Corrective Action Plans

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Finding No.: 2023-002 Area: Cash Management Views of responsible official and planned corrective actions: Management acknowledges the requirements of 2 CFR 200.305(b). Existing cash management procedures are currently under review, and updates will be made to further strengthen compliance with feder...
Finding No.: 2023-002 Area: Cash Management Views of responsible official and planned corrective actions: Management acknowledges the requirements of 2 CFR 200.305(b). Existing cash management procedures are currently under review, and updates will be made to further strengthen compliance with federal requirements. The Trust will ensure that procedures continue to minimize the time between receipt and disbursement of funds and that payments are made in accordance with contract terms. Written procedures will be updated as needed and followed by finance staff, with ongoing reviews to ensure compliance. Contact Person: Melanie Lawrence Aiseam, Chief Financial Officer Expected Completion Date: The Trust started training in Quarter 4 2024, and is ongoing
Reporting – Airport Improvement Program Finding Summary: Adequate supporting documentation for the amount requested for reimbursement with reporting form SF-271 was not available. Responsible Individuals: Aaron Mitchell, Chief Financial Officer Corrective Action Plan: The County is implementing enha...
Reporting – Airport Improvement Program Finding Summary: Adequate supporting documentation for the amount requested for reimbursement with reporting form SF-271 was not available. Responsible Individuals: Aaron Mitchell, Chief Financial Officer Corrective Action Plan: The County is implementing enhanced documentation retention and review procedures to ensure supporting documentation for reimbursement requests is maintained, reviewed, and readily accessible prior to submission. Anticipated Completion Date: Ongoing
Finding Reference Number: SA2023-001 Subrecipient Reimbursement Request Documentation AL Number: 20.507, 20.526 Assistance Listing Title: Federal Transit Cluster, Federal Transit - Formula Grants (Urbanized Area Formula Program) Federal Agency: Department of Transportation Federal Award Identificati...
Finding Reference Number: SA2023-001 Subrecipient Reimbursement Request Documentation AL Number: 20.507, 20.526 Assistance Listing Title: Federal Transit Cluster, Federal Transit - Formula Grants (Urbanized Area Formula Program) Federal Agency: Department of Transportation Federal Award Identification Number: CA-2020-214-01, CA-2023-225-00 • Fiscal Year of Initial Finding: 2023 • Name(s) of the contact person: Ryan Chapman, Director of Public Works Engineering & Transportation • Corrective Action Plan: Staff has developed a procedure to improve monitoring of its subrecipients to include a review of required documentation for reimbursement requests. This procedure has been created specifically for the Unitrans grant award but will be expanded to encompass all grant subawards and subrecipients. • Anticipated Completion Date: May 2026
We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to e...
We recommend that management: ▪ Implement procedures to ensure timely payment of all obligations, particularly those related to federal programs ▪ Establish accounts payable aging monitoring and review processes, with escalation of overdue items ▪ Align disbursement practices with 2 CFR 200.305 to ensure funds are drawn and disbursed promptly ▪ Develop and enforce policies consistent with the Prompt Payment Act, including defined payment timelines ▪ Perform periodic reviews of cash flow and payment cycles to ensure compliance ▪ Assign oversight responsibility to ensure timely processing and documentation of payments Strengthening cash management practices will improve compliance with federal requirements and enhance overall financial control.
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the...
Recommendation We recommend that management implement a comprehensive remediation plan to strengthen financial reporting processes, including: • Ensuring the trial balance is complete, accurate, and finalized prior to audit • Preparing and maintaining reliable rollforward schedules that agree to the general ledger • Performing timely and accurate reconciliations of all key accounts, particularly cash • Establishing procedures to ensure all financial transactions are supported with adequate documentation • Implementing review and approval controls over financial records and reconciliations • Evaluating staffing and resources to ensure the accounting function can meet reporting requirements Strengthening these areas is critical to improving the accuracy, reliability, and auditability of the organization’s financial statements.
Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted re...
Recommendation We recommend that management: ▪ Establish a formal reporting calendar outlining all required financial and performance reports, including due dates ▪ Implement procedures to ensure reports are prepared accurately, reviewed, and submitted timely ▪ Maintain documentation of submitted reports, including confirmation of submission and supporting schedules ▪ Assign clear responsibility for reporting compliance and implement supervisory review controls ▪ Provide training to relevant personnel on federal reporting requirements Strengthening reporting processes will improve compliance, enhance transparency, and ensure that the organization meets its obligations under federal awards.
Audit Finding Reference: 2023-003 Improve Controls Over Cash Management & Application of Indirect Cost Rate (Significant Deficiency) Planned Corrective Action: Federal reimbursement requests will include two or more individuals. Review of the reimbursement request, including the application of the i...
Audit Finding Reference: 2023-003 Improve Controls Over Cash Management & Application of Indirect Cost Rate (Significant Deficiency) Planned Corrective Action: Federal reimbursement requests will include two or more individuals. Review of the reimbursement request, including the application of the indirect rate, will be formally documented and a copy of the documentation will be maintained in our records. Note, the audit finding was originally included in the 2022 single audit report completed in early 2025. Planned Implementation Date of Corrective Action: March 14, 2025. Persons Responsible for Corrective Action: Kirk Geadelmann, Finance Director Tyler Piebes, Bookkeeper Nick Fisichelli, President & CEO
Responsible Individual: Michael Vocu, Executive Director. Corrective Action Plan: Establish and maintain robust internal controls to ensure timely and accurate grant reporting. Anticipated Completion Date: September 30, 2026
Responsible Individual: Michael Vocu, Executive Director. Corrective Action Plan: Establish and maintain robust internal controls to ensure timely and accurate grant reporting. Anticipated Completion Date: September 30, 2026
The Organization agrees with the audit finding. There were gaps in information flow due to staff turnover. The Organization already has a process in place to maintain documentation in a logical manner with adequate access.
The Organization agrees with the audit finding. There were gaps in information flow due to staff turnover. The Organization already has a process in place to maintain documentation in a logical manner with adequate access.
CORRECTIVE ACTION PLAN (Concerning Finding 2023-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2023-006 The current Town Manager was appointed by the Select...
CORRECTIVE ACTION PLAN (Concerning Finding 2023-006) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Town Manager and Select Board will take the following actions to address finding 2023-006 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted, had approved and has implemented the new Internal Controls Policy that addresses this deficiency. This policy will includes sections on risk assessment and management, annual audit, chart of account, general ledger, reconciliation and verification, reserve funds and reserve accounts, investments, financial reporting, fraud, accounting software, online transactions and banking, documentation daily cash-ups, grants and projects, AR process, AP process, and payroll. Anticipated Completion Date: This was completed February 20, 2024.
CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2023 AUDITOR FINDING: 2023-005 According to 2 CFR Part 200.403 factors affecting allowability of costs - costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the perfo...
CORRECTIVE ACTION PLAN FISCAL YEAR OF FINDING: June 30, 2023 AUDITOR FINDING: 2023-005 According to 2 CFR Part 200.403 factors affecting allowability of costs - costs must meet the following general criteria in order to be allowable under Federal awards: (a) be necessary and reasonable for the performance of the Federal award and be allocable thereto under these principles, (b) conform to any limitations or exclusions set forth in these principles or in the Federal award as to types or amount of cost items, (c) be consistent with policies and procedures that apply uniformly to both federally-financed and other activities of the non-Federal entity, (d) be accorded consistent treatment, (e) be determined in accordance with generally accepted accounting principles, (f) to be included as a cost or used to meet cost sharing or matching requirements of any other federally-financed program in either the current or a prior period and (g) be adequately documented. In addition, according to 2 CFR Part 200.303, the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. The Organization did not maintain documentation to support that costs and reimbursement invoices had been approved in accordance with their internal control design. CLIENT PLANNED ACTION: To address the audit finding, we affirm that all reimbursement invoices and cost-related documentation are submitted to a Director-level staff member for review and approval prior to sending. All approved invoices and associated documentation are now stored in a centralized shared drive and onsite file cabinets accessible to relevant finance staff to ensure consistent retention and accessibility for audit and review purposes. These documents will also be accessible within the accounting information system, when organization switches to Sage, which is accessible to all parties that have approval responsibilities. CLIENT RESPONSIBLE PARTY: Cassie Kenney, Director of Accounting COMPLETION DATE: This process started as of June 30, 2024. Documents will be stored within Sage as soon as the switch to this software is effective (tentative July 1st, 2025).
2023-006 Cash Receival – Proper Procedures Recommendation: Auditors recommend that CIES modifies its internal control policies for general review and approval of the reporting requirements set forth by the criteria listed. Criteria: 2 CFR 200.8(a) – Federal agencies responsible for ensuring that spe...
2023-006 Cash Receival – Proper Procedures Recommendation: Auditors recommend that CIES modifies its internal control policies for general review and approval of the reporting requirements set forth by the criteria listed. Criteria: 2 CFR 200.8(a) – Federal agencies responsible for ensuring that specific Federal award conditions and performance expectations are consistent with the program design. 2 CFR 200.208(c)(1) Specific conditions may include requiring payments as reimbursements rather than advance payments. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: As feasible, CIES will implement proper procedures and controls surrounding the receival of cash to ensure proper segregation of duties for funds received. Cash, including checks, received will be received and deposited by one of the CIES’ administrative staff and a different CIES’ administrative staff member will enter the data into the CIES’ financial records. Verification of entry and deposit will be conducted through monthly reconciliations of bank accounts. Name(s) of the contact person(s) responsible for corrective action: Michael Parker, Executive Director Planned completion date for corrective action plan: March 2026
Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: There was no evidence retained that the Organization's cash management requests were reviewed a...
Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.829 Program Name: Section 223 Demonstration Programs to Improve Community Mental Health Services Finding Summary: There was no evidence retained that the Organization's cash management requests were reviewed and approved prior to submission. Corrective Action Plan: The Organization has implemented a process to ensure that formal documentation of review and approval is obtained and retained (i.e. hard copies or email). Responsible Individual: Ashli Glorvigen, CFO Anticipated Completion Date: 12/31/2026
Finding 1179664 (2023-002)
Material Weakness 2023
FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Descriptio...
FINDING 2023-002 Finding Subject: CDBG - Entitlement Grants Cluster - Program Income Contact Person Responsible for Corrective Action: Timothy A. Brown Contact Phone Number and Email Address: 219-755-3225 brownta@lakecountyin.org Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: This same finding was part of the 2022 audit in Finding 2022-003. The department was aware that this same finding would be arising in the 2023 audit again due to multiple year errors of previous staff. The corrective action plan proposed and adopted as part of the Corrective Action Plan for finding 2022-003 is still in force and is working to eliminate such findings in the future. The Lake County Redevelopment Commission adopted Resolution 001-2025 on January 16th, 2025 amending the Policy and Procedures Manual of the Department concerning Program Income (PI) internal controls for proper reporting in the IDIS system to address and correct the finding going forward. Anticipated Completion Date: Done
Corrective Action Plan Action Item Responsible Party Monitoring Maintain complete and accurate records of federal drawdowns, disbursements, and related trial balance activity in accordance with record-retention policies. CFO / Accounting Staff Monthly review Implement procedures to review unearned r...
Corrective Action Plan Action Item Responsible Party Monitoring Maintain complete and accurate records of federal drawdowns, disbursements, and related trial balance activity in accordance with record-retention policies. CFO / Accounting Staff Monthly review Implement procedures to review unearned revenue balances and related cash activity to ensure federal funds are drawn and disbursed in compliance with cash management requirements. CFO Monthly reconciliation In FY 2026, management developed and implemented a formal Records Retention Policy to ensure that accounting records, supporting documentation, and organizational records are properly maintained and retained in accordance with applicable regulatory and audit requirements. CFO Management review Strengthen supervisory oversight of drawdowns and reimbursement requests to ensure compliance with Uniform Guidance and applicable federal regulations. CFO / Board Finance Committee Quarterly review ________________________________________ Management Response Management notes that no additional federal grants, other than the HRSA Section 330 program grant (Assistance Listing 93.224), were received in FY2025 or FY2026. Prior management did not provide a reconciled SEFA schedule for earlier reporting periods, which contributed to the documentation limitations identified during the audit. Beginning in FY2026, management has developed a detailed SEFA tracking schedule for the HRSA Section 330 grant that identifies the date federal funds were drawn down, the amount received, the related expenditures, and the corresponding disbursement dates. This schedule is maintained to improve reconciliation between drawdowns, expenditures, and the general ledger and to ensure documentation is readily available for audit and compliance purposes. ________________________________________ Responsible Official: Chief Financial Officer Expected Completion Date: FY 2026
ROE 40 will put into place a system to ensure timely expenditure reporting for both federal and state programs. Regular review will ensure that expenditures are placed into line items properly, thus making sure expenditures do not exceed budgeted amounts. Procedures will be put in place to ensure an...
ROE 40 will put into place a system to ensure timely expenditure reporting for both federal and state programs. Regular review will ensure that expenditures are placed into line items properly, thus making sure expenditures do not exceed budgeted amounts. Procedures will be put in place to ensure an expenditure is not submitted for reimbursement prior to the ROE paying for the expenditure.
Views of Responsible Officials and Planned Corrective Action The Organization notes the following existing internal control practices, as it relates to cash management subsequent policy and process development and implementation, and the additional controls to be implemented: A. System, Process & Re...
Views of Responsible Officials and Planned Corrective Action The Organization notes the following existing internal control practices, as it relates to cash management subsequent policy and process development and implementation, and the additional controls to be implemented: A. System, Process & Review Controls In Practice. 1. System Controls. The Organization operates in an environment in which system, process & review controls of the United States Department of Health and Human Services (HHS) are practiced in processing cash (draw) transactions in both the Electronic Handbook (EHB) and Payment Management System (PMS) systems, operated by HHS. Only the director of administrative operations and the CEO have system access to the EHB and PMS systems. 2. Process & Review Controls – EHB & PMS. Cash management requests (aka federal draws) are computed by, and entered into the EHB, including the Organization’s justification of the expenditure, by the director of administrative operations, including the CEO on the approval request. The propriety of the cash draw is reviewed by the HHS assigned grants management specialist; and inquiry action, if needed, documented by e-mail from the grants management specialist; and approval documented in the EHB. Once the draw is approved, the director of administrative operations enters information into the PMS, noting that the CEO, is the authorized organization representative (AOR). The grants management specialist must then approve the draw request once more in the PMS system before a PMS representative approves the draw request. 3. Process & Review Controls – Finance Committee & Full Board. The Organization’s monthly Board process and review controls include review of the Organization’s: Statement of Financial Position, Statement of Revenues and Expenditures, Statement of Revenues and Expenditures – Net Income/(Loss) by Fund, Fund Details – Additional Information and Statistics, Active Subcontract Summary, Active Subcontract Listing Related to Funds – Additional Information and Statistics, Native Hawaiian Health Program (Fund 007V), and Native Hawaiian Health Scholarship Program (Fund 017V). B. Internal Control Environment Policy Establishment – July 2025. In July 2025, the Organization developed the following cash management related policies and related procedures: Internal Control Environment; Implementation of Significant Accounting Policies; Revenue Recognition Policy, Including Federal Draws; Implementation of HRSA Related Policies, including cash management processes and procedures. C. Additional Process & Review Controls – March 2026. Beginning March 2026, for federal draws, process and review internal controls will be implemented, via the chief of staff’s review of the director of administrative operations cash management analyses, federal grant receivable composition, reconciliation and related federal grant revenue computations, prior to any director of administrative operations and chief executive officer action in EHB and PMS, respectively.
Contact Person Responsible for Corrective Action Plan: G. Janina Trzmiel, Chief School Financial Officer Corrective Action Plan: We agree with the auditors’ comments and have taken the following actions: The Board will implement policies to ensure proper submission and approval over ESSER funds for ...
Contact Person Responsible for Corrective Action Plan: G. Janina Trzmiel, Chief School Financial Officer Corrective Action Plan: We agree with the auditors’ comments and have taken the following actions: The Board will implement policies to ensure proper submission and approval over ESSER funds for reimbursement. Anticipated Completion Date: September 30, 2024
We will review policies and procedures for expenses to ensure that all payments have an evidenced independent review prior to payment.
We will review policies and procedures for expenses to ensure that all payments have an evidenced independent review prior to payment.
Condition: During audit fieldwork, testing resulted in a restatement of fund balance related to the implementation of a new capital asset policy, implementation of GASB Statement No. 87, and the write-off of forgivable loan balances. Plan: The City and its Finance Department will continue implementi...
Condition: During audit fieldwork, testing resulted in a restatement of fund balance related to the implementation of a new capital asset policy, implementation of GASB Statement No. 87, and the write-off of forgivable loan balances. Plan: The City and its Finance Department will continue implementing revised policies and new accounting standards, some of which may require retroactive restatements. The City will also continue to evaluate the appropriateness of receivable balances, including forgivable loans, prior to audit fieldwork. Anticipated Date of Completion: Fiscal Year 2024 Name of Contact Person: Eric Dubrowski, Finance Director Management Response: As part of its internal review of capital assets, the City implemented a revised capital asset policy. This policy significantly reduced the number of assets required to be tracked while retaining the vast majority of assets on the City’s books, resulting in improved compliance and increased administrative efficiency. The City reviews the implementation of new GASB pronouncements with its auditors in advance of each applicable reporting period. Forgivable loan balances previously corresponded to liens placed on properties and notes issued to borrowers. Upon reevaluation of the criteria required for forgiveness, the City concluded that these loans were highly likely to be forgiven. In the limited circumstance where forgiveness would not occur, such as a borrower ceasing operations, collection of the loan would also be unlikely. As a result, the City determined that these balances should be removed retroactively from the balance sheet, resulting in a restatement of fund balance.
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. Cou...
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. County Manager and Financial Specialist were not trained in Railroad project management. Changes in staff within the County Manager’s Office and private corporations as well as state and federal agencies resulted in change in requirements, poor communication, and delay in reporting ultimately resulting in disruption of reimbursement to the County. Colfax County worked with NM Department of Transportation and Federal Railroad Administration to collect project status information and submit all outstanding progress reports. To date Colfax County has been successful in maintaining open communication and receiving support from NMDOT and FRA. All reporting requirements are current and reimbursement has been issued to the County.
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. Cou...
Colfax County agreed to be the fiscal agent for a collaborative project involving several state and federal agencies within NM, CO, and KS along with private corporations including BNSF and AMTRAK. Colfax County did not have the staffing or cash flow necessary to facilitate such a large project. County Manager and Financial Specialist were not trained in Railroad project management. Changes in staff within the County Manager’s Office and private corporations as well as state and federal agencies resulted in change in requirements, poor communication, and delay in reporting ultimately resulting in disruption of reimbursement to the County. Colfax County worked with NM Department of Transportation and Federal Railroad Administration to collect project status information and submit all outstanding progress reports. To date Colfax County has been successful in maintaining open communication and receiving support from NMDOT and FRA. All reporting requirements are current and reimbursement has been issued to the County.
The Organization hired a new grant and partnership specialist. This specialist reviews all draws to ensure that the draw is for reimbursement for actual expenditure and not estimated expenditure. Reports and draws are also reviewed by the vice president of finance.
The Organization hired a new grant and partnership specialist. This specialist reviews all draws to ensure that the draw is for reimbursement for actual expenditure and not estimated expenditure. Reports and draws are also reviewed by the vice president of finance.
Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of fe...
Reference Number: 2023-005 Finding: Update Documented Policies amt Procedures Over Federal Awards Name of Contact Person: Christine Chamberland Corrective Active Plan: The City will develop and implement comprehensive policies and procedures specifically addressing the management and oversight of federal awards to ensure compliance with the Uniform Guidance. Designated staff will be tasked with drafting these documents, which will be reviewed and approved by senior management. Training sessions will be conducted for all relevant personnel to ensure consistent application of the new policies and procedures. Proposed Completion Date: 3/31/26
Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification sinc...
Finding Number: 2023-003 Finding Title: Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Taylor Spilde Corrective Action Planned: Taylor has been receiving supporting documents and reports since 1/1/2024. Taylor received notification since 2024 and has been reporting since receiving notification. Anticipated Completion Date: 1/1/2024
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