Corrective Action Plans

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Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for...
Finding reference: 2024-008 - 93.224, 93.527 – Health Center Program Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is an employee that works 100% on one grant. Total working hours are recorded to the grant for this individual.
Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for emp...
Finding reference: 2024-003 - 14.218 – CDBG - Entitlement Grants Cluster Significant Deficiency and Noncompliance over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Recommendation: The department should maintain support and rationale for all allocations of payroll costs for employees charged to federal awards. Additionally, employees should earmark their timesheets with the number of hours worked on each program. Action taken: The City has moved to personnel activity reports (PARS) for timesheet reporting to ensure the allocation of the number of hours performed on each program is accurate. The only exception is when an employee works 100% on one grant. Then all working hours are recorded to the grant.
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C....
CORRECTIVE ACTION PLAN Oversight Agency for Audit: U.S. Department of Housing and Urban Development The Town of Oak Bluffs, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Name and address of independent public accounting firm: CBIZ CPAs P.C. 53 State Street, 17th Floor Boston, MA 02109 Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Financial Statement Finding 2024-001 – Document Policies and Procedures Over Federal Awards Condition: During our audit, we noted that the Town did not have formal policies and procedures in place covering the requirements of Uniform Guidance as specified in 2 CFR Part 200. Certain elements, such as procurement standards, subrecipient monitoring, internal control, and other compliance areas, were not addressed in written policies or documented procedures. Criteria: Uniform Guidance (2 CFR Part 200) requires non-federal entities administering federal awards to establish and maintain written policies and procedures to address all requirements specified in the regulations, including but not limited to internal controls, determination of allowable costs, procurement, subrecipient monitoring, financial management, and reporting. Cause: The Town has not developed comprehensive written policies and procedures to address all compliance requirements under Uniform Guidance. Effect: The absence of written policies and procedures increases the risk of noncompliance with federal requirements, reduces consistency in federal program administration, and limits transparency and accountability. Recommendation The Town should develop and implement comprehensive written policies and procedures that address all major compliance requirements under Uniform Guidance (2 CFR Part 200). Periodic review and updates should be performed to ensure ongoing compliance. Views of Responsible Officials: We have been reviewing existing workflows, and unwritten procedures, relative to our management and oversight of federal awards either received directly from the federal or from another intermediary pass-through agency. Once our review is complete, we will commit those procedures to writing and present them to the Select Boad for approval. The anticipation is that we will have documented policies and procedures, that are compliant with the Uniform Guidance, in time for the FY2026 audit.
Criteria Uniform Guidance requires management to provide reasonable assurance that federal awards are expended only for allowable activities, that the cost of goods and services charged to federal awards are allowable and in accordance with the specific cost principles, and to ensure expenditures we...
Criteria Uniform Guidance requires management to provide reasonable assurance that federal awards are expended only for allowable activities, that the cost of goods and services charged to federal awards are allowable and in accordance with the specific cost principles, and to ensure expenditures were incurred and paid prior to requesting for reimbursement. Condition The Organization lacked controls over purchasing and payments to vendors. More specifically, there was no formal process for approving invoices before payment to vendors. There is inadequate segregation of duties among those who: (1) Initiate routine transactions and (2) Review, evaluate, or approve routine transactions. There is also a lack of documentation of reviews performed and closing and reconciliation procedures. Cause The board and management of the Organization did not have adequate financial expertise to exercise effective oversight or design and implement a control environment or control activities sufficient to carry out the objectives of the Organization during the fiscal year. Effect The Organization cannot ensure that its activities and costs charged to the federal award program were allowable during the audit period conducted. Recommendation We recommend the Organization design and implement written accounting policies and procedures to formally approve invoices before payment to vendors to ensure proper segregation of duties.
RE: CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) Contact Person Responsible for Corrective Action: Coleen Laprise, Finance Director Corrective Action: The Town of Bridgton will take the following actions to address finding 2024-001: The Town of Bridgton will review and update the current Mun...
RE: CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) Contact Person Responsible for Corrective Action: Coleen Laprise, Finance Director Corrective Action: The Town of Bridgton will take the following actions to address finding 2024-001: The Town of Bridgton will review and update the current Municipal Purchasing and Sale of Supplies, Materials or Equipment Policy (Approved 9/22/2015) to fully incorporate all elements required by 2 CFR sections 200.317-200.327. We will also implement a regular review policy to ensure we remain in compliance with federal regulations and share the updated policy with all Department Heads and Foremen responsible for procurement. Anticipated Completion Date: June 30, 2026. It is our intention to have a revised, compliant document completed by the end of our fiscal year.
Management Responses: We acknowledge that prior to this audit, CASA relied on summary-level expense reports from subrecipients under the PCCD grant and did not consistently verify underlying invoices. The established oversight also included the following efforts: 1) the individual previously respons...
Management Responses: We acknowledge that prior to this audit, CASA relied on summary-level expense reports from subrecipients under the PCCD grant and did not consistently verify underlying invoices. The established oversight also included the following efforts: 1) the individual previously responsible for invoicing did review submissions for reasonableness against the approved budget, 2) subrecipients were advised to maintain detailed back-up for all expenses, and 3) the Coalition Director regularly visited subrecipient sites to observe work being completed and to meet and observe personnel covered by the grant. However, we acknowledge this process did not meet the full requirements of the Uniform Guidance. While prior audits were not performed under Government Auditing Standards , management notes that the agency has received federal funding since 2016 with no history of previous management-related findings. The identified grant in this finding was a pilot project and the first time the agency has managed subrecipients. Corrective Actions Already Taken: CASA has engaged a new contracted accounting firm with a wider breadth of experience and expertise. CASA has completed an internal restructuring to provide increased opportunity for oversight and review of contracted financial services. CASA has adopted a new review protocol requiring verification of all supporting documentation for subrecipient reimbursements. The Operations Manager now performs a detailed review of invoices, approvals, and alignment with allowable costs prior to releasing funds. Planned Actions: Subrecipient Monitoring Policy: CASA will implement a policy immediately that includes: A standardized invoice review checklist (verifying vendor, date, amount, and allowability). Documentation of management approvals and sign-offs. Monitoring visits or virtual reviews for subrecipients by Coalition Director or Operations Director. Communication: CASA will issue written guidance to all subrecipients outlining documentation requirements and timelines.
Audit Finding Reference: 2024-003 Improve Internal Controls Over Procurement Planned Corrective Action: The Town will review and revise its procurement procedures to ensure that federal requirements under the Uniform Guidance are followed for all federally funded transactions. For future federally f...
Audit Finding Reference: 2024-003 Improve Internal Controls Over Procurement Planned Corrective Action: The Town will review and revise its procurement procedures to ensure that federal requirements under the Uniform Guidance are followed for all federally funded transactions. For future federally funded contracts, the Town will maintain documentation demonstrating adherence to Uniform Guidance procurement requirements, including appropriate justifications for exemptions. The Town will ensure program staff are trained on the distinction between federal and state procurement requirements. Planned Implementation Date of Corrective Action: February 2, 2026
Audit Finding Reference: 2024-006 Improve Documentation and Controls over Allowable Costs Planned Corrective Action: The Town will implement and enforce procedures to ensure all employees whose salaries or wages are charged to federal grants maintain and retain appropriate time and effort documentat...
Audit Finding Reference: 2024-006 Improve Documentation and Controls over Allowable Costs Planned Corrective Action: The Town will implement and enforce procedures to ensure all employees whose salaries or wages are charged to federal grants maintain and retain appropriate time and effort documentation, including timesheets for hourly staff and semi-annual certifications for salaried staff, in compliance with Uniform Guidance. Management has made staff aware of the Time and Effort reporting requirements associated with Federal grants and will work with grant managers and finance department staff to ensure this requirement is implemented during Fiscal 2026; on or about March 18th.
Audit Finding Reference: 2024-005 Improve Procurement Procedures Planned Corrective Action: The Town will revise its internal controls over procurement to ensure compliance with Uniform Guidance requirements, regardless of state law exemptions. The Town will ensure adequate documentation is retained...
Audit Finding Reference: 2024-005 Improve Procurement Procedures Planned Corrective Action: The Town will revise its internal controls over procurement to ensure compliance with Uniform Guidance requirements, regardless of state law exemptions. The Town will ensure adequate documentation is retained for all federally funded procurements, and that procurement staff and grant managers are trained on the distinction between federal and state procurement requirements. Planned Implementation Date of Corrective Action: Management has made staff aware of the Federal procurement requirements associated with Federal grants and will work with grant managers, finance and procurement department staff to ensure this requirement is implemented in fiscal year 2026; on or about March 18, 2026.
This is a reiteration of Finding 2024-002. Please refer to corrective action plan under Finding 2024-002. Management will review procedures and adopt a system to adequately document and retain approval of disbursements.
This is a reiteration of Finding 2024-002. Please refer to corrective action plan under Finding 2024-002. Management will review procedures and adopt a system to adequately document and retain approval of disbursements.
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Pr...
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice a...
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.
Retain Supporting Documentation for Journal Entries (Material Weakness, Compliance Finding) Planned Corrective Action Effective March 1, 2026, the District implemented procedures requiring that all journal entries include appropriate supporting documentation prior to posting in the accounting system...
Retain Supporting Documentation for Journal Entries (Material Weakness, Compliance Finding) Planned Corrective Action Effective March 1, 2026, the District implemented procedures requiring that all journal entries include appropriate supporting documentation prior to posting in the accounting system. Supporting documentation can range from invoices, written explanations describing the purpose of the entry, and calculations. The accounting system has been changed so all entries have supervisory review and approval. The Business Offi ce has established a standardized review process to ensure journal entries affecting federal programs are properly supported and retained within the District’s fi nancial records. Documentation will be maintained electronically to ensure availability for audit and internal review. The Business Offi ce will also provide guidance to staff responsible for fi nancial reporting and grant accounting regarding the requirement to maintain adequate documentation for journal entries in accordance with Uniform Guidance fi nancial management requirements. Periodic internal reviews will be conducted to ensure compliance with these procedures. Name of Contact Person and Completion Date Nancy J. Konisky, Business Manager Completion Date: Implemented March 1, 2026
Establish dual authorization for all disbursements >$500. • Require approval documentation for all payments. • Monthly review of check registers and reconciliations by Board Treasurer or Board President. • Revise Finance Policy Manual to reflect new procedures.
Establish dual authorization for all disbursements >$500. • Require approval documentation for all payments. • Monthly review of check registers and reconciliations by Board Treasurer or Board President. • Revise Finance Policy Manual to reflect new procedures.
The Board of Directors for the district will be monitoring all filing to be able to account for documentation available within the district. Also, there will be implementing document control procedures for all costs and invoices within the district.
The Board of Directors for the district will be monitoring all filing to be able to account for documentation available within the district. Also, there will be implementing document control procedures for all costs and invoices within the district.
U.S. Department of Health and Human Services • Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Condition: During our testing, we noted there were several salary expenditures charged to the grant based on the payroll period ending da...
U.S. Department of Health and Human Services • Material Weakness in Internal Control over Compliance Community Service Block Grant – Assistance Listing No. 93.569 Condition: During our testing, we noted there were several salary expenditures charged to the grant based on the payroll period ending date, however the costs were incurred for the period 12/23/23 - 1/5/24, which the first nine days were prior to the start of the period of performance. Recommendation: The Organization should work with the federal agency to provide additional documentation or justification for the expenses, or to adjust the budget or funding limits to ensure that all expenses are within the approved period of performance. It is important to address any period of performance findings as soon as possible to avoid potential penalties or repayment obligations. The Organization should also review its process of entering invoices and payroll related expenses into the accounting software to ensure the correct period is used for federal expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will strengthen internal controls over the recording of grant-related invoices and payroll expenditures by requiring expenses to be recorded based on the actual date services are incurred rather than invoice date or payroll period end date. Finance staff will be retrained on period-of-performance requirements for federal programs, and a secondary review will be implemented for all federal grant postings to verify proper timing prior to submission for reimbursement or drawdown. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Seco...
Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. The Organization has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respectiveidentifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2026.
U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodit...
U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodities during fiscal year 2024. Recommendation: The Organization should prioritize the timely monitoring of participating agencies to allow for changes in food distributions if any ineligible participants are discovered. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization developed a schedule to complete monitoring and created a checklist to ensure that all documentation is in the appropriate folder. In addition, the organization began conducting internal audits to ensure the developed processes are being followed. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is May 2026.
NDS will implement a time study process to determine the appropriate allocation of staff time to federally funded programs due to limitations in the payroll system. This will replace the prior flat-rate allocation method and ensure salary charges to federal grants are supported by documented time an...
NDS will implement a time study process to determine the appropriate allocation of staff time to federally funded programs due to limitations in the payroll system. This will replace the prior flat-rate allocation method and ensure salary charges to federal grants are supported by documented time and actual work performed, consistent with Uniform Guidance requirements. Human Resources will maintain documentation of approved pay rates for audit and compliance purposes Management expects to have this implemented by April 30, 2026. The process is being monitored by Anthonia Ibe, Chief Financial Officer.
Management acknowledges the importance of ensuring that payroll costs charged to the program are consistent between the payroll system and the employee’s timesheet. The City continues to monitor its internal control process to ensure thorough review procedures are being followed. Timesheets are revi...
Management acknowledges the importance of ensuring that payroll costs charged to the program are consistent between the payroll system and the employee’s timesheet. The City continues to monitor its internal control process to ensure thorough review procedures are being followed. Timesheets are reviewed, bi-weekly, by payroll and adjusted to reflect actual hours as they relate to a specific activity. The City was able to hire a permanent accountant hiring who will provide additional oversight of these processes ensuring that hours worked are both reported correctly on the timesheets and are following the funding allocations that are approved by the grant.
Management acknowledges the importance of ensuring that payroll costs charged to the program are consistent between the payroll system and the employee’s timesheet. The City continues to monitor its internal control process to ensure thorough review procedures are being followed. Timesheets are revi...
Management acknowledges the importance of ensuring that payroll costs charged to the program are consistent between the payroll system and the employee’s timesheet. The City continues to monitor its internal control process to ensure thorough review procedures are being followed. Timesheets are reviewed, bi-weekly, by payroll and adjusted to reflect actual hours as they relate to a specific activity. The City was able to hire a permanent accountant hiring who will provide additional oversight of these processes ensuring that hours worked are both reported correctly on the timesheets and are following the funding allocations that are approved by the grant.
Finding 2024-004 Internal control weakness over activities allowed/allowable costs Name of responsible official: Evan Howard – Business Manager Corrective action: With stabilized staffing in place, management is currently updating the District’s federal funds procurement and compliance policies to a...
Finding 2024-004 Internal control weakness over activities allowed/allowable costs Name of responsible official: Evan Howard – Business Manager Corrective action: With stabilized staffing in place, management is currently updating the District’s federal funds procurement and compliance policies to address Uniform Guidance requirements related to allowable and unallowable costs. In conjunction with this effort, management will design and implement internal control procedures to ensure that expenditures charged to grants are reviewed for allowability prior to payment. These procedures will include documented review and approval processes, supervisory oversight, and periodic monitoring to ensure ongoing compliance. Anticipated completion date: June 30,2026
Finding 2024-003 Material Weakness in Internal Control over Compliance Name of responsible official: Evan Howard – Business Manager Corrective action: The municipality is in the process of reviewing roles, responsibilities, and job descriptions to ensure appropriate segregation of duties and proper ...
Finding 2024-003 Material Weakness in Internal Control over Compliance Name of responsible official: Evan Howard – Business Manager Corrective action: The municipality is in the process of reviewing roles, responsibilities, and job descriptions to ensure appropriate segregation of duties and proper internal controls, in accordance with the Corrective Action Plan. The plan has not yet been formally adopted. Anticipated completion date: June 30,2026
Management recognizes that the payroll software transition and the absence of formally documented procedures governing payroll data preservation and time-and-effort reporting resulted in gaps in compliance. Specifically, legacy payroll and timesheet data were not fully preserved prior to system migr...
Management recognizes that the payroll software transition and the absence of formally documented procedures governing payroll data preservation and time-and-effort reporting resulted in gaps in compliance. Specifically, legacy payroll and timesheet data were not fully preserved prior to system migration, and payroll allocations were, for a period, based on budgeted estimates rather than actual time worked. Management started implementing corrective actions to address both the immediate documentation gaps and the underlying internal control weaknesses. 1. Time-and-Effort Documentation System CPA transitioned to a new standardized payroll and time-reporting system in early 2024, which requires all employees whose compensation is charged in whole or in part to federal awards to document actual time worked, as follows: o Currently employees record time by department and program activity. o In December 2025, management is configuring the payroll system to allow employee time allocations down to the individual contract level. o Time reporting will be based on actual hours worked, not budgeted or estimated percentages and replace prior budget-based allocation methodologies. o Timesheets are reviewed and approved by supervisors on a bi-weekly basis and are maintained as part of CPA’s official payroll and accounting records. Management will establish guidelines and document formal procedures to ensure full data preservation prior to any future system migrations, including payroll, HR, or financial systems. These procedures include: o A mandatory pre-migration data inventory and archival checklist, approved by Finance and IT leadership o Secure retention of legacy payroll, timesheet, and personnel records in accordance with CPA’s record-retention policy o Verification testing to confirm data completeness and accessibility before decommissioning any legacy system o Written approval by the Chief Financial Officer prior to system cutover
As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final a...
As part of the proposal negotiations for the federal program, initial discussions with the sponsoring office of the federal program included a limitation for allowable compensation for employees that were not the Executive Director. Although the limitation was intended to be removed from the final agreement, the budgeted requested salaries were not updated. The Assistance Agreement has been modified to remove any such limitation prospectively beginning with Modification 0015 in April 2024. Implementation Date – April 2025
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