Corrective Action Plans

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2024-006 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: As of August 2026, KCR has begun reconciling the bank account statements each month. As part of the reconciliation process, the finance team is reviewing all outstanding checks/payments and fo...
2024-006 Significant Deficiency in Internal Control and Compliance over Major Programs Management Response: As of August 2026, KCR has begun reconciling the bank account statements each month. As part of the reconciliation process, the finance team is reviewing all outstanding checks/payments and following up with vendors to confirm if the check/payment needs to be voided and resubmitted. KCR is also paying special attention to any check/payment that is being expensed to a federal program, ensuring that only checks/payments that have been negotiated with the bank are refunded by federal awards. Staff responsible: CFO Irmgard Davis irmgardd@kcr.org.
Toledo Northwestern Ohio Food Bank, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Organization Contact Person: James Caldw...
Toledo Northwestern Ohio Food Bank, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Organization Contact Person: James Caldwell, Preside nt/ CEO The findings from the December 31, 2024 schedule offindings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedu le. Financial Statement Findings 2024-001 - Material Journal Entries Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Anticipated Completion Date: February 2025 2024-002 - Timeliness of Bank Reconciliations Responsible Party: Director of Operation s an d third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Completion Date: February 2025 Federal Award Findings 2024-003 - Written Policies and Procedures Responsible Party: Director of Operations and third-party accountantAction to be Taken: Management agr ees with the finding, and we have implemented such a policy. Completion Date: May 14, 2025 2024 -004 - Timeliness of Reporting Audited Financial Statements and Federal Awards Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the findin g, and are in the process of catching up with the reporting of audited financial data and federa l awards. Anticipated Completion Date: June 30, 2026 2024-005 - Timeliness of Reporting Required under Funding Agreements Responsible Party: Director of Operations and third-party accountant Action to be Take n: Management agrees with the finding, and are in the process of implementing a policy to ensure timely reporting of financia l and programmatic data as stipulated by federal funding agreements. Anticipated Completion Date: June 30, 2026
Toledo Northwestern Ohio Food Bank, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Organization Contact Person: James Caldw...
Toledo Northwestern Ohio Food Bank, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Auditor: Maner Costerisan 2425 E. Grand River Avenue, Suite 1 Lansing, MI 48912 Audit Period: Year ended December 31, 2024 Organization Contact Person: James Caldwell, Preside nt/ CEO The findings from the December 31, 2024 schedule offindings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedu le. Financial Statement Findings 2024-001 - Material Journal Entries Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Anticipated Completion Date: February 2025 2024-002 - Timeliness of Bank Reconciliations Responsible Party: Director of Operation s an d third-party accountant Action to be Taken: Management agrees with the finding, and we have implemented such a policy. Completion Date: February 2025 Federal Award Findings 2024-003 - Written Policies and Procedures Responsible Party: Director of Operations and third-party accountantAction to be Taken: Management agr ees with the finding, and we have implemented such a policy. Completion Date: May 14, 2025 2024 -004 - Timeliness of Reporting Audited Financial Statements and Federal Awards Responsible Party: Director of Operations and third-party accountant Action to be Taken: Management agrees with the findin g, and are in the process of catching up with the reporting of audited financial data and federa l awards. Anticipated Completion Date: June 30, 2026 2024-005 - Timeliness of Reporting Required under Funding Agreements Responsible Party: Director of Operations and third-party accountant Action to be Take n: Management agrees with the finding, and are in the process of implementing a policy to ensure timely reporting of financia l and programmatic data as stipulated by federal funding agreements. Anticipated Completion Date: June 30, 2026
Matching Recommendation: Recommended Recovery Connections of Central Florida, Inc. create formal procedures to track grant matching and ensure that there is a monthly review of matching requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Act...
Matching Recommendation: Recommended Recovery Connections of Central Florida, Inc. create formal procedures to track grant matching and ensure that there is a monthly review of matching requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will review each agreement to confirm the matching requirements that must be followed. A designated team member will be responsible for tracking compliance with the required match. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026
State Opioid Response Discretionary Grant-Assistance Listing No. 93.788 Allowable Costs, Period of Performance, and Cash Management Recommendation: Recommended Recovery Connections of Central Florida, Inc. maintain a copy of all contracts, documentation of disbursement approval and supporting docume...
State Opioid Response Discretionary Grant-Assistance Listing No. 93.788 Allowable Costs, Period of Performance, and Cash Management Recommendation: Recommended Recovery Connections of Central Florida, Inc. maintain a copy of all contracts, documentation of disbursement approval and supporting documentation of costs included within requests for payment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will implement a more structured process for documenting the approval of disbursements. This includes ensuring that all underlying contracts are maintained and disbursements are formally approved by the appropriate authority within the organization. We will also maintain a written record of the approval, including the name of the individual who authorized the disbursement and the date of approval, includin the name of the individual who authorized the disbursement and the date of the approval. Name(s) of the contact person(s) responsible for corrective action: George Margoles Planned completion date for corrective action plan: December 31, 2026
ECO has had re-organization within the management team during 2024. During the time of transition few items including cost allocation and indirect cost management were lost in the shuffle. The management team recognizes the high priority to maintain supporting documents for all charges, including ti...
ECO has had re-organization within the management team during 2024. During the time of transition few items including cost allocation and indirect cost management were lost in the shuffle. The management team recognizes the high priority to maintain supporting documents for all charges, including timesheets, and supporting documentation for manual adjustments. The Executive Director and Finance Manager are responsible for this corrective action.
The current Board of County Commissioners acknowledges the finding. The Board is committed to strengthening written procedures related io federal grant administration, including allowable costs, procurement requirements, reporting, and compliance monitoring. Additional review processes will continue...
The current Board of County Commissioners acknowledges the finding. The Board is committed to strengthening written procedures related io federal grant administration, including allowable costs, procurement requirements, reporting, and compliance monitoring. Additional review processes will continue to be implemented to improve oversight and documentation.
The current Board of County Commissioners acknowledges the finding. The Board will continue strengthening grant administration procedures and compliance monitoring related to federal programs. Additional review procedures Will be utilized to ensure federal expenditures and reporting requirements are...
The current Board of County Commissioners acknowledges the finding. The Board will continue strengthening grant administration procedures and compliance monitoring related to federal programs. Additional review procedures Will be utilized to ensure federal expenditures and reporting requirements are adequately documented and reviewed.
The current Board of County Commissioners acknowledges the finding. While portions of this finding relate to prior fiscal years, the current Board is committed to strengthening county-wide internal controls over federal programs. The Board has reviewed the audit recommendations and will continue imp...
The current Board of County Commissioners acknowledges the finding. While portions of this finding relate to prior fiscal years, the current Board is committed to strengthening county-wide internal controls over federal programs. The Board has reviewed the audit recommendations and will continue implementing procedures addressing risk assessment, communication, monitoring, and compliance oversight for federal grants.
The current Board of County Commissioners acknowledges the finding, and I will continue efforts to establish and document county-wide internal controls for federal grant programs, including LATCF.
The current Board of County Commissioners acknowledges the finding, and I will continue efforts to establish and document county-wide internal controls for federal grant programs, including LATCF.
Finding 2024-002 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Head Start Cluster AL# 93.600 Management agrees with this finding, and in the future will ensure to consistently report expenses in accordance with the documented allocation process. Responsible Official: Macey Brin...
Finding 2024-002 Activities Allowed or Unallowed and Allowable Costs/Cost Principles Head Start Cluster AL# 93.600 Management agrees with this finding, and in the future will ensure to consistently report expenses in accordance with the documented allocation process. Responsible Official: Macey Brinich Anticipated Resolution Date: Immediately
Finding 2024-007 – Lack of Separate Bank Account for Restricted Federal Cash Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will establish a separate bank account for restricted federal loan proceeds or implement a general ledger mechanism to ensure proper t...
Finding 2024-007 – Lack of Separate Bank Account for Restricted Federal Cash Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will establish a separate bank account for restricted federal loan proceeds or implement a general ledger mechanism to ensure proper tracking and reconciliation. Anticipated Completion Date: March 31, 2026
Finding 2024-006 – Deficiencies in Disbursement Procedures and Documentation Retention Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will implement formal procedures for disbursement review, approval, and documentation. Staff will be trained on federal docu...
Finding 2024-006 – Deficiencies in Disbursement Procedures and Documentation Retention Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will implement formal procedures for disbursement review, approval, and documentation. Staff will be trained on federal documentation and record retention requirements. Anticipated Completion Date: March 31, 2026
Finding 2024-005 – Lack of Written Policies Required by the Uniform Grant Guidance Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will develop and adopt written policies and procedures to comply with Uniform Guidance requirements, including internal controls...
Finding 2024-005 – Lack of Written Policies Required by the Uniform Grant Guidance Contact Person: Gary Kloosterman, Village Manager Planned Corrective Action: The Village will develop and adopt written policies and procedures to comply with Uniform Guidance requirements, including internal controls, procurement, cash management, and allowable costs. Anticipated Completion Date: March 31, 2026
Finding 2024‐002 ‐ Allowable Costs and Activities Payroll Documentation Management response. Management acknowledges the need for the grant file to clearly demonstrate the basis for payroll allocations and the final amount charged to and paid from the federal award. The corrective action focuses on ...
Finding 2024‐002 ‐ Allowable Costs and Activities Payroll Documentation Management response. Management acknowledges the need for the grant file to clearly demonstrate the basis for payroll allocations and the final amount charged to and paid from the federal award. The corrective action focuses on the completeness and traceability of payroll and time‐and‐effort support; it is not an admission that the underlying services were not performed or that the costs were otherwise unallowable. Corrective action already implemented / being implemented. The Foundation is implementing the federal grant tracking, payroll allocation, time‐and‐effort support, and grant reimbursement documentation procedures contained in the Foundation Financial & Procurement Manual. The control framework includes: Maintaining grant‐specific accounting records that identify payroll costs, related fringe benefits, and other amounts charged to each federal award. Retaining payroll registers, time‐and‐effort or other personnel activity records, allocation calculations, and evidence of the work performed for the applicable period. Preparing a reconciliation that traces the approved allocation methodology from payroll records to the general ledger, the grant reimbursement request, and the amount ultimately charged to the award. Requiring documented management review of the allocation and reimbursement support before submission or posting, with corrections retained as part of the grant file. Retaining payroll and grant reimbursement support in accordance with applicable federal and organizational record‐retention requirements.
AIRS management will work with ADES to gain access to the ARRPODS data. AIRS will also begin to keep records outside of ADES systems.
AIRS management will work with ADES to gain access to the ARRPODS data. AIRS will also begin to keep records outside of ADES systems.
Management agrees with the finding. Management has downloaded 2 CFR Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly.
Management agrees with the finding. Management has downloaded 2 CFR Part 200 for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly.
Management agrees with the finding. Management has downloaded 2 CFR Part 200, section 200.318(i) for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly.
Management agrees with the finding. Management has downloaded 2 CFR Part 200, section 200.318(i) for review and to familiarize. Assistance has been requested to develop additional policies in accordance with the Uniform Guidance. Policies will be reviewed and approved by the Board regularly.
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures...
AUDIT FINDINGS 2024-001: In one of 25 selections for testwork over period of performance, expenditures related to contract labor were submitted for reimbursement to the Federal Emergency Management Agency (FEMA) that were outside of the project period. Further, the review performed over expenditures was not completed appropriately to identify this error, this is an instance of the District’s internal control not operating as designed. Name of Contact Person: Daria Heimerman, Director of Financial Reporting, dtheimerman@evergreenhealthcare.org Corrective Action Planned: Assess process and controls for improvements to identify expenditures incurred outside of the designated project period. Anticipated Completion Date: August 2025 Statement of Concurrence or Nonconcurrence: Management concurs with audit finding 2024-001.
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: During testing, we noted the following: 21.027 • 1 of 11 Non-IDC Individually Important Items (IIIs) did not have an indication ...
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1034 Condition: During testing, we noted the following: 21.027 • 1 of 11 Non-IDC Individually Important Items (IIIs) did not have an indication of review/approval of a journal entry (JE) reallocating funds from the program. • 2 of 2 IDC IIIs did not have indication of review/approval on the indirect cost allocation JE. 93.445 • 5 of 7 Non-IDC IIIs had no purchase requisition documentation provided. • 1of 1 IDC IIIs did not have indication of review/approval on the indirect cost allocation JE. 11.029 • 7 of 11 IIIs had no purchase requisition documentation provided. Corrective Action: Review and authorization procedures will be implemented for purchase orders and journal vouchers requiring an authorizing signature prior to processing. Anticipated date of completion: November 30, 2026.
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1035 Condition: During testing, we noted the following: 93.445 • For 2 of 2 samples, we were not provided documentation to verify that the expen...
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1035 Condition: During testing, we noted the following: 93.445 • For 2 of 2 samples, we were not provided documentation to verify that the expenditures were incurred prior to the date of the reimbursement request. • For 2 of 2 samples, there was no documentation of review and approval of the reimbursement requests. Corrective Action: Review and authorization procedures will be implemented for reimbursement requests requiring an authorizing signature prior to processing. This authorization will ensure the expenditures have been validly and correctly incurred and are eligible for reimbursement. Anticipated date of completion: November 30, 2026.
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1036 Condition: During testing, we noted the following: 21.027 • The Tribe was unable to provide documentation demonstrating that the required A...
Person responsible for corrective action plan: Stacey Mike, Interim Tribal Chair Marjianne Yonge, Tribal Treasurer PO Box 747 Lone Pine, CA 93545 (760) 876-1036 Condition: During testing, we noted the following: 21.027 • The Tribe was unable to provide documentation demonstrating that the required Annual Project and Expenditure Report was prepared and submitted. Additionally, the Tribe was unable to provide documentation supporting the calculation of revenue loss used to support expenditures reported under the revenue replacement provision. Corrective Action: Documentation shall be kept to verify timely submission of the Annual Project and Expenditure Report as well as the supporting calculations. Anticipated date of completion: November 30, 2026.
The City of Redmond takes seriously its responsibility to administer federal funds in compliance with the Uniform Guidance (2 CFR Part 200) and acknowledges the findings identified in this audit related to suspension and debarment verification, SLFRF reporting accuracy, and subrecipient monitoring. ...
The City of Redmond takes seriously its responsibility to administer federal funds in compliance with the Uniform Guidance (2 CFR Part 200) and acknowledges the findings identified in this audit related to suspension and debarment verification, SLFRF reporting accuracy, and subrecipient monitoring. The City has reviewed each finding, confirmed the underlying facts, and taken corrective action to address both the specific instances identified and the broader control gaps that enabled them. Independent of this audit, the City had already begun a citywide effort in 2025 to strengthen its grant management practices. This effort produced a new Grant Management Policy and Procedure Manual and accompanying Standard Operating Procedures (SOPs), which leadership approved and published citywide in April 2026. Every department attended an in-person presentation on the new policy and received training on available grant management resources. The SOPs set minimum standards for procurement; suspension/debarment verification; monitoring, reconciliation of allowable costs, and subrecipient monitoring; and grant reporting — directly addressing the root causes identified in this audit. In 2025 and 2026, the City also created and filled new positions to centralize grant management functions citywide, adding a required second-party review of progress reports and reimbursement requests before submission to funding agencies. The City views the specific instances identified in this audit as isolated gaps that existed prior to these citywide improvements, and believes the policy, staffing, and procedural changes described below directly resolve them. Suspension and Debarment The City's standard contract templates for federally funded procurements include suspension and debarment verification requirements, and this requirement applied to all applicable City contracts except the design contract at issue, where the verification was not completed and documented 76 days after the contract's effective date. The City has since confirmed the contractor was not suspended, debarred, or otherwise excluded during the relevant period, and no federal funds were paid to an ineligible party. • Added a required step to the contract routing process to verify completion of the debarment check and attach verification documentation before a contract proceeds. • Confirmed debarment verification is included on applicable checklists for all work involving labor and/or federal funding of $25,000 or more, and re-emphasized to staff the requirement to complete and retain this verification before contract execution and fund disbursement. • Both Finance and Capital Projects have been made aware of this error. Capital Projects has confirmed its understanding that the SAM.gov check must be completed and documented before finalizing any applicable contract. • Finance is revising the contract routing form to add a required field confirming whether a contract will be paid partially or fully with grant funds, alerting Purchasing and Accounts Payable to confirm that verification was completed before any payment is released. • The new citywide SOPs define the required timing for suspension/debarment checks, closing the procedural gap that allowed this contract to proceed without documented, timely verification. • The City will update agreement boilerplates to require vendors to attest that they are not debarred. This will supplement the City's existing verification process performed before contract execution and fund disbursement. Reporting During 2025, City staff began developing a citywide Grant Management Policy and Procedure Manual and accompanying Standard Operating Procedures (SOPs) to strengthen the City's compliance with federal grant requirements. The manual was approved by leadership and published citywide in April 2026. Every department attended an in-person presentation on the new policy, along with training on how to access additional grant management resources. The new SOPs establish specific standards for grant reporting, including required reconciliation practices and review procedures intended to prevent the type of discrepancies identified in this finding. In 2025 and 2026, the City created and filled new positions to centralize grant management functions citywide. These positions are responsible for tracking grant deadlines and providing a required second-party review of progress reports and reimbursement requests before they are submitted to funding agencies. The City views this finding as an isolated gap that predates these citywide improvements and believes the staffing and procedural changes described below directly address the identified root cause. Corrective Action Taken • New centralized grant management positions now review and approve all progress reports and reimbursement requests before submission to the funding agency, ensuring a required two-party review of all external reporting. • The new SOPs require staff to reconcile grant transactions multiple times throughout the year, rather than solely at year-end, so discrepancies are identified and corrected well before reporting deadlines. Subrecipient Monitoring The City's subrecipient monitoring procedures required subrecipients to submit financial statements or Single Audit reports only during the initial application year and did not include a documented process for annual verification in subsequent years. As a result, for the six subrecipients tested, the City could not confirm whether required Single Audits were received or whether applicable audit findings had been addressed in the years following the first year of the subaward agreement Corrective Action Taken • Staff who manage subawards have completed additional training on subrecipient monitoring requirements, including verification of Single Audit compliance. • Staff who manage subawards will update the sub-monitoring checklist to include “Single Audit” as part of the update every year. • Revised risk assessment tools now specify a minimum required frequency for completing subrecipient risk assessments and reviewing subrecipient financial reports. • The new citywide SOPs establish a defined minimum frequency for subrecipient monitoring activities, including annual verification of Single Audit status for all active subrecipients.
Allowable Costs - HCVP Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to review both cash disbursements and payroll disbursements for all program expenditures. Explanation of disagreement with audit finding: ...
Allowable Costs - HCVP Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Recommendation: We recommend that the Authority designate an individual to review both cash disbursements and payroll disbursements for all program expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2025, the HA hired the financial consulting firm of Kubas Keller and Associates. They have vast experience with HA’s all around the country and will work with staff and possibly a new CFO to ensure that all program expenditures are recorded and allocated in an appropriate manner based on actual work performed. Name(s) of the contact person(s) responsible for corrective action: Tony Palmer, CPA Kubas Keller and Associates Planned completion date for corrective action plan: April 2025.
Interfund Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Public Housing Operating Fund – Assistance Listing No. 14.850 Recommendation: We recommend management should create processes to track interfunds and transfers as well as designate an individual to review and approve these ...
Interfund Housing Voucher Cluster – Assistance Listing No. 14.871 and 14.879 Public Housing Operating Fund – Assistance Listing No. 14.850 Recommendation: We recommend management should create processes to track interfunds and transfers as well as designate an individual to review and approve these transactions. Additionally, the Authority should begin the process of reimbursing the respective programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In April 2025, the HA hired the financial consulting firm of Kubas Keller and Associates. They have vast experience with HA’s all around the country and will work with staff and possibly a new CFO to ensure if interfunds and transfers are properly tracked and eliminated on the financials. This includes reviewing past transactions and correcting them in FY 2026. Name(s) of the contact person(s) responsible for corrective action: Tony Palmer, CPA Kubas Keller and Associates Planned completion date for corrective action plan: June 2026.
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