Corrective Action Plans

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Condition: Program expenses are approved via budget documents and during program director meetings. Recommendation: Any expenses that are associated with a federal grant should be approved by the appropriate program manager on an individual basis as incurred. Action Taken: All expenses are now appro...
Condition: Program expenses are approved via budget documents and during program director meetings. Recommendation: Any expenses that are associated with a federal grant should be approved by the appropriate program manager on an individual basis as incurred. Action Taken: All expenses are now approved by the appropriate supervisor on an individual basis as incurred. Company credit card purchases: As of June 2025, the organization is utililizing an online credit card reporting system that requires supervisors to review and approve purchases. Check requests, mileage and personal expenses: As of September 2025, the organization is requiring that all requests go to the supervisor, which are then reviewed and forwarded to bookkeeping, together with an approval statement, for processing.
Finding 2024-005- Suspension and Debarment Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Respo...
Finding 2024-005- Suspension and Debarment Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Suspension & Debarment Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: All contracts over $25,000 will now include a Suspension and Debarment Clause. Anticipated Completion Date: Immediately
Finding 2024-003- Allowable Activities and Allowable Cost Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Activities allowed or unallowed and allowable cost/cost principles. Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Emai...
Finding 2024-003- Allowable Activities and Allowable Cost Finding Subject : Covid-19. Coronavirus State and Local Fiscal Recovery Funds- Activities allowed or unallowed and allowable cost/cost principles. Contact Person Responsible for Corrective Action : Ashley Huffman Contact Phone Number and Email Address: 765-521-6803 nccityclerk@gmail.com Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Claims for ARPA monies will be reviewed to confirm it is allowable. Anticipated Completion Date: Immediately
View Audit 368998 Questioned Costs: $1
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of ...
FINDING 2024-004 Finding Subject: Covid-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Findings: Material Weakness, Other Matters Contact Person Responsible for Corrective Action: Ann Stark Contact Phone Number and Email Address: 317-745-9315 / astark@co.hendricks.in.us Views of Responsible O􀆯icials: We concur with the findings. Description of Corrective Action Plan: The Grant Administrator will monitor all claims that will be used for the quarter and send them to the reporting agent to report after the quarter ends. She will be diligent to track any claims coming in outside of that quarter so that reporting is accurate. She will provide the reporting agent with all claims relevant to that quarter’s report. Anticipated Completion Date: This will be done quarterly starting with the quarter ending on September 30th, 2025. The Grant Administrator will submit these claims to the reporting agent one week after the quarter ends. The Financial Administrator will sign o􀆯 on the LOW report to verify the claims match.
Finding 2024-002: Allowable Costs Condition: The Organization did not allocate shared costs appropriately between program and non-program related activities, resulting in approximately $15,078.56 in costs charged incorrectly to the Weatherization Assistance Program. Corrective Action: Management has...
Finding 2024-002: Allowable Costs Condition: The Organization did not allocate shared costs appropriately between program and non-program related activities, resulting in approximately $15,078.56 in costs charged incorrectly to the Weatherization Assistance Program. Corrective Action: Management has developed and implemented a cost allocation methodology consistent with 2 CFR 200.400. Beginning in 2025, costs will be allocated between programs (Weatherization Assistance Program and others) based on employee time distribution. This allocation policy will be documented and reviewed annually. Staff involved will be trained to ensure consistent application of cost allocation procedures. Responsible Party: Program/Fiscal Director
ALLOWABLE COSTS Recommendation: The County should review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response t...
ALLOWABLE COSTS Recommendation: The County should review the listing of employees working on certain programs on a periodic basis throughout the year and document the review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will review procedures and implement changes as needed to ensure reports are formally reviewed, submitted timely, and proper documentation is retained. Name of the contact person responsible for corrective action: Charlene Dale, Human Services Supervisor Planned completion date for corrective action plan: December 31, 2025
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising...
Contact Person(s): Bridgette Zappacosta Corrective Action Planned: Management concurs with the finding. The Organization will strengthen eligibility verification procedures to ensure that only participants meeting the specific award requirements are approved for benefits. This will include: revising intake and eligibility documentation protocols to require verification and supervisory sign-off that the individual meets the award’s eligibility definition and providing targeted staff training on eligibility requirements under the Refugee Admissions Program. Quarterly internal reviews of eligibility determinations will be conducted, with exceptions reported to management for corrective action. Anticipated Completion Date: December 31, 2025
View Audit 368884 Questioned Costs: $1
Contact Person(s): Bridgette Zappacosta, CFO Corrective Action Planned: Management concurs with the finding. We acknowledge that expenditures were charged outside of the applicable award period due to timing of invoice receipt and data entry errors. The Organization has reviewed its internal control...
Contact Person(s): Bridgette Zappacosta, CFO Corrective Action Planned: Management concurs with the finding. We acknowledge that expenditures were charged outside of the applicable award period due to timing of invoice receipt and data entry errors. The Organization has reviewed its internal controls and will strengthen procedures to ensure compliance with federal requirements. Specifically, we are revising our grant expenditure procedures, implementing new software which includes additional review controls and is specific to grant reporting, and providing targeted staff training on period of performance compliance. We will also perform quarterly monitoring of federal award expenditures to verify compliance. Anticipated Completion Date: December 31, 2025
View Audit 368884 Questioned Costs: $1
Condition Found During allowable cost testing, we noted that there was a lack of internal control over allowable costs. We noted items that did not include proper support, were outside the contract period, or were for the incorrect amount. Corrective Action Plan Continue to verify for every federal ...
Condition Found During allowable cost testing, we noted that there was a lack of internal control over allowable costs. We noted items that did not include proper support, were outside the contract period, or were for the incorrect amount. Corrective Action Plan Continue to verify for every federal charge: allowability, allocability, reasonableness, consistent treatment, and compliance with period of performance. Require source documentation supporting the nature, amount, and purpose. Responsible Person for Corrective Action Plan The Controller for Mission Edge San Diego and Accounting personnel. Implementation of Corrective Action Plan Policy adoption within 30 days of report. Management’s Statement of Concurrence Mission Edge concurs with the findings and has initiated the corrective actions described herein. Management is committed to timely implementation, continuous monitoring, and transparent communication with the pass-through entity, federal agencies, and auditors as required.
Condition Found During allowable cost testing, it was noted that one of the contracts with the vendors included a rate that exceeded the rate cap without prior approval. Upon inquiry no prior approval was obtained. Corrective Action Plan Before execution, route all vendor and subrecipient agreements...
Condition Found During allowable cost testing, it was noted that one of the contracts with the vendors included a rate that exceeded the rate cap without prior approval. Upon inquiry no prior approval was obtained. Corrective Action Plan Before execution, route all vendor and subrecipient agreements funded by federal awards to Controller/Accounting for verification of allowability, rate caps, prior approvals, and special terms. Additional review during the A/P process ensures compliance. Responsible Person for Corrective Action Plan The Controller for Mission Edge San Diego and Accounting personnel. Implementation of Corrective Action Plan Policy adoption within 30 days of report.
View Audit 368823 Questioned Costs: $1
Finding 1156477 (2024-002)
Material Weakness 2024
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underly...
Corrective Action: After receiving finding 2023-005 in mid-2024, LifeWire implemented a procedure wherein staff were required to attest to their percentages of time worked to LifeWire’s various contracts. Unfortunately, this procedure is heavily manual, and a small number of the calculations underlying the attestations were erroneous. In addition, LifeWire was not able to secure an attestation from a former employee before they departed the organization. In 2025, LifeWire is revising their attestation procedure such that contract-supported staff members will attest to the nature of their work instead of amounts of time to contracts. This will simplify the administrative burden of attestations and reduce opportunities for errors while still meeting our audit and contract funders’ requirements. We anticipate this revised method will be rolled out by the end of Q3-2025. Name of Responsible Individual(s): E. Jeannette Biffle, Controller Anticipated Completion Date: Procedure rollout will be completed by the end of Q3-2025. Anticipated full compliance with the requirement will be in evidence through the end of 2025 and beyond.
U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee sp...
U.S. Department of Agriculture Food Distribution Cluster - The Emergency Food Assistance Program - Assistance Listing No. 10.565, 10.568, 10.569 Recommendation: We recommend that EFN incorporate a system of internal controls that clearly documents the time and effort that each individual employee spends on each grant per month. This can be done by tracking and recording the actual hours each employee, regardless of position, spends working on each grant, on their time sheet or with a specific grant code, that specifies how many hours per day were spent on each federal and nonfederal activity. Alternatively, EFN can implement an after-the-fact review procedure to ensure the proper allocation of payroll expenditures to Federal and non-Federal awards, in accordance with 2 CFR 200.430. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Emergency Food Network (EFN) engaged a new audit firm for the 2024 audit. Before this year the EFN audit was administered by Johnson, Stone Pagano for 9 years. No deficiencies were previously reported or identified during those audits regarding time estimates for employees used for allocations including most of those specifically identified funding sources. In response to the 2024 audit finding by Clifton Larson Allen (CLA) in July of 2025, when the audit was conducted, EFN implemented an immediate individual employee time study that was approved by CLA to meet the recommendation. This time study methodology will be implemented twice per year on an ongoing basis with records retained and available for future audit verification. EFN has received written response from CLA that implementing this method meets all the requested requirements to be in compliance and mitigate future findings on this issue. Name of the contact person responsible for corrective action: Michelle Douglas, CEO Planned completion date for corrective action plan: August 2025 If anyone has questions regarding this plan, please call Michelle Douglas, CEO, at 253-208- 2962.
View Audit 368815 Questioned Costs: $1
We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.
We are planning to close the current policy. We are opening a separate policy for Council Towers II, Council Towers III and Council Towers IV that we covered by that policy.
View Audit 368800 Questioned Costs: $1
Personnel Responsible for the Corrective Action Plan: Darlene Sowell, President/CEO Anticipated Completion Date: December 31, 2025 Corrective Action Plan: Unleashing Potential will modify its internal procedures to track actual hours devoted to the program and perform a monthly review of actual hour...
Personnel Responsible for the Corrective Action Plan: Darlene Sowell, President/CEO Anticipated Completion Date: December 31, 2025 Corrective Action Plan: Unleashing Potential will modify its internal procedures to track actual hours devoted to the program and perform a monthly review of actual hours incurred compared to the estimated amounts by individuals assigned to federal grant programs prior to requesting reimbursement from the funding course. The review will be performed by an individual other than the preparer of the reimbursement request, with knowledge of the federal grant program and will be formally documented.
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of co...
The City acknowledges that it did not close out or document the HQS deficiencies discovered as part of this audit. In recognition of continued growth of the OH housing portfolio, including HOME Program assisted projects, and OH’s capacity to maintain its inspection compliance, OH is in process of contracting with a third-party vendor to complete its annual inspections, including HOME inspections for 2025. The contractor will inspect HUD’s NSPIRE level. With this additional support, OH anticipates it will have the capacity to see that corrections have been completed and documented consistent with the HOME program requirements.
The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) M...
The Department acknowledges this finding. The overage occurred following a period of prolonged vacancy in the contract specialist position and while newly assigned staff were still receiving training. To address this issue, the Department has hired a permanent Federal Grants Management Unit (FGMU) Manager to provide consistent leadership and supervision. The contract specialist receives structured management oversight and ongoing training to strengthen capacity for accurate budget monitoring. In July 2025, the FGMU updated its ESG policies and procedures to incorporate improved controls for earmarking. In addition, the Department has instituted regular training sessions for all staff responsible for federal grant management to reinforce compliance with earmarking and other federal requirements. These corrective actions are designed to strengthen internal controls, provide clearer oversight, and ensure that future expenditures remain within established budget and earmarking limits.
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Cont...
Findings and Questioned Costs – Major Federal Award Programs Audit Federal Agency: U.S. Department of Treasury Federal Program and Assistance Listing Number: Coronavirus State and Local Fiscal Recovery Funds, 21.027 2024-002: Controls over Payroll Allowable Costs – Material Weakness in Internal Control over Compliance Criteria and Condition: According to Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (the Uniform Guidance), section 200.430, charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Budget estimates alone do not qualify as support for charges to Federal awards, but may be used for interim accounting purposes, provided that the system for establishing the estimates produces reasonable approximations of the activity actually performed; significant changes in the corresponding work activity are identified and entered into the records in a timely manner; and the non-Federal entity’s system of internal controls includes processes to review after-the-fact interim charges based on budget estimates. Proof of these employees' approved compensation and job title is required to ensure their roles are allowable under the grant. Timesheets provided to support payroll charges did not accurately support the payroll expenses charged to the grants. Also, approval of the timesheets was not evident by the documentation provided. Finally, documentation supporting approval of each employee’s compensation was not maintained and provided to support the accuracy of employee compensation. Cause: During 2024, CVC’s management team underwent significant turnover, including the top finance officer, who represents the entire accounting department, as well as the HR director. Documentation was not maintained or could not be located to support payroll expenses allocated to the federal program. Effect and Context: When adequate support is not obtained and used to support the amount charged to the federal program, there is a risk that unsupported or inaccurate costs are being charged to the federal program. Questioned Costs: Payroll costs charged to the awards total $2,570,558. Recommendation: We recommend proper control activities should be implemented to allow for a consistent, accurate, and allowable method to support distribution of personnel charges to federal programs. Documentation should be properly maintained in the organization’s records. Views of responsible officials and planned corrective actions: CVC management will implement a process to perform timely review of salary expenses charged to federal awards, and retain records by pay period, and any pay rate and title changes, as support for expenditures charged to federal awards. Name of Contact Person: Gil Catbagan, Director of Finance Proposed Completion Date: December 31, 2025
View Audit 368632 Questioned Costs: $1
Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inad...
Finding 2024-002 Material Weakness in Controls over Compliance and Material Noncompliance – Allowable Costs Federal Program: 93.137 Community Programs to Improve Minority Health Year: 2024 Federal Agency: Department of Health and Human Services Condition – Payroll expenses for one employee were inadvertently recorded twice for the fiscal year, resulting in an overstatement of personnel costs charged to the federal award. Further, indirect costs were charged in excess of the budgeted and approved amount under the grant agreement. Corrective Action Plan – Henry Ford Health agrees with this finding. The payroll expense was corrected in the Schedule of Expenditures of Federal Awards and will be corrected in September 30, 2025, Federal Financial Report. Prospectively the payroll for the employee in question will be processed through our automated payroll time and effort process, rather than through manual journal entries, thus reducing the risk of error. Additionally, set up and review procedures have been enhanced to improve the controls related to recovery of indirect costs. Anticipated Completion Date – December 31, 2025. Contact Person – J. Douglas Clark, Senior Vice President and Chief Accounting Officer.
View Audit 368602 Questioned Costs: $1
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ...
The Board of Education has acknowledged the finding and has agreed to the finding. We have reviewed the affected payroll records and confirmed the underpayment. We have issued a check to pay the difference owed to the employee. At fiscal year end, we will implement a more detailed review process to ensure all employees' salary schedules are updated when we process the system-wide update. We will have an additional person to review and sign the new salary schedules before the first payroll is processed in the new fiscal year.
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2024-001 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Proposed Completion Date: January 1, 2026
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and ...
Finding 2024-002 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that the five transactions tested that did not have documentation of appropriate approval occurred prior to August 2024, the remediation date of Finding 2023-002. Completion Date: Matter was remediated in August 2024
Management concurs with the finding and intends to add additional detail to timesheets completed by employees to properly document payroll allocated to specific programs.
Management concurs with the finding and intends to add additional detail to timesheets completed by employees to properly document payroll allocated to specific programs.
View Audit 368543 Questioned Costs: $1
View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authoriz...
View of Responsible Official: We have undertaken additional training and review of regulations in this area to ensure compliance. Finding resolved timeline: December 1, 2025. Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President and program Authorized Representative
View of Responsible Official: The timesheet implemented in July 2024 properly reflects the actual vs budgeted hours for employees with multiple funding sources. We will continue to analyze discrepancies to determine if budget revisions are necessary. Finding resolved timeline: October 2025 Designate...
View of Responsible Official: The timesheet implemented in July 2024 properly reflects the actual vs budgeted hours for employees with multiple funding sources. We will continue to analyze discrepancies to determine if budget revisions are necessary. Finding resolved timeline: October 2025 Designated of employee position responsible for meeting this deadline: Bruce Young-Candelaria, President; Ricardo Colon Padilla, financial officer.
AACF concurs with this finding. AACF submitted a corrective action plan to AmeriCorps and on January 31, 2025 AmeriCorps accepted their corrective action plan and closed the finding. AACF will ensure all requirements under 2 CFR 200.403 and 45 CFR 2540.200-207 are met moving forward.
AACF concurs with this finding. AACF submitted a corrective action plan to AmeriCorps and on January 31, 2025 AmeriCorps accepted their corrective action plan and closed the finding. AACF will ensure all requirements under 2 CFR 200.403 and 45 CFR 2540.200-207 are met moving forward.
View Audit 368447 Questioned Costs: $1
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