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Corrective Action Plans

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Finding 575294 (2023-002)
Significant Deficiency 2023
Kama'aina Care, Inc.
HI
Subrecipient Monitoring Reporting Significant Deficiency § 200.329
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
Management concurs with the finding and will ensure that records are maintained to indicate timely submission of reports.
View Audit 365320
Finding 575283 (2023-007)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Internal Control / Segregation of Duties Period of Performance Reporting
Corrective Action Plan: ALN 93.568: The LIHEAP program reports were submitted late and the obligations were reported on the Federal Financial Reports and Carryover/Allotment Report. The LIHEAP carryover/allotment report was late due to staff turnover. Person(s) Responsible: Deanne Bear Catches, LIHE...
Corrective Action Plan: ALN 93.568: The LIHEAP program reports were submitted late and the obligations were reported on the Federal Financial Reports and Carryover/Allotment Report. The LIHEAP carryover/allotment report was late due to staff turnover. Person(s) Responsible: Deanne Bear Catches, LIHEAP Director Estimated Completion Date: December 31, 2025
View Audit 365312
Finding 575281 (2023-003)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Cash Management § 200.305
Corrective Action Plan: The Program will work with the finance department to better match advanced drawdowns to the actual disbursement for the period. This will be done by comparing the funds on hand (bank balance) to program costs. If sufficient funds are on hand a drawdown request will not be ma...
Corrective Action Plan: The Program will work with the finance department to better match advanced drawdowns to the actual disbursement for the period. This will be done by comparing the funds on hand (bank balance) to program costs. If sufficient funds are on hand a drawdown request will not be made. Person(s) Responsible: Deanne Bear Catches, LIHEAP Director Estimated Completion Date: Effectively immediately
View Audit 365312
Finding 575276 (2023-005)
Significant Deficiency 2023
Standing Rock Sioux Tribe
ND
Eligibility Internal Control / Segregation of Duties § 200.303
Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alv...
Corrective Action Plan: ALN 93.441 (participant eligibility): The Program was able to locate the missing eligibility documents which were subsequently provided to the auditor. The Program will ensure that such documentation is maintained in participant files in the future. Person(s) Responsible: Alvonne Penola, Treatment Program Director Estimated Completion Date: Effective immediately
View Audit 365312
Finding 575275 (2023-010)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Subrecipient Monitoring Internal Control / Segregation of Duties
Corrective Action Plan: ALN 93.441: The Tribe’s HR Department will develop and implement policies and procedures requiring that character investigations be performed for all program personnel. In addition, notation of the appropriate independent verification will be clearly notated. ALN 93.575 and 9...
Corrective Action Plan: ALN 93.441: The Tribe’s HR Department will develop and implement policies and procedures requiring that character investigations be performed for all program personnel. In addition, notation of the appropriate independent verification will be clearly notated. ALN 93.575 and 93.596: The Program hired a Training Monitor. The Training Monitor is responsible for scheduling training and ensuring all providers are up to date on training that is required by the CCDF program. The documentation will be kept on file. Person(s) Responsible: Violet Black Cloud, Human Resources Director,Jackie Brownotter, Child Care Assistance Program Director Estimated Completion Date: September 30, 2025, December 31, 2024
View Audit 365312
Finding 575273 (2023-004)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Eligibility Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance ...
Corrective Action Plan: ALN 93.575 and 93.596 (CPR Certifications): Starting in October 2024 the Program has hired a company to provide CPR training to the staff. This training occurred throughout fiscal year 2024. ALN 93.575 and 93.596 (Provider files): In July 2025, the Program hired a Compliance Specialist to review provider files for compliance. In addition, the Program hired an employee to assist with the demanding workload. ALN 93.568 (participant files): the identified items of non-compliance was a direct result of program personnel turnover, including the Director. The Director position was vacant for the entire fiscal year. The Program is now fully staffed and working on ensuring that all intake items are clearly documented/retained in the participant files. Person(s) Responsible: Jackie Brownotter, Child Care Assistance Program Director, Deanne Bear Catches, LIHEAP Director Estimated Completion Date: ALN 93.575 and 93.596 (CPR Certifications): October 2024, ALN 93.575 and93.596 (Provider files): Effective immediately ALN 93.568 (participant files): effectively immediately
View Audit 365312
Finding 575272 (2023-008)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Procurement, Suspension & Debarment
Corrective Action Plan: ALN 15.518 and 93.445: Policies and procedures will be enforced requiring that the Tribe’s procurement policies and procedures are followed, including evidencing suspension and debarment verification. Person(s) Responsible: Randez Bailey, SRST OMR/MRI Director Estimated Compl...
Corrective Action Plan: ALN 15.518 and 93.445: Policies and procedures will be enforced requiring that the Tribe’s procurement policies and procedures are followed, including evidencing suspension and debarment verification. Person(s) Responsible: Randez Bailey, SRST OMR/MRI Director Estimated Completion Date: Effectively immediately
View Audit 365312
Finding 575271 (2023-009)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Reporting
Corrective Action Plan: The Tribe will develop a quarterly, semi-annual, and annual checklist with timelines to complete the federal financial reports to ensure timely submission. Person(s) Responsible: Ernestine Jamerson, Chief Finance Officer Estimated Completion Date: December 31, 2025
Corrective Action Plan: The Tribe will develop a quarterly, semi-annual, and annual checklist with timelines to complete the federal financial reports to ensure timely submission. Person(s) Responsible: Ernestine Jamerson, Chief Finance Officer Estimated Completion Date: December 31, 2025
View Audit 365312
Finding 575270 (2023-006)
Material Weakness 2023
Standing Rock Sioux Tribe
ND
Matching / Level of Effort / Earmarking § 200.306
Corrective Action Plan: ALN 10.760: The Program will work with the Finance Department to thoroughly review the grant award documentation for any cost-sharing contribution requirements. If identified, this requirement will be marked on the intake form and tracked by the Finance Department. ALN 93.575...
Corrective Action Plan: ALN 10.760: The Program will work with the Finance Department to thoroughly review the grant award documentation for any cost-sharing contribution requirements. If identified, this requirement will be marked on the intake form and tracked by the Finance Department. ALN 93.575 and 93.596: The Program satisfied these matching requirements in fiscal year 2024. In future awards, the Program will ensure that the match requirements are met in the appropriate period of performance. Person(s) Responsible: Randez Bailey, SRST OMR/MRI Director,Jackie Brownotter, Child Care Assistance Program Director Estimated Completion Date: September 30, 2025, March 31, 2024
View Audit 365312
Finding 575242 (2023-002)
Significant Deficiency 2023
Houston Regional Hiv/aids Resource Group, Inc.
TX
Subrecipient Monitoring Reporting Significant Deficiency § 200.303 § 200.332
2023-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with ...
2023-002 Compliance and Internal Controls over Subrecipient Fiscal Monitoring (Significant Deficiency) Corrective Action: In accordance with 2 CFR Section 200.332, The Resource Group as the pass-through entity will ensure subrecipient fiscal monitoring is completed in 2024 to ensure compliance with federal and state requirements. The Finance Director is responsible for oversight and administration of fiscal monitoring. Fiscal monitoring will be conducted at least annually in accordance with HRSA Monitoring Standards 45 CFR 74.51 and 45 CFR 75.352. As a pass-through entity, fiscal monitoring will include at minimum reviews of financial performance and compliance with federal and state statues, regulations and terms and conditions. The process will include desktop/remote verification of applicable financial policy and procedures and an onsite review. A standardized monitoring tool will be used to evaluate financial compliance. The fiscal monitoring observations will result in a monitoring report, disseminated to the subrecipient within 60 days of the onsite review. Progress to date: 1. To support the financial monitoring efforts, technical assistance was received on February 5-7, 2024, from the DSHS Fiscal Support and Oversight Department. The primary objective of the visit was to discuss financial monitoring requirements as it applies to state and federal regulations, statues and terms and conditions. The standardized monitoring tool was also evaluated for compliance. 2. The Finance Director developed and implemented a comprehensive fiscal monitoring schedule for calendar year 2024. In alignment with strengthened oversight practices, onsite fiscal reviews of subrecipients commenced in February 2024. As part of the enhanced monitoring approach, the testing period for subrecipient fiscal reviews was expanded beyond the standard scope to include transactions and activities from both Fiscal Year 2022 and Fiscal Year 2023. 3. As of September 2024, the Finance Director completed 100% of fiscal monitoring visits. a. Support Documentation: to establish additional guidelines for fiscal monitoring, the Fiscal Monitoring Policy was drafted and approved by the Board on November 18, 2024. 3 Responsible Party: Finance Director, Garland Thompson Date Complete: November 18, 2024
View Audit 365302
Finding 575150 (2023-004)
Material Weakness 2023
Municipality of Loiza
PR
Allowable Costs / Cost Principles § 200.208 § 200.302 § 200.339 § 200.403
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control sturcture to prevent the situation from happening in the future. The Municipality Managem...
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control sturcture to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed contrl strucure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Disaster Grants disbursement policies.
View Audit 365237
Finding 575149 (2023-003)
Material Weakness 2023
Municipality of Loiza
PR
Questioned Costs Allowable Costs / Cost Principles § 200.302 § 200.339 § 200.403
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Manageme...
The Municipality Administration is committed to identify the control of deficiency that allowed for the deficiency to happen. Additionally, the administration is committed to implementing the correct control structure to prevent the situation from happening in the future. The Municipality Management will continue the search of supporting documentation of the highlighted transactions. New proposed control structure to be evaluated by Municipality for adequacy. The Municipality ensures the compliance with the Coronavirus State and Local Fiscal Recovery Funds Assistance disbursement policies.
View Audit 365237 Questioned Costs: $1
Finding 575148 (2023-002)
Material Weakness 2023
Municipality of Loiza
PR
Reporting Significant Deficiency
The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditor's firm to comply with such requirements.
The Municipality Administration is committed to complying with all submissions and has ensured the proper signing of an external auditor's firm to comply with such requirements.
View Audit 365237
Finding 575141 (2023-001)
Significant Deficiency 2023
Regional School Unit No. 18
ME
Internal Control / Segregation of Duties
Management’s response/corrective action plan: Management takes compliance matters seriously and is committed to ensuring that all applicable regulations, including Davis-Bacon Act requirements, are adhered to. We have conducted a review of our processes and procedures related to prevailing wage rate...
Management’s response/corrective action plan: Management takes compliance matters seriously and is committed to ensuring that all applicable regulations, including Davis-Bacon Act requirements, are adhered to. We have conducted a review of our processes and procedures related to prevailing wage rate compliance. This review has helped us identify areas where improvements can be made to ensure full compliance with these requirements. We have taken the following actions to address the identified compliance issue: 1. Management will proactively include prevailing wage language in any qualifying district construction project bids and contracts. 2. To strengthen our compliance efforts, we have improved monitoring to regularly assess our adherence to prevailing wage rate requirements for projects with federal assistance. This includes periodic reviews of construction projects, and proposed projects, to identify any potential non-compliance issues. Additionally, we will conduct prevailing wage compliance reviews of all certified payrolls as they are received. Management will oversee this monitoring to ensure ongoing compliance.
View Audit 365228
Finding 575025 (2023-009)
Significant Deficiency 2023
Leadership Memphis
TN
Allowable Costs / Cost Principles
Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across prog...
Corrective Action: This finding is a continuation of a prior year deficiency related to the lack of formal allocation methodologies. Management is currently drafting a cost allocation policy that includes specific guidance on how to allocate shared costs (e.g., rent, insurance, software) across programs, management & general, and fundraising functions. The new policy will include acceptable bases such as square footage, staff headcount, or usage logs and will be reviewed annually. All allocations will be supported by schedules retained with the audit documentation.
View Audit 365202
Finding 575024 (2023-008)
Significant Deficiency 2023
Leadership Memphis
TN
Allowable Costs / Cost Principles
Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required...
Corrective Action: The Organization lacked adequate timekeeping and pay rate documentation controls during FY23, and no current management or staff were present at the time. As of FY26, the Organization has begun implementing new payroll oversight processes. Going forward, timecards will be required for any employee whose time is allocated to multiple functions or funding sources. Management will also require documentation of payroll approvals (e.g., signed letters or memos) for all employees and will store these documents in both hard copy and electronic format. Payroll allocation methodologies will be reassessed at least every three years using a representative time study.
View Audit 365202
Finding 575023 (2023-007)
Significant Deficiency 2023
Leadership Memphis
TN
Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initi...
Corrective Action: Although current management was not involved during the audit period, the Organization recognizes the importance of documented expenditure review under Uniform Guidance. A formal procedure is being developed that will require all grant-related expenditures to be reviewed and initialed or electronically approved by authorized personnel. The policy will require documentation that clearly demonstrates both the allowability of the cost and its alignment with approved program activities. These procedures will be implemented and tested beginning with FY26 expenditures.
View Audit 365202
Finding 575015 (2023-005)
Significant Deficiency 2023
New Orleans Career Center
LA
Procurement, Suspension & Debarment Matching / Level of Effort / Earmarking Subrecipient Monitoring § 200.303
Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to require verifying all vendors against the SAM.gov suspension and debarment list. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimated Completion Date: December 31,...
Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to require verifying all vendors against the SAM.gov suspension and debarment list. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimated Completion Date: December 31, 2025
View Audit 365197
Finding 575014 (2023-004)
Significant Deficiency 2023
New Orleans Career Center
LA
Subrecipient Monitoring Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303
Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to ensure that employees classified to federal programs receive updated offer letters detailing their compensation. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimat...
Status: In progress. Planned Corrective Action: The New Orleans Career Center will update its financial policies to ensure that employees classified to federal programs receive updated offer letters detailing their compensation. Person(s) Responsible: Claire Jecklin, CEO; Darius Munchak, CFO Estimated Completion Date: December 31, 2025
View Audit 365197
Finding 574731 (2023-001)
Significant Deficiency 2023
Pro Viviendas Iv, Inc.
PR
HUD Housing Programs Cash Management
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be ...
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be notified about the matter and while the amount is adjusted through the monthly mortgage payment, Management will continue to make monthly deposits of $812.00 through 2023 fiscal year to cover the deficiency. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Administrative Director. The estimated completion date for the finding is May 31, 2024. Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.
View Audit 365039
Finding 574730 (2023-001)
Significant Deficiency 2023
Pro Viviendas Iii, INC
PR
HUD Housing Programs Cash Management
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be ...
Management will proceed to transfer from the operational to the reserve account $5,684 corresponding to the undeposited deficiency ($812 per month) during the period from June to December 2023. Evidence of the deposit to the reserve account will be sent to HUD office as agreed. Popular bank will be notified about the matter and while the amount is adjusted through the monthly mortgage payment, Management will continue to make monthly deposits of $812.00 through 2023 fiscal year to cover the deficiency. The responsible person for the corrective action plan is Carmen G Rivera, Blanco’s Administrative Director. The estimated completion date for the finding is May 31, 2024. Management will ensure deposits to the replacement reserve account are made on a monthly basis as stated in the use agreement.
View Audit 365038
Goshen Valley Foundation
GA
Goshen Valley will submit the 2023 report package and ensure that all future audit reports are submitted to the FAC in a timely manner.
Goshen Valley will submit the 2023 report package and ensure that all future audit reports are submitted to the FAC in a timely manner.
View Audit 365035
Finding 574716 (2023-003)
Significant Deficiency 2023
City of Wilkes-Barre, Pennsylvania
PA
Reporting
The City plans to have information ready for auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the City hopes to have cleared by the 2025 audit
The City plans to have information ready for auditors to get 2024 done in a reasonable time frame. This finding will likely carry to 2024 but between staffing and priorities, the City hopes to have cleared by the 2025 audit
View Audit 365027
Finding 574708 (2023-001)
Significant Deficiency 2023
National Council of Negro Women, Inc.
DC
Management will implement measures to ensure thst financial statements are completed as expeditiously as possibe to enable the Single Audit to be completed in the required time frame
Management will implement measures to ensure thst financial statements are completed as expeditiously as possibe to enable the Single Audit to be completed in the required time frame
View Audit 364988
Finding 574610 (2023-003)
Material Weakness 2023
Southwestern Christian University, Inc.
OK
Material Weakness
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, fami...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University acknowledges the importance of the Gramm-Leach-Bliley Act (GBLA) and the responsibilities it places on higher education institutions to protect personal and financial information of students, families, and employees. We are committed to safeguarding sensitive data as part of our responsibility to operate with integrity and stewardship. To address these findings, SCU is working closely with our IT specialist in taking the following steps: a. Information Security Program: we are formalizing a written information security plan that meets the GLBA requirements, including risk assessment, safeguards, and monitoring. b. Designation of Coordinator: A qualified staff member has been designated to oversee GLBA compliance and ensure accountability in implementing safeguards. c. Employee training: Faculty and staff will be trained on data privacy, cybersecurity practices, and proper handling of sensitive information. d. Technical Safeguards: We will be enhancing systems for data encryption, access controls, and monitoring to reduce risks related to unauthorized access or disclosure. e. Ongoing review: Regular testing, audits, and updates will be conducted to ensure continuous improvement and adherence to GLBA standards. At Southwestern Christian University, we believe in protecting the personal information of our students and families is part of our mission of stewardship. Just as we are called to be faithful with financial resources, we are equally called to be trustworthy in safeguarding data. We are confident that the corrective actions being implemented will ensure that SCU not only meets compliance standards but also reflects our values of integrity, accountability and care. Person Responsible for Corrective Action Plan: Mark Arthur, Chief Financial Officer Anticipated Date of Completion: June 30, 2026
View Audit 364874
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