and brought to management’s attention during the audit. Management considers this matter an isolated case. However, more attention will be given to the matter in all future contracts in which the Builder’s Risk Insurance Coverage is required. Accordingly, the Church will complement the existing review process by developing and using a “Requested Document Form (Checklist)” to verify compliance with all contract requirements prior to contract execution and project commencement. Implementation Date: August 2026 Responsible Person: Mr. Luis F. Sierra Galíndez Administrative Assistant
Finding No. 2025-002: Procurement- Compliance Finding and Significant Deficiency in Internal Control over Compliance EPIC acknowledges that documentation confirming vendor suspension or debarment was not present in various vendor files for FY25. Corrective Action Plan: EPIC has updated its vendor on...
Finding No. 2025-002: Procurement- Compliance Finding and Significant Deficiency in Internal Control over Compliance EPIC acknowledges that documentation confirming vendor suspension or debarment was not present in various vendor files for FY25. Corrective Action Plan: EPIC has updated its vendor onboarding process to include confirmation of all new vendors prior to being awarded contracts. In addition, all current vendors will be confirmed eligible to receive federal funds during the RFP process for each subsequent project award. Contact Person Responsible for Corrective Action: Thomas Sperti, Chief Financial Officer
FINDING 2025-002: Waiting List Selections Condition The Housing Authority did not maintain documentation showing how preference criteria determined the participant's place on the waiting list. Corrective Action Plan The Housing Authority has purged the waiting list to obtain updated information from...
FINDING 2025-002: Waiting List Selections Condition The Housing Authority did not maintain documentation showing how preference criteria determined the participant's place on the waiting list. Corrective Action Plan The Housing Authority has purged the waiting list to obtain updated information from applicants. The Housing Authority is now utilizing its’ wait list management software to apply preference points (if applicable) to each applicant on the waiting list per the tenant selection policy. Name(s) of Contact Person(s) Responsible for Corrective Action: Jessica Oleson-Bue Anticipated Completion Date: Ongoing
The Company will continue to use supervisory reviews such as monitoring financial reports and budget reports and will use other secondary reviews where possible.
The Company will continue to use supervisory reviews such as monitoring financial reports and budget reports and will use other secondary reviews where possible.
The Company accepts this condition and will concentrate on the review and approval process.
The Company accepts this condition and will concentrate on the review and approval process.
FINDING 2025-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Responsible Officials: We concur with ...
FINDING 2025-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor will provide copies of the Report to Council for review prior to submission to verify the dates and amounts are correct for the reporting period, this will also be reviewed by the Deputy Auditor. Anticipated Completion Date: December 31, 2026
FINDING 2025-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Respons...
FINDING 2025-004 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Control procedures will be put into place effective immediately, which will include implementing a federal procurement policy. The Auditor will start checking all vendors paid from grants for suspension, debarred or excluded from being able to enter into contracts. Anticipated Completion Date: December 31, 2026
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Cost, and Period of Performance Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackma...
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Activities Allowed or Unallowed, Allowable Cost, and Period of Performance Contact Person Responsible for Corrective Action: Amy L. Glackman Contact Phone Number and Email Address: 317-392-6310; aglackman@co.shelby.in.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Control procedures will be put into place effective immediately. The Auditor’s Office will supply the Council with copies of invoices for approval and complete a check off list for the steps needed to complete this procedure . Anticipated Completion Date: December 31, 2026
Recommendation: CLA recommended that there is an appropriate reviewer of each claim, and expenditure reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: County will have someone other than the p...
Recommendation: CLA recommended that there is an appropriate reviewer of each claim, and expenditure reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: County will have someone other than the preparer review the report prior to submission going forward. Name(s) of the contact person(s) responsible for corrective action: Jason Jerome Planned completion date for corrective action plan: December 31, 2026
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Management has reviewed the finding above and concurs. A corrective action plan addressing the deficiencies will be completed and submitted within 60 days of the report.
Community Project Funding / Congressionally Directed Spending – Assistance Listing No. 17.289 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program – Assistance Listing No. 10.561 Recommendation: We recommend management revise procurement policies to fully align with...
Community Project Funding / Congressionally Directed Spending – Assistance Listing No. 17.289 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program – Assistance Listing No. 10.561 Recommendation: We recommend management revise procurement policies to fully align with Uniform Guidance requirements and strengthen procedures to ensure procurement decisions, management approvals, competitive procurement documentation, and suspension and debarment verifications are consistently performed, documented, and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has reviewed and updated the financial policies and Procedures Manual as of 01/2026. Procurement procedures have been strengthened. Federal procurement documentation requirements have been incorporated into our process. Suspension and debarment reviews are now being conducted and documented for all new vendors. Procurement files now include approval and compliance documentation. Name(s) of the contact person(s) responsible for corrective action: Stacia Russell Planned completion date for corrective action plan: 01/01/2026
Financial Statement Finding: 2025-002 Significant Deficiency in Internal Control over Subrecipient Monitoring Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: A process is being developed to ensure that the review performed is properly documented and retained for all s...
Financial Statement Finding: 2025-002 Significant Deficiency in Internal Control over Subrecipient Monitoring Name and Contact Person: Pete Kelly, Chief Executive Officer Corrective Action: A process is being developed to ensure that the review performed is properly documented and retained for all subawardee’s risk assessments through reviewing their status via sam.gov. Proposed Completion Date: March 2027
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Port of Ilwaco January 1, 2025 through December 31, 2025 This schedule presents the corrective action the Port is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Port of Ilwaco January 1, 2025 through December 31, 2025 This schedule presents the corrective action the Port is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The Port did not have adequate internal controls for ensuring compliance with federal procurement requirements, and did not comply with federal suspension and debarment and wage rate requirements. Name, address, and telephone of Port contact person: Tina Hayes, Executive Director 165 Howerton Way SE Ilwaco, WA 98624 (360) 642-3143 Corrective action the auditee plans to take in response to the finding: The Port will establish internal controls to comply with federal procurement requirements, including establishing written procurement procedures that conform to federal procurement standards in Uniform Guidance (2 CFR § 200.318-327). The Port will strengthen its internal controls to verify all contractors it pays $25,000 or more, all or in part with federal funds, are not suspended or debarred from participating in federal programs and maintain documentation demonstrating compliance with this requirement. The Port will strengthen internal controls to ensure compliance with federal wage rate requirements. This should include implementing effective monitoring processes to collect and review all weekly certified payroll reports from subcontractors. The Port will provide training to ensure staff overseeing compliance with federal program s are aware of all applicable requirements. Anticipated date to complete the corrective action: December 31,2026
Management's Response: Our Financial Management Policy has been updated to include the following required procedure pertaining to the preparation of annual financial statements: Preparation of Annual Financial Statements (Annual Close Process) OSA conducts a formal, documented year-end financial clo...
Management's Response: Our Financial Management Policy has been updated to include the following required procedure pertaining to the preparation of annual financial statements: Preparation of Annual Financial Statements (Annual Close Process) OSA conducts a formal, documented year-end financial close process that includes detailed cutoff procedures, identification and recording of necessary accruals, review and approval requirements, and retention of supporting documentation to ensure that we are following GAAP accrual protocol. The Finance Director will complete an annual closing checklist in collaboration with the CPA and assign responsible personnel to ensure all financial transactions are recorded accurately and in the appropriate accounting period prior to finalizing the financial statements. Anticipated Completion Date: September 1, 2026 – Already Completed Responsible officials: Kirsten Elfendahl, Cathleen McCluskey Executive Director
Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management began having another employee review and approve grant reimbursement requests and grant re...
Contact Person Brenna Ohman, Finance Director Corrective Action Plan Management acknowledges that due to limited personnel there is not always proper segregation of duties. Starting in October 2025, Management began having another employee review and approve grant reimbursement requests and grant reporting prior to submission. Completion Date Rural Development Finance Corporation implemented the plan in October 2025.
Lack of segregation of duties Recommendation: The Center's governing board should be cognizant of the issue and provide appropriate oversight. Management should provide reasonable oversight to accounting functions including accounts payable disbursements, reconciliations, and reporting including jou...
Lack of segregation of duties Recommendation: The Center's governing board should be cognizant of the issue and provide appropriate oversight. Management should provide reasonable oversight to accounting functions including accounts payable disbursements, reconciliations, and reporting including journal entry preparation. Action Taken: The Center agrees with the recommendations. The Center recognizes this deficiency due to the size of the financial department and limited resources to adequately divide duties or hire enough additional staff to completely segregate duties. The Center hired an account payable staff to the team in December 2021 to assist with workload and help create better division of duties. The Center also hired a part-time employee from August 2023-2024 to assist with financial preparation. In May 2024 Northland hired an additional part-time employee to assist with billing data analysis. A new part-time accountant was hired in February 2025 to assist with accounting and financial functions. This is an ongoing process.
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