Corrective Action Plans

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Views of Responsible Officials and Planned Corrective Actions: ATS has drafted an organization-wide procurement policy to ensure it includes all the Uniform guidance procurement elements. The draft will be reviewed by senior management for comment prior to formal issuance.
Views of Responsible Officials and Planned Corrective Actions: ATS has drafted an organization-wide procurement policy to ensure it includes all the Uniform guidance procurement elements. The draft will be reviewed by senior management for comment prior to formal issuance.
Views of Responsible Officials and Planned Corrective Actions: The Finance Department will ensure an accurate SEFA in conjunction with the response for Finding 2024-002.
Views of Responsible Officials and Planned Corrective Actions: The Finance Department will ensure an accurate SEFA in conjunction with the response for Finding 2024-002.
Response: MSP plans to implement changes overall to timekeeping processes to ensure that payroll costs accurately reflect the work performed and to reconcile and true up any budget estimates on a consistent basis.
Response: MSP plans to implement changes overall to timekeeping processes to ensure that payroll costs accurately reflect the work performed and to reconcile and true up any budget estimates on a consistent basis.
Finding Number: 2024-009 Planned Corrective Action: The district will implement enhanced procedures for monitoring and tracking federal grant expenditures to ensure expenditures do not exceed awarded grant amounts and are properly reported. The Treasurer will review grant agreements, monitor availab...
Finding Number: 2024-009 Planned Corrective Action: The district will implement enhanced procedures for monitoring and tracking federal grant expenditures to ensure expenditures do not exceed awarded grant amounts and are properly reported. The Treasurer will review grant agreements, monitor available grant balances on a regular basis, and maintain supporting documentation for all federal expenditures and reporting to ensure compliance with federal requirements and accurate reporting on the Schedule of Expenditures of Federal Awards. At the time of the creation of this corrective action plan all COVID-19 related grants have been totally expended. The district is required to provide the board, ODEW, and the Financial Planning Commission with monthly monitoring documents. Within these documents is contained a worksheet that requires the treasurer to list each fund balance for all accounts and explain any negative balances and whether a PCR has been created to eliminate negative balances. This policy forces the district to pay close attention to any grant funds that are carrying negative balances. Anticipated Completion Date: 05/31/2026 Responsible Contact Person: Ashley Miller
Finding 2023-006 ● Criteria or Specific Requirement: 2 CFR Section 200.403 states the factors that determine allowability of costs charged to federal awards and requires costs to be determined in accordance with generally accepted accounting principles. ● Condition: We identified costs incurred in 2...
Finding 2023-006 ● Criteria or Specific Requirement: 2 CFR Section 200.403 states the factors that determine allowability of costs charged to federal awards and requires costs to be determined in accordance with generally accepted accounting principles. ● Condition: We identified costs incurred in 2023 that were incorrectly recorded as 2024 costs and charged to federal awards. ● Corrective Action Plan: Management agrees with the finding and they will evaluate our findings to determine an appropriate corrective action. After evaluation, Glacierland will designate specific tasks to the ‘Bookkeeper’ and ‘Executive Assistant’. These tasks will be reviewed by one another and the Executive Director. Creation of these two roles and review procedures will allow for increased internal controls to ensure costs are recorded in accordance with GAAP. Contact Person: Kirsten Jurcek Anticipated Date of Completion: September 1, 2026
Finding 2023-005 ● Condition: There are no written policies and procedures for allowable costs/cost principles, cash management, procurement and suspension and debarment requirements. ● Cause: The Organization does not have a process for reviewing their accounting policies and procedures manual on a...
Finding 2023-005 ● Condition: There are no written policies and procedures for allowable costs/cost principles, cash management, procurement and suspension and debarment requirements. ● Cause: The Organization does not have a process for reviewing their accounting policies and procedures manual on a regular basis to ensure written procedures conform to Uniform Guidance requirements. ● Corrective Action Plan: Management agrees with the finding and they will evaluate our findings to determine an appropriate corrective action. Financial policies and procedures will be created and implemented. Annual schedule of expenditures will be created by Executive Director or Bookkeeper and reviewed by Board of Directors. Contact Person: Kirsten Jurcek Anticipated Date of Completion: September 1, 2026
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. W...
Significant Deficiency Finding Number: 2024-003 Federal Award Finding and Questioned Costs Corrective Action Plan The City will evaluate their processes and procedures over internal controls to ensure that all employee rate changes and payroll registers are appropriately documented and maintained. While we maintain that oversight was in place, we concur with the finding and have identified the responsibility of the process to be placed on the finance department's fiscal assistants. The lack of documented review of the reporting process is noted, and procedures are now in place for documentation of the review and approval of the data as it is reported on portals as required. The Finance Officer will direct an accountant on staff or a professional consultant to complete the preparation of the reporting so that he/she can review and authorize the submission of reports. The implementation of upgraded software and strengthened internal control policies and procedures is a priority. Anticipated Completion Date September 30, 2026 Responsible Party The Finance Officer
Corrective Action Planned: Management acknowledges the finding related to the lack of formal documentation maintained evidencing a hindsight review of employee working hours to verify alignment between actual hours. The Effort Reporting requirement is now met with a revamped process that includes an...
Corrective Action Planned: Management acknowledges the finding related to the lack of formal documentation maintained evidencing a hindsight review of employee working hours to verify alignment between actual hours. The Effort Reporting requirement is now met with a revamped process that includes an updated institutional effort reporting policy and development of a newly developed effort reporting workflow that aligned with the relatively recent (April 2024) implementation of new ERP system Oracle. This new process applies to those team members who have effort either charged, in-kind or cost-shared, to a grant funded project. The new Effort Reporting workflow formally went live institution wide on 10/1/25, with a pilot implementation done in September 2025. Effort reporting is conducted monthly and requires a preview of all team members with effort allocated to grants from an automated report. Each report is reviewed for accuracy and then each line item is entered into a Smartsheet format for automated delivery of an individual effort report to each team member. A mid-month report is automated to flag and identify upcoming end dates of grant funding in preparation of the next month effort report. This midmonth review is necessary to adjust for any edits needed in preparation for the next month effort report workflow. In addition, the new process allows for follow up with escalation if individual effort report(s) are not signed by respective team member(s) within the prescribed monthly due date. Name(s) of Contact Person(s) Responsible for Corrective Action: Kimberly Davey, Director Office for Sponsored Programs Anticipated Completion Date: Completion 9/30/2025, active as of 10/01/2025
Recommendation: The Organization should reinforce its policies and procedures in regards to record keeping. Responsible Officials' Response: We agree and will make sure that all percentage allocations are properly verified and maintained in a separate ledger for reconciliations.
Recommendation: The Organization should reinforce its policies and procedures in regards to record keeping. Responsible Officials' Response: We agree and will make sure that all percentage allocations are properly verified and maintained in a separate ledger for reconciliations.
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding. The delayed submission of the Data Collection Form and reporting package was primarily the result of an extended audit timeline caused by the transition to a new audit firm. In addition, delays ...
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding. The delayed submission of the Data Collection Form and reporting package was primarily the result of an extended audit timeline caused by the transition to a new audit firm. In addition, delays associated with the completion of prior audit matters and the new auditor's initial review process contributed to the timing of the final audit report and subsequent FAC submission. Since that time, the Organization has hired a new auditor, improved internal closing procedures, and implemented enhanced monitoring of audit and federal reporting deadlines. Management is committed to timely compliance with all Uniform Guidance reporting requirements and believes these improvements will help prevent future delays. PROPOSED COMPLETION DATE: May 30, 2026
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Or...
NAME OF CONTACT: Terri Brown, Director of Finance CORRECTIVE ACTION: Management acknowledges the finding; however, it is important to clarify that the circumstances leading to the deficiency were significantly impacted by delated and unresponsive actions from the federal agency. Specifically, the Organization submitted required reports and sought timely guidance and approvals from the federal agency, but responses were not received within the federal deadlines. These delays were outside of the Organization’s control and directly affected the timely reconciliation and finalization of reported amounts. Notably, the federal government has acknowledged delayed reports and there were no findings in their FY24 audit. Management will continue to improve internal controls and documentation practices while also documenting all federal communications and follow-up efforts to document the impact of future federal delays. PROPOSED COMPLETION DATE: Implemented and Ongoing
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls o...
The agency proactively enacted rigorous internal controls and systemic enhancements for FY25 to ensure optimal oversight and adherence to federal guidelines. Management has addressed this recommendation by deploying a strict, comprehensive expense request process to ensure robust internal controls over all Other Than Personal Services (OTPS) expenditures. To ensure full compliance with 2 CFR 200.303 and 200.403, Finance has deployed the following enhancements to our accounts payable workflows: • Strict Electronic Approval Workflow: Finance has established a stringent review and approval protocol that requires direct involvement from Program Directors and Department Heads. All OTPS expenditures are now routed through a formalized electronic workflow, which mandates documented review and secure electronic signatures from authorized leadership prior to any payment processing. • System-Integrated Documentation: The new process strictly requires that all supporting documentation-including invoices, receipts, and evidence of allowability-be provided upfront. These documents are now uploaded and attached directly to the specific transaction within the accounting program, creating a permanent, easily accessible, and audit-ready trail for every federal charge. • Targeted Training and Oversight: To support this modernized workflow, Finance is providing targeted training to all staff responsible for initiating and approving transactions, ensuring a clear understanding of Uniform Guidance requirements. Furthermore, Finance leadership conducts periodic supervisory reviews directly within the accounting system to verify that all electronic approvals are captured and source documents are properly attached.
Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. F...
Management has reviewed the finding, noting the inherent complexity of time allocation in our operational environment. Because our personnel routinely serve multiple clients simultaneously across various federal grants, tracking exact hours per case presents a significant administrative challenge. Furthermore, the delayed receipt of the FY23 audit-delivered post-FY24-precluded the implementation of procedural adjustments during the audited timeframe. To address our operational realities and ensure strict, ongoing adherence to 2 CFR § 200.430, the agency immediately instituted systemic enhancements for FY25. The Organization has transitioned all time tracking to a streamlined, system-driven process within our UKG platform: • Integrated UKG Time Tracking and Approvals: All employees are now required to punch in and out directly through the UKG system, efficiently assigning their actual hours worked to specific program and grant codes to generate functional, after-the-fact timesheets. To further streamline this documentation, the Organization is gradually transitioning our existing supervisory reviews into UKG’s electronic sign-off workflow, which will centralize our approval records and ensure accurate distribution across federal awards.
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorpor...
Management has reviewed the finding and recommendations. We note that this item was identified as a repeat issue primarily due to the timing of the prior year's audit. Because the FY23 findings were delivered after FY24 had already concluded, the Organization did not have the opportunity to incorporate the auditors' feedback during the FY24 audited period. However, the Organization took immediate, proactive steps to deploy enhanced internal controls for FY25 to ensure continuous alignment with federal standards. To ensure strict adherence to 2 CFR § 200.302(a), we are actively implementing a more regular reconciliation process between government grant revenue claimed and actual revenue earned. As a key part of this initiative, the Organization has developed and deployed new internal financial tools designed to incorporate automation into our daily workflows. By utilizing these automated tools-such as standardized templates for recording cash receipts and systematically clearing Accounts Receivable-we have significantly enhanced the accuracy of our data entries and reduced the risk of manual misstatements. Our ongoing objective is to leverage these tools to establish clear, standardized documentation procedures, ensuring that all financial reports and claims are consistently generated from a reconciled general ledger. Management remains fully committed to dedicating the necessary time and resources to mature these financial controls and ensure robust compliance with federal regulations.
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: • DNA prov...
Recommendation We recommend DNA formally respond, in detail, to all deficiencies reported in the OIG Report, including Accounting Policies and other Policies such as the Vehicle Use Policy. As the Board needs to formally adopt all revised policies as noted in the OIG Report, we recommend: • DNA provide the Board a redline copy of the changes for each revised policy, • correlate each revised policy to each finding in the OIG report and • provide the Board each related policy section guidance in the LSC Financial Guide. Management Response Corrective Action As of January 15, 2026, our accounting department is short one person and we are supporting accounting staff training needs As of January 15, 2026, management has drafted updates and received acceptance by the OIG to all but one of the policies and procedures referenced in the OIG report. Updated policies, including a revised Accounting Manual and an updated Personnel Manual presented to the Board, the Board Budget & Audit Committee and the Board Executive Committee prior to the June 2, 2025 OIG response deadline. Management acknowledges that during the 2024 audit period the Legal Services Corporation Office of Inspector General (OIG) issued a final report on December 2, 2024 noting inadequate accounting policies, practices, and oversight for the period of January 1, 2022 through April 30, 2023. Also, while many of the policies noted in the OIG report have been updated, the policies mentioned in the OIG report have not been reviewed or adopted by the Board. Three primary causes contributed to the deficiencies noted during the period under review by the OIG (January 1, 2022 through April 30, 2023), and before the issuance of the final LSC OIG report in December 2024: • Staffing shortages. For most of the January 1, 2022 to April 30, 2023 review period DNA had three vacancies in our five-person accounting operation. Additionally, our Chief Financial Officer was hired during the middle of the period under review, and even though he has extensive legal services accounting experience, he just started learning about DNA’s organizational structure and accounting practices, and refamiliarizing himself with LSC accounting policies and financial guidelines. • A change in LSC accounting standards applicable to nonprofit LSC funded organizations was implemented during the period under review which made some of our policies and procedures outdated. • Management made a strategic decision to wait for the issuance of the final OIG report to ensure that updates to policies and practices would fully align with the OIG's expectations, rather than implementing piecemeal or interim measures that might have required further revision. Due Date of Completion: February 28, 2026. Responsible Person(s) Executive Director and Chief Financial Officer
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colora...
The District acknowledges the material correction of an error to the District’s financial statements. This situation occurred due to a material weakness in internal controls over compliance with federal award requirements for the Education Stabilization Fund (CFDA 84.425U), passed through the Colorado Department of Education, for the fiscal year ended June 30, 2024. Specifically, the District lacked adequate segregation of duties over payroll and human resources processes, both of which were performed by a single employee without a secondary review. In addition, the District did not maintain adequate reimbursement request documentation or regularly reconcile ESSER grant expenditures to reimbursement requests, as required under 2 CFR 200.303. These conditions resulted in material audit 60 adjustments, significant audit delays, and the engagement of a third-party accounting firm to reconstruct grant records. Notwithstanding these control deficiencies, the District was in compliance with allowable activities, allowable costs, and cash management requirements, as allowable costs exceeded the amounts requested for reimbursement. Current management has improved procedures related to the oversight of federal grant compliance and payroll processes. The District has engaged a third-party accounting firm and hired new staff to assist with grants reconciliation, reimbursement request preparation, and internal controls over federal awards. A secondary review process has been established for payroll and human resources transactions to ensure that no single employee has unchecked control over these functions. Grant reconciliation responsibilities have been reassigned to incorporate segregation of duties, and a defined schedule for monthly ESSER reconciliations and reimbursement submissions has been implemented. We plan to have all ESSER grant activity fully reconciled, reimbursement documentation complete and available for review, and monthly reconciliation and secondary review procedures operational and documented for all applicable federal grant programs prior to the start of the audit process. Estimated date of implementation of the corrective action plan: June 30, 2026 Person responsible for implementation of the corrective action plan: Dr. Kirk Henwood
Controls Over Federal Programs Management acknowledges that documented control procedures were absent across all selections tested for federal expenditures, and that payroll allocations were not consistently reviewed or supported throughout the year. The Organization will require that all invoices c...
Controls Over Federal Programs Management acknowledges that documented control procedures were absent across all selections tested for federal expenditures, and that payroll allocations were not consistently reviewed or supported throughout the year. The Organization will require that all invoices coded to federal award programs include documentation of review, proper allocation rationale, and management approval before payment is processed. Payroll allocations will be updated in both the payroll and accounting systems on a regular basis, supported by actual time records or documented time studies rather than year-end estimates. This process has already taken place in late 2025 and the CFO and Controller will oversee the process.
2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake...
2024-004 Activities Allowed and Allowable Costs Material Weakness Corrective Action: We now have staff that will complete the TEFAP and CSFP administrative cost reimbursement report and a signoff will be completed on the day of review by management level employees. Person Responsible: Stephano Blake Email: SBlake@harvesthope.org Phone: 803-636-6635
The Parish has written a Standard Operating Procedure for "Grant Maangement - Financial Reporting & Reconciliation" which outlines the role of the Finance Department in monitoring grant activities including measures to ensure correct general ledger coding for budget planning, complete and accurate r...
The Parish has written a Standard Operating Procedure for "Grant Maangement - Financial Reporting & Reconciliation" which outlines the role of the Finance Department in monitoring grant activities including measures to ensure correct general ledger coding for budget planning, complete and accurate recording of grant expenditures and revenues, and administrative review to confirm reconciliation of grant activities against the general ledger on a monthly basis.
U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional ...
U.S. Department of Health and Human Services - Community Service Block Grant Significant Deficiency in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc. reevaluate its current process, implement proper controls and perform additional training over time and effort reporting. The Neighborhood Service Center, Inc. should not report salaries and wages unless it can substantiate that the time and effort was dedicated to the federal program. Documentation should be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Neighborhood Service, Inc. will require employees whose salaries are allocated to several funding areas to do periodic (at least 2 times per year) time studies to provide documentation to support how salaries are being allocated in the payroll system to grants and other funding areas. These documents will be signed on June 15 and December 15 of each year. Name of the contact persons responsible for corrective action: E. Yvette Robinson, Deputy Director Planned completion date for corrective action plan: For immediate implementation and ongoing.
U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation ...
U.S. Department of Health and Human Services - Community Service Block Grant Material Weakness in Internal Control over Compliance - Other Matters Recommendation: We recommend the Neighborhood Service Center, Inc require both check signers to evidence review and approval of supporting documentation prior to signing the check. Documentation of that review and approval shold be readily for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: All checks presented for signatures have supporting documentation attached. Authorized check signers are instructed to review all documentation for appropriate authorization, payee name, and amounts prior to signing checks. No checks are signed without supporting documentation. The agency will require check signers to initial the check request page or other supporting documentation when signing checks for grant expenditures. The Neighborhood Service Center, Inc. is implementing a procedure to provide the Finance Committee of the Board with a listing of all checks issued between Board meetings for their review/reference. The Finance Director keeps all check stock locked in their office to avoid any potential misuse of the check stock. Name of the contact persons responsible for corrective action: R. Andrew Hollis, Executive Director Michele Lednum, Finance Director Planned completion date for corrective action plan: For immediate implementation and ongoing.
The Organization is in the process of strengthening its documentation retention procedures to ensure all federally funded disbursements are supported by complete source documentation, including invoices, rental reasonableness forms, management approvals, non-financial support records, and executed c...
The Organization is in the process of strengthening its documentation retention procedures to ensure all federally funded disbursements are supported by complete source documentation, including invoices, rental reasonableness forms, management approvals, non-financial support records, and executed contracts. Staff have been instructed on updated filing and retention requirements, and the accounting department will perform periodic reviews to confirm that required documentation is maintained in the accounting records prior to payment.
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