Corrective Action Plans

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2023‐008 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working to establish better financial reporting to ensure that costs a...
2023‐008 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working to establish better financial reporting to ensure that costs are appropriately allocated to grants for reimbursement and to establish adequate supporting documentation for all expenditures reimbursed with federal, state, or grant funding. Planned implementation date of corrective action – Calendar year 2025.
View Audit 363689 Questioned Costs: $1
2023‐007 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working within the invoice approval system to build in safeguards to p...
2023‐007 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – Management is working within the invoice approval system to build in safeguards to prevent invoices from being routed without CEO approval. Planned implementation date of corrective action – Calendar year 2025.
2023‐006 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – The financial management team is reviewing the requirements for federal expenditures...
2023‐006 Allowable Costs and Allowable Activities - COVID‐19 Coronavirus State and Local Fiscal Recovery Funds Person responsible for corrective action – Devlyn Brooks, Executive Director Corrective action planned – The financial management team is reviewing the requirements for federal expenditures under Uniform Guidance for better understanding of the requirements and to establish appropriate policies and procedures for handling of federal funding. Planned implementation date of corrective action – Calendar year 2025.
Finding 572502 (2023-001)
Significant Deficiency 2023
Finding 2023-001 Adherence and Application of Fiscal and Accounting Policies and Procedures – Repeat Finding ...
Finding 2023-001 Adherence and Application of Fiscal and Accounting Policies and Procedures – Repeat Finding Federal Agency: U.S. Department of Health and Human Services Program Name: Protecting and Improving Health Globally: Building and Strengthening Public Health Impact, Systems, Capacity and Security Assistance Listing #: 93.318 Questioned Costs: None Corrective Action: We agree with the auditor’s comments and the recommended actions. The Organization recognizes the importance of consistent adherence to its established Financial Management Policies and Procedures, specifically related to the required approval of expenditures by upper management. To address this finding and prevent recurrence, Alianza Americas will implement the following corrective actions: ● Policy Reinforcement: Revise and redistribute the organization’s Financial Management Policies and Procedures manual to all staff involved in the review, processing, or approval of financial transactions. ● Training: Conduct mandatory refresher training for all staff involved in the review, processing, or approval of financial transactions by July 31, 2025. ● Controls and Compliance Checks: Developed and implemented a financial transaction spreadsheet to ensure that all required approvals are obtained before processing. Finance staff have been instructed to reject any incomplete or non-compliant documentation. ● Monitoring and Oversight: Monthly internal audits will be conducted by the Associate Director of Operations to verify compliance and address any discrepancies proactively. These measures will ensure that expenditures are reviewed and approved in accordance with policy, and that proper documentation is maintained for all financial transactions. Contact Person: Dulce Guzmán, Executive Director Anticipated Completion Date: July 31, 2025
Audit Finding Reference: 2023-001 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melis...
Audit Finding Reference: 2023-001 Planned Corrective Action: The district created a Federal and State Grants Procedures Manual that includes specific procedures for Time and Effort. The Grant Procedure Manual was approved by the District Committee on December 12, 2023. Name of Contact Person: Melissa Martel, Director of Finance Completion Date: December 12, 2023
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of ...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF will provide training to personnel on the requirements and regulations related to subrecipient monitoring. Recommendation to management will be implemented, internal controls and compliance measures that allow for the identification, reporting, and monitoring of subrecipient activities Prevention Activities/TANF. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-...
VIEWS OF RESPONSIBLE OFFICIALS Establish a peer or supervisory review process for a percentage of eligibility determinations prior to final approval and implement a common error log to identify areas requiring further training or adjustment of procedures. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Sidnia Vélez, Child Care Program Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)
View Audit 363366 Questioned Costs: $1
VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026....
VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and ...
VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Estab...
VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Establish an indirect cost policy to standardize the evaluation and approval for subrecipient. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)
VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPL...
VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Doris Jiménez, Finance Director Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)
View Audit 363366 Questioned Costs: $1
Planned Corrective Action: We will develop internal reports to align with UDS reporting requirements. We will also create a reconciliation log to track changes and justifications. We will assign an individual to oversee data integrity and submission. Name of Contact Person: Ruth Cable, CFO, Lane Bak...
Planned Corrective Action: We will develop internal reports to align with UDS reporting requirements. We will also create a reconciliation log to track changes and justifications. We will assign an individual to oversee data integrity and submission. Name of Contact Person: Ruth Cable, CFO, Lane Baker, COO, and Tomiko Fisher, COO Anticipated completion date: October 31, 2025
Issue: Summary Condition: The Auditee submitted reimbursement requests to the Mississippi Department of Education (MOE) that were not fully supported: Standard monthly amounts requested for Digital Learning Instructor (DU) labor exceeded actual contract costs, resulting in overstatements. 1 of 60 it...
Issue: Summary Condition: The Auditee submitted reimbursement requests to the Mississippi Department of Education (MOE) that were not fully supported: Standard monthly amounts requested for Digital Learning Instructor (DU) labor exceeded actual contract costs, resulting in overstatements. 1 of 60 items sampled lacked support for $11,700 in charges. Cause: The Consortium requested funds before receiving invoices or verifying actual expenses. There was no reconciliation process in place to verify that reimbursement requests matched actual expenditures. Effect: Federal funds were received in excess of allowable costs and not returned to the grantor. These excess reimbursements represent questioned costs which the grantor could request funds to be refunded. Criteria: In accordance with 2 CFR 200.403 and 200.430, costs must be necessary, reasonable, and allocable, and adequately documented to be allowable under federal awards. Questioned Costs: Total known questioned costs are $49,082, which includes: $37,382 related to Digital Learning Instructor (DLI) contract labor, including $34,445 in excess labor charges and $2,937 in related indirect costs. These charges were identified through a 100% review of all DU contract labor activity for fiscal year 2023. $11,700 from a single reimbursement request that partially lacked supporting documentation. This item was identified during testing of a sample of 60 items totaling $6,545,759.87. Response: The Consortium acknowledges the finding and agrees with the audit's assessment. The practice of requesting reimbursement based on estimated monthly amounts without timely reconciliation to actual expenses was not in alignment with federal cost principles under 2CFR 200.403 and 200.430. We recognize that this oversight led to the disbursement of excess federal funds, and we are committed to promptly resolving this issue and implementing strong internal controls to prevent recurrence. Corrective Action Plan: Reconciliation Process Implementation: We have implemented a formal reconciliation process to ensure reimbursement requests are in line with actual cost. This includes reviewing all invoices and matching them to amounts requested. Return of Excess Funds: We are identifying and preparing to return any excess federal funds that were distributed as a result of these overstatements, as part of our reconciliation review. Corrective Action Timeline: The reconciliation process was initiated in June 2025. The return of fund to Mississippi Department of Education will begin with sending the audit report to MDE and getting directions on how to return overstated funds. Responsible Individuals: Mark Brown, business manager, is leading the implementation of the corrective action measures, in collaboration with Projects Coordinator, Susan Scott.
View Audit 363217 Questioned Costs: $1
Finding 572058 (2023-004)
Significant Deficiency 2023
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develo...
Finding 2023.004 - Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken I will work directly with the Chief Executive Officer, Alexis Charpentier, to develop written policies requiring cash disbursements to follow a clear, tiered approval process based on the amount. For example: • Up to a set threshold: Department manager approval • Above threshold: Department manager plus finance director/CFO approval • High-value disbursements: Additional executive or board-level approval. Requiring supporting documents (invoices, contracts, purchase orders) for every disbursement. Approvers must verify accuracy and completeness before authorizing payment. If there are any questions regarding this plan, please e-mail Yumiko Molden at ymolden@waikikihealth.org. Sincerely, Yumiko Molden CFO
Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing ...
Finding 2023-003 - Material Weakness in Internal Control over Compliance and Material Noncompliance (Qualified Opinion) - Inadequate Tracking of Expenditures and Retention of Documentation: Activities Allowed or Unallowed: Allowable Costs/Cost Principles and Reporting (A/B/L) for Assistance Listing Number 19.510 and 93.567 Criteria: The Code of Federal Regulations (CFR) Section 200.510(b) states in part, “The auditee must also prepare a schedule of federal expenditures for the period covered by the auditee’s consolidated financial statements which must include the total Federal awards expended as determined in accordance with 200.502.” Also, in accordance with CFR Section 200.302(b) - Financial Management, the auditees financial management system must provide 1) identification of all federal awards received and expended; 2) accurate, current, and complete disclosure of the financial results of each federal award or program; 3) records that identify adequately the source and application of funds for federally‐funded activities; 4) effective control over, and accountability for, all funds, property, and other assets; 5) comparison of expenditures with budget amounts for each Federal award; 6) written procedures to implement the requirements of section 200.305 and; 7) written procedures for determining the allowability of costs in accordance with Subpart E and the terms and conditions of the Federal award. Recipients of federal awards must submit accurate, complete and timely financial and performance reports. The Organization should have internal controls designed to ensure compliance with those provisions. The Organization should retain sufficient documentation such as invoice and allocation support for expenditures to retain documentation for audit purposes. Condition: During detail testing of expenditures, it was noted that the Organization did not maintain adequate documentation to support how certain costs were allocated to the federal program. Several transactions lacked sufficient detail, such as invoice or expense reimbursement form. Several expenditures selected for testing did not obtain sufficient approval by an individual at the Organization. It was noted that quarterly reports provided to the federal program were not reviewed by an individual at the Organization prior to submission to ensure accurate report of expenditures. Cause: The Organization does not have an adequate system in place to ensure quarterly reports have sufficient supporting documentation, proper approval/review, and accurate reporting prior to submission. Responsibilities for expenditure tracking were not clearly assigned, and there was no formal review process in place. The Organization is not following their Document Retention Policy. Effect: The effect of this condition increases the possibility that quarterly financial reports are misstated or inaccurate and increase the risk of noncompliance with federal requirements. The effect of this condition also increases the risk that expenditures are unallowable per the grant, federal regulations, or cost principles due to the insufficient support of proper approval retained. Questioned costs: None Repeat Finding: Yes - 2022-004 Recommendation: Policies and procedures should be in place to ensure quarterly financial reports are properly supported, accurately reported, and adequately approved and reviewed. A formal review process should be established to ensure compliance. The Organization should following the Document Retention Policy that was put in place and required by law. Management Response: There is no disagreement with the audit finding. Management has taken steps to address these deficiencies in fiscal year 2025 including but not limited to: the implementation of a new accounting system that includes document retention and review/sign off logs, the engagement of a third-party CPA firm to provide client advisory and accounting services and the review and updating of accounting policies and procedures for best practices. Responsible Person for Corrective Action Plan: Marc Hall, Director of Operations Implementation Date for Corrective Action Plan: Fiscal year 2025
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
No corrective action plan is need as this was a singular one-time event involving provider relief funding from HRSA. Person(s) Responsible: Tracy Busse and Greg Toutant Timing for Implementation: N/A
View Audit 362889 Questioned Costs: $1
Finding 571810 (2023-001)
Significant Deficiency 2023
Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate t...
Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate that the policies and procedures will be completed and approved by June 30, 2026. Contact Person: Julie Hebert, Finance Director
Finding 571807 (2023-002)
Significant Deficiency 2023
Correction Action Plan – Finding 2023-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: The Treasurer/Collect...
Correction Action Plan – Finding 2023-002 “Improve Time and Effort Documentation” Correction Action to be taken: The Town is reviewing all school contracts and time sheets for inefficiencies and requiring adjustments or more documentation as necessary. Expected Completion Date: The Treasurer/Collector’s office has taken over most of the school’s payroll in FY25 and is working with our new School Business Manager to correct all of the timesheet inadequacies. We anticipate that all major inefficiencies within school payroll will be eradicated by December 31, 2025. The Town is also shifting to a new payroll system which will properly report time and attendance. Contact Person: Julie Hebert, Finance Director; Janet Jannell, Treasurer/Collector; Kaitlyn Shelar, School Business Manager
Finding 571806 (2023-007)
Significant Deficiency 2023
The annual budget for fiscal year 2023-2024 was submitted late due to a computer crash. The computer had to be repaired so the report could not be completed until the computer was repaired and returned. All reports will be initialed and dated to show independent review and will be timely submitted f...
The annual budget for fiscal year 2023-2024 was submitted late due to a computer crash. The computer had to be repaired so the report could not be completed until the computer was repaired and returned. All reports will be initialed and dated to show independent review and will be timely submitted from now on.
Management’s Response/Corrective Action Plan (Unaudited): Management agrees to address the finding in its capital asset tracking schedule. The Organization and its outsourced accountant have discussed the finding and will implement procedures on tracking capital assets funded with federal grants. Th...
Management’s Response/Corrective Action Plan (Unaudited): Management agrees to address the finding in its capital asset tracking schedule. The Organization and its outsourced accountant have discussed the finding and will implement procedures on tracking capital assets funded with federal grants. This tracking will be incorporated to the current capital asset tracking schedule. Planned Completion Date: June 2025 Contact Person Responsible for Correction Action: Adam Courtney
Finding 2023-005 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF will enhance its internal processes and staffing to ensure the timely submission of future Single Audit Reporting Packages...
Finding 2023-005 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF will enhance its internal processes and staffing to ensure the timely submission of future Single Audit Reporting Packages. In January 2025, CDF hired an Outsourced Grant Manager dedicated to overseeing federal grant management, including the coordination and timely submission of all required audit and reporting packages. Key actions include:  Establishing and maintaining a robust timeline for audit activities, closely collaborating with both the accounting team and external auditors to guarantee adherence to submission deadlines.  Implementing a cross-training program within the accounting and compliance departments to mitigate the risk of disruption due to staff turnover, ensuring multiple staff members are proficient in handling audit-related tasks.  Scheduling regular internal audits and compliance checks to proactively identify and address potential issues well in advance of filing deadlines. Anticipated Completion Date: December 31, 2025.
Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant adm...
Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant administration and compliance. The grant manager's duties will include ensuring that all reimbursement requests are substantiated by adequate documentation, such as actual invoices, payroll registers, and payment records. Key actions include:  Establishing a systematic process for the collection, organization, and retention of all requisite documents.  Implementing internal review and approval procedures to guarantee that every reimbursement request undergoes thorough vetting and receives approval prior to submission, with explicit documentation of the review process.  Instructing both existing and new personnel on these newly instituted procedures to prevent future inconsistencies. Anticipated Completion Date: December 31, 2025.
Finding 2023-002 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal a...
Finding 2023-002 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 to oversee compliance and internal control processes for federal awards, ensuring adherence to 2 CFR Part 200. The Outsourced Grant Manager will implement systems to accurately allocate salaries, wages, and other expenditures. Key actions include:  Payroll Expenditures: Establish procedures to approve payroll allocations based on actual time and effort reporting, requiring supervisor approval and periodic reviews for compliance.  Non-Payroll Expenditures: Develop approval processes for non-payroll expenses, ensuring detailed documentation and implementing checks to verify overhead allocations.  Documentation and Review: Implement a comprehensive filing system for approvals and supporting documents, with regular training for staff.  Ongoing Compliance Monitoring: Conduct periodic internal audits to ensure adherence to internal controls and federal regulations, addressing issues promptly. These measures will strengthen CDF’s internal controls, ensure compliance, and maintain the integrity of federal award management. Anticipated Completion Date: December 31, 2025.
View Audit 362526 Questioned Costs: $1
Finding 571537 (2023-001)
Significant Deficiency 2023
Audit Finding Reference: 2023-001 - Improve Controls and Documentation over Reporting Process Planned Corrective Action: The Town acknowledges the discrepancy noted in the audit finding regarding the timing and documentation of expenditures included in the P&E Annual Report for the ARPA grant. We a...
Audit Finding Reference: 2023-001 - Improve Controls and Documentation over Reporting Process Planned Corrective Action: The Town acknowledges the discrepancy noted in the audit finding regarding the timing and documentation of expenditures included in the P&E Annual Report for the ARPA grant. We appreciate the opportunity to address this issue and confirm that we will implement improvements to strengthen our reporting process. Moving forward, the Town will utilize the MUNIS accounting system more effectively to ensure all expenditures are properly recorded and reported within the appropriate reporting periods. In addition, internal procedures will be reviewed and updated to reinforce timely data entry and review of grant-related transactions. Responsible staff have been made aware of the finding, and steps will be taken to ensure compliance with federal reporting requirements. Planned Implementation Date of Corrective Action: May 2025 Persion Resonsible for Corrective Action: Stephanie Pemberton, Town Accountant Please consider this the Town's official corrective action response to be included in the final audit report.
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