Corrective Action Plans

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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
Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create...
Federal Agency: U.S. Department of Labor Assistance Listing No. 17.270 Type of Finding: ● Significant Deficiency in Internal Control Over Compliance – Cash Management and Reporting Recommendation: The Organization should update and strengthen their policies to match UG and DOL guidelines, and create an internal control for drawdown request and report approval and review. The Organization should ensure these policies are followed for all drawdowns, reports and that documentation related to these policies are maintained. Views of Responsible Officials: Management agrees with the finding and recommendation. To address this, the Organization will update its Cash Management Policy to implement a documented, two-level review and approval process for all drawdown requests and reports, requiring both preparer and approver sign-off and develop a standard checklist to ensure each drawdown is supported by allowable, documented expenditures prior to submission. The Grants Manager will conduct quarterly internal reviews to ensure this process is being followed. Contact information for this finding: If the U.S. Department of Labor has questions regarding this schedule, please call Brandi Janke at (816) 520-4404. Completion Date: September 2025
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
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. This revised process will be put in place on October 1, 2025.
View Audit 368617 Questioned Costs: $1
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
With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance wit...
With regard to Federal Award Finding 2024-002, Procedures for Match Requirements, in the audit report for Mountain Home Montana, Inc. for the year ended December 31, 2024, we offer the following response: Mountain Home will immediately implement written policy and procedures to ensure compliance with federal grant matching requirements. The new policy and procedures are attached.
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the find...
Finding 2024-003 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds- Reporting Contact Person Responsible for Corrective Action: Cindy Poore Contact Phone Number and Email Address: 317-733-2809, cpoore@zionsville-in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Below is the process for submitting required grant reporting. 3. The Director will input the required information 4. Prior to submission of the report, the Director will have the Deputy Director verify the information that has been entered against the supporting documentation. 5. The Deputy Director will let the Director know if it is ok to submit the report. 6. The Director will submit and print a completed submission document that the Deputy Director will verify again. 7. The Deputy Director and Director will both sign and date the completed report. 8. This will be filed for audit purposes. Anticipated Completion Date: This is already taking place. The 2025 filing in April followed this process.
DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will d...
DAWI acknowledges the finding and will implement the following: 1. Cash Management Policy: We will update this policy to require signed documentation of reimbursement requests. a. We will then follow this policy and retain signed documentation of reimbursement requests. 2. Matching Policy: We will develop a match policy to include documented review and signed document retention for matching contributions, ensuring compliance with CFR §200.306. a. We will then follow this policy and retain signed documentation of matching contributions. Proposed Completion Date – October 31, 2025
Management has put procedures in place in the current year to ensure timely submission.
Management has put procedures in place in the current year to ensure timely submission.
Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any rev...
Finding Number: 2024-002 Planned Corrective Action: To prevent future reporting deficiencies, the County will implement additional review processes, including but not limited to review by the Clerk of Court Board Finance Office, of the payroll costs submitted with the reimbursement requests. Any reviews will be documented with an approval via a formal email confirmation. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail
Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion ...
Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail
1. Will create a federal procurement compliance checklist before applying for another contract by a federal award. 2. Will hire legal counsel familiar with federal awards to review the contract. 3. Will request that the engineers amend/revise the Grunloh contract and any other contract issues as par...
1. Will create a federal procurement compliance checklist before applying for another contract by a federal award. 2. Will hire legal counsel familiar with federal awards to review the contract. 3. Will request that the engineers amend/revise the Grunloh contract and any other contract issues as part of the EPA loan to come into compliance with the statute and grant-specific requirements for procurement language.
The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and som...
The initial eligibility determinations are currently handled by the HCV department and are centralized. It has been determined that considerable investment in staff training has been made during the past twelve months. As a result, there has been staff turnover, some at the decision of TGHA, and some at the decision of staff. Initial eligibility is currently being restructured with an emphasis on new admissions. All procedures and processes are being evaluated for accuracy, with emphasis on the noted area of noncompliance and includes a complete review and update to the Administrative Plan. There will be increased staff training and file review. In July 2024, TGHA transitioned project-based files from a property management team to the Housing Choice Voucher Department. The files had not been electronically stored. Evidence pointed to deficiencies in file maintenance. TGHA has hired temporary staff for an extended period to focus on file organization and to correct documentation deficiencies. All HCV staff have completed Rent Calculation courses provided by NAHRO or Nan McKay during the fiscal year. There have been two managers hired for the department, one exclusively for project-based vouchers. Both attended NAHRO supervisory training in September. There will be an intensive focus on program integrity throughout the programs, including staff capability, training and monitoring. TGHA has contracted with a professional recruiter to assist in hiring a Director of the HCV and MTW programs. Recertification transactions will be monitored on a monthly basis. This will include validation of calculations and verification of correct documentation. TGHA files were fully in order by July 2025.
Finding 2024-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidenc...
Finding 2024-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to review and approve FEMA expenditures submitted to the FEMA Portal. Corrective Action Plan: Management implemented corrective action on December 31, 2024 to ensure evidence of controls is retained. Responsible Party: Wah-chung Hsu, Chief Financial Officer Completed Date: December 31, 2024
Finding Number: 2024-003 USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will review the loan terms and conditions to evaluate the amounts required to be in the applicable loan reserve accounts, and will bring the reserve accounts to the required balances. Person Respon...
Finding Number: 2024-003 USDA Community Facilities Loan Reserve Accounts Planned Corrective Action: We will review the loan terms and conditions to evaluate the amounts required to be in the applicable loan reserve accounts, and will bring the reserve accounts to the required balances. Person Responsible for Corrective Action: Gabriel Moreno, Executive Director. Anticipated Date of Completion: December 31, 2025
Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct G...
Finding 2024-002 Information on the federal program: Subject: Home Investment Partnership Program – Internal Controls Federal Agency: Department of Housing and Urban Development Federal Program: Home Investment Partnership Program Assistance Listing Number: 14.239 Pass-Through Entity: N/A - Direct Grant Compliance Requirement: Special Tests and Provisions - Underwriting Requirements Audit Findings: Significant Deficiency Condition: The Consortium did not have a documented review control in place to ensure the underwriting calculation was prepared, reviewed, and maintained. Context: In a sample of three, the following items were noted: • For the first selection, project underwriting support was not available. The underwriting calculation was prepared by a former employee. Review of the calculation was also performed by a former employee. The Consortium does not have record of the calculation. • For the second selection, the underwriting calculation did not have formal sign off by the reviewer. Only the preparer signed the calculation. • For the third selection, the underwriting calculation did not have formal sign off by the preparer. Only the reviewer signed the calculation. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will implement a system of internal controls to ensure the required underwriting calculations are prepared, reviewed, and maintained. Responsible Party and Timeline for Completion: The Consortium Director (or their designee) and the Federal Grant Administrator are responsible for implementation, which will go into effect immediately.
2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of tim...
2024-001 Time and Effort Payroll Documentation Corrective action planned: Cahaba Medical Care will implement a formal process to document time and effort for personnel, subject to the level of effort requirements. This process will require time and effort for personnel to attest to the amount of time spent on a grant monthly. These personnel have been informed of the proposed process and trained to promote consistent and accurate reporting relative to federal standards Anticipated completion date: October 2025 Contact person responsible for corrective action: Russ Chambliss
To ensure compliance with applicable regulations, the Domestic and Foreign Missionary Society (Society) requires employee whose compensation is charged to the Federal grant-funded programs to complete monthly timesheets to document their actual time spent on those programs. In two instances, employe...
To ensure compliance with applicable regulations, the Domestic and Foreign Missionary Society (Society) requires employee whose compensation is charged to the Federal grant-funded programs to complete monthly timesheets to document their actual time spent on those programs. In two instances, employees whose compensation was charged to the programs were terminated from employment and did not complete time sheets prior to their termination. Supervisors were subsequently able to verify the allocation of their time to the programs and the amounts charged to grants, and the audit did not note any instances of noncompliance. Management will strengthen internal controls in the future to ensure that final time sheets are obtained and verified by supervisors prior to the termination of any employees whose compensation is charged to the programs.
IBBG will develop and adopt a written procurement policy that is consistent with the Uniform Guidance, 2 CFR §§200.318–200.326, and applicable state and local laws. The policy will outline procurement methods, competitive bidding requirements, conflicts of interest, and documentation standards. In a...
IBBG will develop and adopt a written procurement policy that is consistent with the Uniform Guidance, 2 CFR §§200.318–200.326, and applicable state and local laws. The policy will outline procurement methods, competitive bidding requirements, conflicts of interest, and documentation standards. In addition: • A draft policy will be prepared by the I Be Black Girl leadership, the finance committee, and D&K Financial LLC. • The Board of Directors will adopt the final policy. • Training will be provided to staff involved in procurement to ensure consistent implementation of the procurement process.
Management Response: The Organization will establish a procurement policy in 2025. Anticipated Completion Date: 12/31/2025 Responsible Party: Board of Directors
Management Response: The Organization will establish a procurement policy in 2025. Anticipated Completion Date: 12/31/2025 Responsible Party: Board of Directors
WRTP has reviewed the organization’s fiscal policy manual including all subsections regarding contractual provisions and procurement. Additional training has been provided and completed by management and staff. The fiscal policy manual procurement section will undergo further review by a third party...
WRTP has reviewed the organization’s fiscal policy manual including all subsections regarding contractual provisions and procurement. Additional training has been provided and completed by management and staff. The fiscal policy manual procurement section will undergo further review by a third party and if recommended, will be updated and presented to the Finance Committee of the Board of Directors.
B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file...
B. Corrective action steps taken and/or planned: ACHD will maintain lists of subrecipients used and checklists to help ensure that monitoring activities are performed for each. Also working on establishing a process to incorporate language into our contracts. In addition, ACHD will complete and file out of compliance sub recipient forms per the timetable noted in Section D below. C. Timetable of dates for performance of planned corrective action steps including completion date: Slated to begin new process August 1, 2025 for new contracts and/or contract renewals. Once process has been finalized, ACHD Fiscal will also review past agreements that are still in effect. D. Description of monitoring to be performed to ensure corrective action steps are taken: ACHD Financial Manager and Grants Manager will ensure lists and monitoring activities are maintained.
We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by ...
We review each invoice monthly as they are submitted. Most of the review is insuring the items being invoiced are eligible under HUD and making sure the amounts are added correctly. We will review more closely the match submitted. Match for HUD is now reported based on the entire funding and not by individual grants. All match from all HUD programs is added together and submitted on one final report at the end of each funding year. The requirement is 25% on all budget lines except for Leasing. However, if one program’s match is short of the 25% requirement, the overall CoC is responsible for the filll match, so additional DHS admin costs are used to represent the additional match needed. For our FY23-24 annual report to HUD, we submitted 32.94% in match for the overall fimding. This amount did not include any additional HMIS (data system) costs, Allegheny Link (our coordinated entry system) costs or additional DHS admin costs. With these additional eligible activities, our matching amount could have been over 50%. Therefore, even if some identified items were considered ineligible our match would not be in jeopardy since we have a lot of eligible costs that DHS covers that would be considered match.
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