Corrective Action Plans

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Management agrees and will develop review procedures to respond to the findings.
Management agrees and will develop review procedures to respond to the findings.
View Audit 369054 Questioned Costs: $1
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
Management agrees with the finding and will work with the City of San Antonio to correct the issue, and develop review procedures to respond to the finding.
View Audit 369054 Questioned Costs: $1
Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed mont...
Corrective Action Plan: Strengthen detailed process for review over payroll charges billed to federal programs. To address the significant deficiency over allowable costs identified in the Single Audit, the Organization will enhance its existing review procedures by implementing a more detailed monthly review process. This will include verifying payroll charges against supporting documentation such as payroll registers, time records, and allocation spreadsheets. Management will also explore the development of a standardized reconciliation checklist and introduce a secondary review step to ensure accuracy and completeness. These measures, combined with continued monthly oversight by the CFO, are intended to reduce the risk of billing errors due to human oversight and reinforce the reliability of payroll cost allocations. Name of Responsible Person: Nora Davis, Chief Financial Officer Anticipated Completion Date: April 30, 2026
Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interp...
Belmont County Department of Job and Family Services reviews employee’s job duties routinely to determine the most appropriate and accurate cost pool they should be assigned. The essential job duties and how they align with the program area determine cost pool assignment based on the agency’s interpretation. As a result of this finding, BCDJFS will reassign the FCFC Coordinator to the shared cost pool and reimburse the shared cost pool from the applicable FCFC allocations through a MOU signed between the council and BCDJFS
View Audit 369030 Questioned Costs: $1
Finding 1156667 (2024-006)
Material Weakness 2024
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
The Children Service Department will seek legal advice on the implementation of a policy that meets the requirements set for in 2 CFR 200.302(b)(7) for determining the allowability of costs in accordance with Subpart E-Cost Principles.
Finding 1156666 (2024-005)
Material Weakness 2024
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
Training will occur with staff on the correct entry of rates into the SACWIS system and the importance of rates matching what was agreed to with the provider. Staff will review the invoices with the SACWIS entry prior to them being paid by the fiscal officer.
Finding 1156665 (2024-004)
Material Weakness 2024
The Commissioner’s office will consult with legal counsel to update polices to meet requirements of 2 CFR 200.
The Commissioner’s office will consult with legal counsel to update polices to meet requirements of 2 CFR 200.
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children an...
Finding 2024-004 Repeat of Finding 2023-004 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children and Families State Agency: Wisconsin Department of Children and Families State Program ID Number and Title: 435.560100 ADRC 435.000561/000681 Basic County Allocation State Agency: Wisconsin Department of Health Services State Program ID Number and Title: 395.168 Specialized Transit County Operating Aids (Elderly & Disabled) State Agency: Wisconsin Department of Transportation State Program ID Number and Title: 435.000283 IMAA State Share State Agency: Wisconsin Department of Health Services Award Numbers: Unknown Criteria: 2 CRF 200.303 Internal Controls requires that non-federal entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with federal laws, regulations and program compliance requirements. The State Single Audit Guidelines (SSAG) require that local entities receiving State awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including appropriate review and approval of expenditures. Condition/Context: During our testing, we were unable to view approval for the following number of payroll expenditures in each program: • 93.778: 13 out of 20 expenditures tested. • 435.000561/000681, 437.3561/3681: 7 out of 40 expenditures tested. • 435.560100: 14 out of 20 expenditures tested. For programs 395.168 and 435.000283, these are carried over from the prior year as controls have not changed within the system. These samples were not statistically valid. Corrective Action Plan Corrective Action Planned: In response to Finding 2024-004 regarding Internal Control Over Financial Reporting, note that the County is aware that there is lack of controls over its year-end financial reporting process. The County will endeavor to evaluate the need to increase additional staff to meet the deficiencies noted in the finding. However, due to its size, the County does not feel it is cost-effective to hire the number of employees needed to complete these task in house at this point in time and will rely on an outside audit firm. Administration is aware the current payroll and financial system allows to only go back to view payroll approvals within one year. Name(s) of Contact Person(s) Responsible for Corrective Action: Ron Barger, Marquette County Administrator Anticipated Completion Date: Administration will examine the lack of internal financial reporting on a yearly ongoing basis.
Finding 2024-002 Repeat of Finding 2023-002 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services Program Federal Assistance Listing and Title: 21.027 COVID-19 C...
Finding 2024-002 Repeat of Finding 2023-002 Program Federal Assistance Listing and Title: 93.778 Medicaid Cluster, Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services Program Federal Assistance Listing and Title: 21.027 COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Wisconsin Department of Health Services State Program ID Number and Title: 437.3561/3681 CW Children and Families State Agency: Wisconsin Department of Children and Families State Program ID Number and Title: 435.560100 ADRC 435.000561/000681 Basic County Allocation State Agency: Wisconsin Department of Health Services Award Numbers: Unknown Criteria: The State Single Audit Guidelines (SSAG) require that local entities receiving State awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations and program compliance requirements. The Uniform Guidance and State Single Audit Guidelines further require auditors to obtain an understanding of the local entity's internal control over federal and state programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of reports, which should be reviewed and approved by a responsible party other than the original preparer. Condition/Context: The County does not have controls in place to ensure there is documentation of the approval and review of reports prior to submission. Of the reports tested for the current year single audit, 12 of the 13 reports did not have documentation of the review process prior to submittal as follows: 10 of 10 monthly GEARS reports and 1 of 1 WIMCR annual reports did not have documentation of approval, and 1 of 2 monthly SPARC reports did not have documentation of approval. The sample was not statistically valid. Corrective Action Plan Corrective Action Planned: {The county is reviewing and updating its internal controls to put processes in place to ensure documentation of the review process prior to submittal of reports.} Name(s) of Contact Person(s) Responsible for Corrective Action: {Mandy Stanley and Jennifer Vote.} Anticipated Completion Date: {Beginning with reports dated 1/1/2026 and later.}
Significant Deficiency
Significant Deficiency
Condition: Program expenses are approved via budget documents and during program director meetings. Recommendation: Any expenses that are associated with a federal grant should be approved by the appropriate program manager on an individual basis as incurred. Action Taken: All expenses are now appro...
Condition: Program expenses are approved via budget documents and during program director meetings. Recommendation: Any expenses that are associated with a federal grant should be approved by the appropriate program manager on an individual basis as incurred. Action Taken: All expenses are now approved by the appropriate supervisor on an individual basis as incurred. Company credit card purchases: As of June 2025, the organization is utililizing an online credit card reporting system that requires supervisors to review and approve purchases. Check requests, mileage and personal expenses: As of September 2025, the organization is requiring that all requests go to the supervisor, which are then reviewed and forwarded to bookkeeping, together with an approval statement, for processing.
Finding 2024-005- Suspension and Debarment Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Respo...
Finding 2024-005- Suspension and Debarment Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All contracts over $25,000 will now include a Suspension and Debarment Clause. Anticipated Completion Date: Immediately
Finding 2024-003- Allowable Activities and Allowable Cost Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Activities allowed or unallowed and allowable cost/cost principles. Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Emai...
Finding 2024-003- Allowable Activities and Allowable Cost Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Activities allowed or unallowed and allowable cost/cost principles. Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Claims for ARPA monies will be reviewed to confirm it is allowable. Anticipated Completion Date: Immediately
View Audit 368998 Questioned Costs: $1
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of ...
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of Responsible O􀆯icials: We concur with the findings. Description of Corrective Action Plan: The Grant Administrator will monitor all claims that will be used for the quarter and send them to the reporting agent to report after the quarter ends. She will be diligent to track any claims coming in outside of that quarter so that reporting is accurate. She will provide the reporting agent with all claims relevant to that quarter’s report. Anticipated Completion Date: This will be done quarterly starting with the quarter ending on September 30th, 2025. The Grant Administrator will submit these claims to the reporting agent one week after the quarter ends. The Financial Administrator will sign o􀆯 on the LOW report to verify the claims match.
Finding 2024-002: Allowable Costs Condition: The Organization did not allocate shared costs appropriately between program and non-program related activities, resulting in approximately $15,078.56 in costs charged incorrectly to the Weatherization Assistance Program. Corrective Action: Management has...
Finding 2024-002: Allowable Costs Condition: The Organization did not allocate shared costs appropriately between program and non-program related activities, resulting in approximately $15,078.56 in costs charged incorrectly to the Weatherization Assistance Program. Corrective Action: Management has developed and implemented a cost allocation methodology consistent with 2 CFR 200.400. Beginning in 2025, costs will be allocated between programs (Weatherization Assistance Program and others) based on employee time distribution. This allocation policy will be documented and reviewed annually. Staff involved will be trained to ensure consistent application of cost allocation procedures. Responsible Party: Program/Fiscal Director
ALLOWABLE COSTS Recommendation: The County should review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response t...
ALLOWABLE COSTS Recommendation: The County should review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2025
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025
View Audit 368884 Questioned Costs: $1
Contact Person(s): Bridgette Zappacosta, CFO Corrective Action Planned: Management concurs with the finding. We acknowledge that expenditures were charged outside of the applicable award period due to timing of invoice receipt and data entry errors. The Organization has reviewed its internal control...
Contact Person(s): Bridgette Zappacosta, CFO Corrective Action Planned: Management concurs with the finding. We acknowledge that expenditures were charged outside of the applicable award period due to timing of invoice receipt and data entry errors. The Organization has reviewed its internal controls and will strengthen procedures to ensure compliance with federal requirements. Specifically, we are revising our grant expenditure procedures, implementing new software which includes additional review controls and is specific to grant reporting, and providing targeted staff training on period of performance compliance. We will also perform quarterly monitoring of federal award expenditures to verify compliance. Anticipated Completion Date: December 31, 2025
View Audit 368884 Questioned Costs: $1
Condition Found During allowable cost testing, we noted that there was a lack of internal control over allowable costs. We noted items that did not include proper support, were outside the contract period, or were for the incorrect amount. Corrective Action Plan Continue to verify for every federal ...
Condition Found During allowable cost testing, we noted that there was a lack of internal control over allowable costs. We noted items that did not include proper support, were outside the contract period, or were for the incorrect amount. Corrective Action Plan Continue to verify for every federal charge: allowability, allocability, reasonableness, consistent treatment, and compliance with period of performance. Require source documentation supporting the nature, amount, and purpose. Responsible Person for Corrective Action Plan The Controller for Mission Edge San Diego and Accounting personnel. Implementation of Corrective Action Plan Policy adoption within 30 days of report. Management’s Statement of Concurrence Mission Edge concurs with the findings and has initiated the corrective actions described herein. Management is committed to timely implementation, continuous monitoring, and transparent communication with the pass-through entity, federal agencies, and auditors as required.
Condition Found During allowable cost testing, it was noted that one of the contracts with the vendors included a rate that exceeded the rate cap without prior approval. Upon inquiry no prior approval was obtained. Corrective Action Plan Before execution, route all vendor and subrecipient agreements...
Condition Found During allowable cost testing, it was noted that one of the contracts with the vendors included a rate that exceeded the rate cap without prior approval. Upon inquiry no prior approval was obtained. Corrective Action Plan Before execution, route all vendor and subrecipient agreements funded by federal awards to Controller/Accounting for verification of allowability, rate caps, prior approvals, and special terms. Additional review during the A/P process ensures compliance. Responsible Person for Corrective Action Plan The Controller for Mission Edge San Diego and Accounting personnel. Implementation of Corrective Action Plan Policy adoption within 30 days of report.
View Audit 368823 Questioned Costs: $1
Finding 1156477 (2024-002)
Material Weakness 2024
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.
U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee sp...
U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by tracking and recording the actual hours each employee, regardless of position, spends working on each grant, on their time sheet or with a specific grant code, that specifies how many hours per day were spent on each federal and nonfederal activity. Alternatively, EFN can implement an after-the-fact review procedure to ensure the proper allocation of payroll expenditures to Federal and non-Federal awards, in accordance with 2 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Emergency Food Network (EFN) engaged a new audit firm for the 2024 audit. Before this year the EFN audit was administered by Johnson, Stone Pagano for 9 years. No deficiencies were previously reported or identified during those audits regarding time estimates for employees used for allocations including most of those specifically identified funding sources. In response to the 2024 audit finding by Clifton Larson Allen (CLA) in July of 2025, when the audit was conducted, EFN implemented an immediate individual employee time study that was approved by CLA to meet the recommendation. This time study methodology will be implemented twice per year on an ongoing basis with records retained and available for future audit verification. EFN has received written response from CLA that implementing this method meets all the requested requirements to be in compliance and mitigate future findings on this issue. Name of the contact person responsible for corrective action: Michelle Douglas, CEO Planned completion date for corrective action plan: August 2025 If anyone has questions regarding this plan, please call Michelle Douglas, CEO, at 253-208- 2962.
View Audit 368815 Questioned Costs: $1
We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.
We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.
View Audit 368800 Questioned Costs: $1
Personnel Responsible for the Corrective Action Plan: Darlene Sowell, President/CEO Anticipated Completion Date: December 31, 2025 Corrective Action Plan: Unleashing Potential will modify its internal procedures to track actual hours devoted to the program and perform a monthly review of actual hour...
Personnel Responsible for the Corrective Action Plan: Darlene Sowell, President/CEO Anticipated Completion Date: December 31, 2025 Corrective Action Plan: Unleashing Potential will modify its internal procedures to track actual hours devoted to the program and perform a monthly review of actual hours incurred compared to the estimated amounts by individuals assigned to federal grant programs prior to requesting reimbursement from the funding course. The review will be performed by an individual other than the preparer of the reimbursement request, with knowledge of the federal grant program and will be formally documented.
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of co...
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of contracting with a third-party vendor to complete its annual inspections, including HOME inspections for 2025. The contractor will inspect HUD’s NSPIRE level. With this additional support, OH anticipates it will have the capacity to see that corrections have been completed and documented consistent with the HOME program requirements.
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