Corrective Action Plans

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Condition: Controls in place were not adequate to ensure the policy included a well-defined Simplified Acquisition Threshold and related procurement method. Additionally, controls were not adequate to ensure price or rate quotations were obtained from an adequate number of qualified sources for cont...
Condition: Controls in place were not adequate to ensure the policy included a well-defined Simplified Acquisition Threshold and related procurement method. Additionally, controls were not adequate to ensure price or rate quotations were obtained from an adequate number of qualified sources for contracts above the Simplified Acquisition Threshold. Planned Corrective Action: Management understands the importance of adhering to procurement thresholds and methods. Procurement policies and Grant policies will be updated to include federal thresholds and methods to reflect federal Uniform Guidance. Additionally, the procurement procedures will be amended to include additional review and sign-off from Grant and Purchasing leadership prior to purchases being made with federal funds to ensure price and rate quotations were obtained for contracts above the Simplified Acquisition Threshold. Contact person responsible for corrective action: Stephanie Cihon and Andy Vollmar Anticipated Completion Date: October 31, 2025
View Audit 369422 Questioned Costs: $1
To ensure compliance with grant requirements and address the issue with employee timecards and vouchers submitted, the following steps will be implemented: 1. Time Tracking: Employees will continue to be required to record their time every two weeks (through HourTimeSheet), ensuring that the hours w...
To ensure compliance with grant requirements and address the issue with employee timecards and vouchers submitted, the following steps will be implemented: 1. Time Tracking: Employees will continue to be required to record their time every two weeks (through HourTimeSheet), ensuring that the hours worked align with the percentage of time allocated to the grant for those two weeks. 2. Clear Communication: The Project Director will clarify the importance of matching monthly hours with the percentage allocated to all staff participating in the grant. This will help prevent misunderstandings regarding time reporting. 3. Reviews: The Project Director will continue to conduct monthly reviews of timecards to verify that reported hours correspond with the grant’s allocation requirements before submitting vouchers. By implementing these measures, we aim to ensure that timecards accurately reflect the allocation of employee-related costs on a monthly basis, promoting compliance with grant requirements moving forward.
Action Taken: The Association has eliminated the third-party accounting firm, which has eliminated challenges related to communication and follow-up. The Association has restructured its staff finance team to ensure appropriate segregation of duties and greater efficiency and accuracy in managing fi...
Action Taken: The Association has eliminated the third-party accounting firm, which has eliminated challenges related to communication and follow-up. The Association has restructured its staff finance team to ensure appropriate segregation of duties and greater efficiency and accuracy in managing financial processes. Further, the Association has implemented standardized monthly reconciliation procedures for all accounts. These procedures create opportunities for the timely identification and resolution of discrepancies. There is a documented monthly close, review and approval process that involves an initial review by the finance team, including the Senior Finance Director. In addition, team leads, who are responsible for overseeing departmental budgets, also conduct a monthly review and note discrepancies that require correction. Finally, the COO and CEO conduct a review of monthly departmental reports and monthly financial statements prior to them being presented to the Association Board’s Finance Committee for further review.
Action Taken: Upon the discovery of fraud in 2024, Management took immediate action to address the issue and prevent future occurrences. Actions taken in 2024 include: • Improved the segregation of duties between the approval and recording of all expense transactions. • Automated the uploads of cred...
Action Taken: Upon the discovery of fraud in 2024, Management took immediate action to address the issue and prevent future occurrences. Actions taken in 2024 include: • Improved the segregation of duties between the approval and recording of all expense transactions. • Automated the uploads of credit card transactions directly into the accounting system to prevent any manual manipulation and reconciled the transactions to the statements. • Updated the Association policies around vendor management and allowable/non allowable operating expenses. • The employee was terminated prior to discovering the fraud.
View Audit 369419 Questioned Costs: $1
2024-001 Allowability Manufacturing Extension Partnership – Assistance Listing No. 11.611 Recommendation: We recommend that the Organization update the cost allocation plan for shared administrative expenses. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
2024-001 Allowability Manufacturing Extension Partnership – Assistance Listing No. 11.611 Recommendation: We recommend that the Organization update the cost allocation plan for shared administrative expenses. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. CORRECTIVE ACTION PLAN Action taken in response to finding: Maryland MEP will update the cost allocation process to include a review of the allocation of all costs, including payroll processing fees. Through this update, Maryland MEP will ensure all costs are allowable and that all shared administrative expenses are allocated and attributed to all of Maryland MEP’s programs in a manner consistent with the organizational policy. In addition to updating the cost allocation process, Maryland MEP will ensure effective controls are in place to review the allocation performed on a regular basis. Name of the contact person responsible for corrective action: Michael Kelleher Planned completion date for corrective action plan: 10/31/2025
View of Responsible Officials and Planned Corrective Action: The Club has reviewed the finding and acknowledges that $7,000 related to funds received in advance for 2025 expenditures and $9,00 related to 2023 expenditures due to a true up of allowable indirect charges for the grant fiscal year were ...
View of Responsible Officials and Planned Corrective Action: The Club has reviewed the finding and acknowledges that $7,000 related to funds received in advance for 2025 expenditures and $9,00 related to 2023 expenditures due to a true up of allowable indirect charges for the grant fiscal year were inaccurately reported on the SEFA submitted for an audit. The Club acknowledges the importance of accurately preparing the SEFA in accordance with Uniform Guidance. To address this finding the following corrective actions are currently being implemented:  Tracking of Federal Awards: All grant expenditures will be tracked to grant codes in the accounting software. This procedure has already been implemented in 2025.  Year-End SEFA Review Process: A formal review checklist will be implemented and signed off by both the Grant Accountant and Senior Staff Accountant prior to audit submission.
View of Responsible Officials and Planned Corrective Action: The Club has reviewed the findings and acknowledges the importance of documented controls over federal expenditures. The expenses noted were submitted for payment by the appropriate approver via Email, however, the emails were not maintain...
View of Responsible Officials and Planned Corrective Action: The Club has reviewed the findings and acknowledges the importance of documented controls over federal expenditures. The expenses noted were submitted for payment by the appropriate approver via Email, however, the emails were not maintained due to staff turnover. To address this finding, all grant expenditures are documented with approval and scanned prior payment.
Management Response #2024-005: Due to staff turnover the Corporation did not have adequate personnel or infrastructure in place to monitor costs in order to calculate and determine an updated indirect cost rate. Also, the current indirect cost rate allocations is based on historical assumptions. Cor...
Management Response #2024-005: Due to staff turnover the Corporation did not have adequate personnel or infrastructure in place to monitor costs in order to calculate and determine an updated indirect cost rate. Also, the current indirect cost rate allocations is based on historical assumptions. Corrective Action Plan: The Finance Team will develop overall operational costs reports to calculate and support a new rate. The proposed rate will be submitted to HRSA for approval. This will allow us to ensure the calculation for indirect costs and documentation supporting the indirect cost pool conform to the current regulations. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO
Management Response #2024-004: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. Corrective Action Plan: All eligibility verification data...
Management Response #2024-004: Due to staff turnover, the Corporation did not consistently enforce segregation of duties between the individual responsible for determining income eligibility and the one completing the medical risk assessment. Corrective Action Plan: All eligibility verification data, including screenshots and signed Rights and Obligations statements, will be stored in a centralized, secure shared drive maintained and managed by the WIC Director to ensure it is protected with limited access and password protection. The drive will be organized using a de-identified naming convention to ensure privacy while maintaining ease of access for authorized staff. To maintain a robust system of checks and balances, tasks related to eligibility verification and documentation will be divided among different team members. This separation will prevent any one individual from having full control over the process, reducing the risk of oversight or potential errors. The WIC Department’s policy and procedure manuals will be revised and updated to include the new eligibility verification process. To ensure adherence to the new protocols, periodic audits and review sessions will be conducted by the WIC Director or designated compliance staff to verify that documentation is being properly maintained and that all procedures are followed. Staff will be required to undergo refresher training sessions as needed to reinforce the updated protocols and best practices. Management expects to be completed by December 31, 2026. Responsible Party: Tracy Harrison, COO
Management Response #2024-002: Due to the financial system and time keeping infrastructure, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Also, the current fringe cost rate and allocations is based on historical assumptions. Corrective Action Plan: • The f...
Management Response #2024-002: Due to the financial system and time keeping infrastructure, the Corporation did not maintain evidence of fringe benefit cost objectives calculations. Also, the current fringe cost rate and allocations is based on historical assumptions. Corrective Action Plan: • The finance team will work to ensure fringe costs are entered into the financial system based on actual costs paid by the Corporation for each employee. • The grants finance department will also create actual to budget reports in accordance with HRSA guidelines for fringe costs • The Finance Team will develop fringe costs reports to calculate, monitor and support the current rate. This will allow us to ensure the fringe cost allocation conform to the current regulations. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO
Management Response #2024-001: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations. Due to the influx of grants and staffing resources the Corporation was...
Management Response #2024-001: The time keeping system and process does not currently allow tracking of time based on funded resources. The past practice had been for the finance department manually calculated salary allocations. Due to the influx of grants and staffing resources the Corporation was unable to maintain this process. Corrective Action Plan: Finance Management, Human Resources, and Payroll will collaborate to integrate time-tracking functionality into the current timekeeping system, enabling real-time tracking of time worked on grants for FY25. The rollout of this new process is expected to begin in Q4 of FY25. Responsible Party: Tamara Barnes, CFO
Management Response #2024-003: Previously, the Corporation faced challenges in effectively monitoring and documenting grant activity due to limited formal processes. Documentation of policies and procedures was insufficient, and supporting materials were not stored in a centralized location, making ...
Management Response #2024-003: Previously, the Corporation faced challenges in effectively monitoring and documenting grant activity due to limited formal processes. Documentation of policies and procedures was insufficient, and supporting materials were not stored in a centralized location, making information retrieval difficult. Since then, processes have improved, with enhanced documentation practices and better organization of grant-related records to support more efficient oversight and compliance. Corrective Action Plan: The Corporation has implemented the following corrective measures: • The Corporation established comprehensive, formal policies and procedures that document the current compliance practices. These procedures have been disseminated across the organization and incorporated into training programs to ensure all employees are aligned with the updated standards. • A procedure enhancement has been implemented in the procurement process, which requires the procurement manager to obtain three bids prior to the creation of certain purchase orders. This ensures competitive bidding and transparency in vendor selection. • Once a vendor is selected, the procurement manager will forward the vendor’s details to the compliance department. The compliance team will then verify the vendor's debarment status and federal eligibility to ensure compliance with all regulatory requirements. • A central repository platform has been created to store all vendor bids, price analyses, and related procurement documentation. This ensures that all relevant information is easily accessible and properly organized. • All accounts payable invoices designated for grant funding are now routed for prior approval to the respective grant program manager via the WorkPlace software before any payments are processed. This ensures proper oversight and alignment with grant requirements. These corrective actions aim to strengthen compliance, improve document management, and streamline oversight processes to prevent future issues related to grant monitoring and procurement. Management expects to be completed by December 31, 2026. Responsible Party: Tamara Barnes, CFO
In response to the audit finding regarding federal reporting requirements, we have developed a structured calendar and timeline that outlines all target dates and deliverables to ensure full compliance moving forward. This timeline includes clearly defined reporting deadlines, assigned responsibilit...
In response to the audit finding regarding federal reporting requirements, we have developed a structured calendar and timeline that outlines all target dates and deliverables to ensure full compliance moving forward. This timeline includes clearly defined reporting deadlines, assigned responsibilities for each deliverable and internal checkpoints to monitor progress and ensure timely submission.
We have hired an outside independent company, Infinity File Compliance, LLC to work with us on updating and maintaining all HUD documentation requirements. We are working on applying all the new policies and procedures and will be implementing trainings to ensure future compliance.
We have hired an outside independent company, Infinity File Compliance, LLC to work with us on updating and maintaining all HUD documentation requirements. We are working on applying all the new policies and procedures and will be implementing trainings to ensure future compliance.
Management has updated its compliance responsibility procedures to clarify roles and responsibilities and to ensure accountabilities for all federal reporting requirements. Specifically: • A compliance calendar will be established to track all non-standard reporting deadlines (other than monthly or ...
Management has updated its compliance responsibility procedures to clarify roles and responsibilities and to ensure accountabilities for all federal reporting requirements. Specifically: • A compliance calendar will be established to track all non-standard reporting deadlines (other than monthly or quarterly cost reimbursement grant request). • Responsibility for preparing and submitting DRGR reports has been formally assigned to Finance Department. • Verification procedures have been implemented to confirm that all reports are filed timely. • Periodic internal reviews will be conducted to ensure compliance with reporting requirements.
Authority's Response and Planned Corrective Action: Management agrees with the Auditors' finding and will implement the required updates and safeguards to ensure that the Authority complies with Section 19 of the ACC to remedy the aforementioned deficiencies. Donald Paredez, Executive Director, is r...
Authority's Response and Planned Corrective Action: Management agrees with the Auditors' finding and will implement the required updates and safeguards to ensure that the Authority complies with Section 19 of the ACC to remedy the aforementioned deficiencies. Donald Paredez, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
View Audit 369361 Questioned Costs: $1
Authority's Response and Planned Corrective Action: Management agrees with the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies related to selection from the waiting list are being documented and ...
Authority's Response and Planned Corrective Action: Management agrees with the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies related to selection from the waiting list are being documented and followed on a timely basis. Donald Paredez, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
Authority's Response and Planned Corrective Action: Management agrees with the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Don...
Authority's Response and Planned Corrective Action: Management agrees with the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies related to HQS inspections are being followed on a timely basis. Donald Paredez, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
Authority's Response and Planned Corrective Action: Management agrees with the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Donald Paredez,...
Authority's Response and Planned Corrective Action: Management agrees with the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster to ensure that established internal control policies are being followed accurately and on a timely basis. Donald Paredez, Executive Director, is responsible for implementing this corrective action by December 31, 2025.
Finding Reference Number: 2024-002 Condition Found: The Organization expended more than $750,000 in federal awards during the fiscal years ended December 31, 2022 and December 31, 2023, but did not have Single Audits performed for those periods. Recommendation: The auditors recommend the Organizatio...
Finding Reference Number: 2024-002 Condition Found: The Organization expended more than $750,000 in federal awards during the fiscal years ended December 31, 2022 and December 31, 2023, but did not have Single Audits performed for those periods. Recommendation: The auditors recommend the Organization establish procedures to monitor annual federal award expenditures and ensure timely compliance with Single Audit requirements. Corrective Action Planned: Management acknowledges that the Organization did not comply with the Single Audit Act requirements for the fiscal years ended December 31, 2022, and December 31, 2023. This was due to a lack of awareness regarding the Single Audit threshold requirements. The Organization has taken the following corrective actions: 1. Quarterly Review of Federal Expenditures: Internal procedures have been implemented to review federal expenditures quarterly to determine whether the Single Audit threshold of $750,000 (increased to $1,000,000 for fiscal year 2025) has been met. 2. Designation of Compliance Officers: The Director of Accounting and the Director of Finance have been designated as responsible for monitoring compliance with 2 CFR §200.501 and ensuring auditors are engaged annually. 3. Compliance Calendar: A compliance calendar has been established to track key federal filing deadlines, including submission of the Data Collection Form and reporting package to the Federal Audit Clearinghouse. 4. Agency Notification: The Organization will contact the relevant federal awarding agencies to inform them of the missed audits for 2022 and 2023 and to seek guidance on any required remedial actions. Responsible Contact Person: Nikel Davis, Director of Accounting Anticipated Completion Date: October 15, 2025
For the Waukegan Supportive Housing Facility - FINDING 2024-003: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 PAID THE EXPENSE OF ANOTHER PROJECT UNDER COMMON MANAGEMENT Recommendation: The Project should carefully review invoices before payment to make sure it pays the correct amount. Action Taken...
For the Waukegan Supportive Housing Facility - FINDING 2024-003: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 PAID THE EXPENSE OF ANOTHER PROJECT UNDER COMMON MANAGEMENT Recommendation: The Project should carefully review invoices before payment to make sure it pays the correct amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment.
View Audit 369357 Questioned Costs: $1
For the Rockford Supportive Housing Facility - FINDING 2024-002: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 TENANT FILE CONTAINED MATHEMATICAL ERROR IN COMPUTING HOUSEHOLD INCOME Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future month...
For the Rockford Supportive Housing Facility - FINDING 2024-002: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 TENANT FILE CONTAINED MATHEMATICAL ERROR IN COMPUTING HOUSEHOLD INCOME Recommendation: The Project should recompute the HUD subsidy and tenant rent for this tenant and adjust a future monthly billing. Project managers should be aware of the importance of computing the tenant's household income correctly. Action Taken: The Project agrees with the finding. Tenant rent was recomputed in January 2025 and will be corrected on a future HAP voucher.
View Audit 369357 Questioned Costs: $1
For the OTR - Arboretum West Apartments Facility FINDING 2024-004: SECTION 223(f), ASSISTANCE LISTING NUMBER 14.155 PAID THE EXPENSE OF ANOTHER PROJECT UNDER COMMON MANAGEMENT Recommendation: The Project should carefully review invoices before payment to make sure it pays the correct amount. Action ...
For the OTR - Arboretum West Apartments Facility FINDING 2024-004: SECTION 223(f), ASSISTANCE LISTING NUMBER 14.155 PAID THE EXPENSE OF ANOTHER PROJECT UNDER COMMON MANAGEMENT Recommendation: The Project should carefully review invoices before payment to make sure it pays the correct amount. Action Taken: The Project agrees with the finding. The accounts payable staff will be reminded to be careful when entering invoices for payment.
View Audit 369357 Questioned Costs: $1
Over the Rainbow Association and Subsidiaries respectfully submits the following corrective action plans for the year ended December 31, 2024. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit period: De...
Over the Rainbow Association and Subsidiaries respectfully submits the following corrective action plans for the year ended December 31, 2024. Name and address of independent public accounting firm: Baker Meinz & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit period: December 31, 2024. The findings from the December 31, 2024 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT - NONE; FINDINGS - FEDERAL AWARD PROGRAMS AUDIT - DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT; For the Hill Housing Facility - FINDING 2024-001: SECTION 8, ASSISTANCE LISTING NUMBER 14.195 SPONSOR LOAN PAYMENT WITHOUT HUD APPROVAL Recommendation: The Sponsor should obtain HUD approval for the repayment of the sponsor loan. Action Taken: The Sponsor will contact HUD to obtain HUD permission to retain the unauthorized sponsor loan payments.
View Audit 369357 Questioned Costs: $1
USDA Food Distribution and Authorized Signers– The Organization acknowledges it did not consistently obtain signatures from "approved shoppers" for USDA food products. Additionally, in at least one instance, the individual signing for a USDA distribution was not listed as an authorized signer. These...
USDA Food Distribution and Authorized Signers– The Organization acknowledges it did not consistently obtain signatures from "approved shoppers" for USDA food products. Additionally, in at least one instance, the individual signing for a USDA distribution was not listed as an authorized signer. These issues indicate a lack of adherence to required procedures for verifying and documenting authorized individuals who pick up USDA food products. The Organization will provide comprehensive training to all relevant staff on the correct procedures for obtaining and cross-referencing signatures for USDA food product distribution. This will help ensure compliance with requirements and improve the integrity of the distribution process.
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