Corrective Action Plans

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RESPONSE: The practice of checking the debarment list had occurred in the past; the keeping of a "proof of practice" was not done. Going forward, this practice will be documented. TIMEFRAME FOR CORRECTIVE ACTION: Immediate. RESPONSIBLE CONTACT PERSON: Katy Posey, Financial Director/Treasurer
RESPONSE: The practice of checking the debarment list had occurred in the past; the keeping of a "proof of practice" was not done. Going forward, this practice will be documented. TIMEFRAME FOR CORRECTIVE ACTION: Immediate. RESPONSIBLE CONTACT PERSON: Katy Posey, Financial Director/Treasurer
Description: Significant deficiency in internal control over compliance related to suspension and debarment. Cause: Though the Organization has established internal controls for suspension and debarment, the Organization made an incorrect determination that the suspension and debarment requirements ...
Description: Significant deficiency in internal control over compliance related to suspension and debarment. Cause: Though the Organization has established internal controls for suspension and debarment, the Organization made an incorrect determination that the suspension and debarment requirements outlined in 2 CFR 200 Part 180 only applied to subawards. Effect: The Organization did not fully comply with the suspension and debarment requirements regarding covered transactions. Corrective Action: • The Organization’s management previously had an incorrect understanding of the Suspension & Debarment requirements of 2 CFR Part 180. Management was aware that Suspension & Debarment verification is required for subawards, but did not realize that this requirement also extends to vendors when procuring goods or services in excess of $25,000. Washington Maritime Blue’s management is committed to ongoing professional development in order to maintain the highest standards for financial reporting and regulatory compliance, and we became aware of this error mid-way through the year under audit. At that point, we took the following corrective action: o Contract templates were updated to include Suspension & Debarment terms. This updated template was used for all new purchase contracts. • Unfortunately, several federally-funded purchase contracts in excess of $25,000 had already been entered into before this update was made to our processes. We acknowledge that regulations related to Suspension & Debarment were not observed with respect to these earlier purchases, but are confident that the error will not be completed moving forward. Contact Person: Daniel Pulse, CFO Anticipated completion date: November 2025, Corrective action has been completed.
Corrective Action Plan Contact Person(s): Janet Carbary, Deana Gilpin Management agrees with this finding and recognizes the need to strengthen internal controls over purchasing processes to ensure compliance with Uniform Guidance requirements (§200.317–§200.326; §200.213). To address the deficiency...
Corrective Action Plan Contact Person(s): Janet Carbary, Deana Gilpin Management agrees with this finding and recognizes the need to strengthen internal controls over purchasing processes to ensure compliance with Uniform Guidance requirements (§200.317–§200.326; §200.213). To address the deficiency, the Organization will implement the following actions: 1. Update Purchasing Policies and Procedures o Purchasing policies will be revised to clearly incorporate Uniform Guidance requirements, including competitive bidding thresholds, procurement method selection, and documentation standards. o Policies will explicitly require verification of suspension and debarment status for all vendors receiving federal funds. 2. Implement Mandatory Suspension and Debarment Verification o Staff will be required to document verification through SAM.gov or other approved sources before awarding or renewing contracts funded by federal awards. o A verification will be maintained and reviewed by Finance leadership. 3. Enhance Procurement Documentation Controls o Leadership will ensure all federal purchases meet the requirement below before purchase approval. • Competitive purchasing requirements are met • Cost/price analyses are documented when required • Suspension/debarment verifications are completed and retained 4. Training for Finance Staff o Staff involved in purchasing, contract approval, and grant management will receive training on Uniform Guidance procurement rules and suspension/debarment requirements. 5. Periodic Internal Monitoring o Revenue accountant will monitor expenses related to federal programs monthly to ensure compliance. o Senior management will be notified if corrective steps are needed. Anticipated Completion Date: December 31, 2025 Responsible Officials: • Chief Financial Officer (CFO) • Accounting Manager • Director of Financial Planning
Rural Housing Site Loan - Federal Assistance Listing #10.411 Recommendation: The Organization should implement a formal internal control policy over the suspension and debarment rules and follow them before entering into a covered transaction with another entity and that this search is reviewed. Exp...
Rural Housing Site Loan - Federal Assistance Listing #10.411 Recommendation: The Organization should implement a formal internal control policy over the suspension and debarment rules and follow them before entering into a covered transaction with another entity and that this search is reviewed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will implement and follow a suspension and debarment policy in accordance with 2 CFR section 180.995 and specify the review of a vendor must be done prior to entering into a covered transaction. Names of the contact persons responsible for corrective action: Nicole Olson, Office Manager Planned completion date for corrective action plan: June 30, 2026
The following actions will be taken to ensure compliance with the Uniform Guidance requirements over internal controls: Management concurs with the finding. Effective immediately, The Greater Washington Community Foundation has implemented the following corrective actions: (1) Prior to entering into...
The following actions will be taken to ensure compliance with the Uniform Guidance requirements over internal controls: Management concurs with the finding. Effective immediately, The Greater Washington Community Foundation has implemented the following corrective actions: (1) Prior to entering into any subaward agreement involving federal funds as well as at the time of each payment, designated staff will verify that potential subrecipients are not suspended or debarred by conducting searches in the System for Award Management (SAM) at www.sam.gov, with documentation maintained in the grant file. This verification will also be performed when subaward agreements are amended or extended. (2) The standard subaward agreement template will be updated to include all required information specified in 2 CFR §200.332(b)(1), including the federal assistance listing number, subrecipient's unique entity identifier, federal award project description, amount of federal funds obligated, total federal award amount, applicable compliance requirements, and reporting and monitoring requirements. To strengthen ongoing compliance, the Foundation's procurement and cash management policies have been updated to incorporate these federal compliance requirements and will be reviewed annually. Given that federal funding is not received on a recurring basis, upon receipt of future federal funding, the Controller will serve as the Compliance Coordinator with full oversight of compliance activities. The Controller will review applicable federal regulations, update internal procedures as necessary, and provide comprehensive training to appropriate staff managing the contract to ensure adherence to all grant requirements. The finance team will complete a quarterly review process to verify that all active federal subawards contain required compliance elements, with the Controller maintaining oversight of this review and reporting any deficiencies to the Chief Financial Officer for immediate remediation. Individual Responsible for Corrective Action Plan: Contact: Rachel Crawford Title: Controller Phone Number: 202-303-2437 Estimated Completion Date: December 31, 2025
Training for grant manager and all employees of the purchasing division will be mandatory. Grant manager to review all City grants, ensuring that the City complies with each grant agreement's terms. Purchasing Manager will review current purchase order procedures to ensure purchase orders are not ap...
Training for grant manager and all employees of the purchasing division will be mandatory. Grant manager to review all City grants, ensuring that the City complies with each grant agreement's terms. Purchasing Manager will review current purchase order procedures to ensure purchase orders are not approved when formal contracts are required.
Recommendation: We recommend the District maintain records that all vendors are not on the suspended or debarred listing. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensu...
Recommendation: We recommend the District maintain records that all vendors are not on the suspended or debarred listing. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensure records are retained for verification compliance. Name of the contact person responsible for corrective action: Lauren Syrup, Business Manager Planned completion date for corrective action plan: June 30, 2026
2025-003 – UNALLOWABLE COSTS Corrective Action Plan: The School District staff has subsequently reviewed all reimbursements under the Fresh Fruits and Vegetables Program grant and has repaid the funds to the Michigan Department of Education in the amount of $2,178.68. In the future when a new grant ...
2025-003 – UNALLOWABLE COSTS Corrective Action Plan: The School District staff has subsequently reviewed all reimbursements under the Fresh Fruits and Vegetables Program grant and has repaid the funds to the Michigan Department of Education in the amount of $2,178.68. In the future when a new grant is received, the School District will print the grant documents and review them with the necessary employees to ensure they are aware of the allowable and unallowable costs. Additionally, all invoices will be reviewed by the Food Service Director prior to being submitted to the business office for payment. Responsible Party(ies): • Food Service Head Cook Anticipated Completion Date: December 31, 2025
Corrective Action Plan: Effective September 2025, the District has implemented a procedure to perform this review on vendors associated with federal grants annually. Responsible School District Official: Jennifer Mulligan, Director of Business and Finance Completion Date: September 30, 2025
Corrective Action Plan: Effective September 2025, the District has implemented a procedure to perform this review on vendors associated with federal grants annually. Responsible School District Official: Jennifer Mulligan, Director of Business and Finance Completion Date: September 30, 2025
Finding 2025-002: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 and entity-wide Recommendation: Our auditors recommended that we schedule and hold an annual meeting of the board of directors and document minutes ...
Finding 2025-002: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 and entity-wide Recommendation: Our auditors recommended that we schedule and hold an annual meeting of the board of directors and document minutes and the annual report of directors. Additionally, they recommended that we adopt a board governance calendar with statutory checkpoints (annual meeting, director elections, policy reviews) and assign responsibility for compliance tracking. Action Taken: Sacred Heart Apartments has drafted an annual report of directors and are in the process of scheduling an annual meeting. Additionally, Sacred Heart Apartments has implemented a governance calendar and checklist. Name of Contact Person Responsible for Corrective Action: John Lutz, Vice President of Finance, (315) 424- 1821. Anticipated Completion Date: March 31, 2026
Finding 2025-002: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 and entity-wide Recommendation: Our auditors recommended that we schedule and hold an annual meeting of the board of directors and document minutes ...
Finding 2025-002: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 and entity-wide Recommendation: Our auditors recommended that we schedule and hold an annual meeting of the board of directors and document minutes and the annual report of directors. Additionally, they recommended that we adopt a board governance calendar with statutory checkpoints (annual meeting, director elections, policy reviews) and assign responsibility for compliance tracking. Action Taken: Bishop Harrison Apartments has drafted an annual report of directors and are scheduling an annual meeting. Additionally, Bishop Harrison Apartments has implemented a governance calendar and checklist. Name of Contact Person Responsible for Corrective Action: John Lutz, Vice President of Finance, (315) 424- 1821. Anticipated Completion Date: March 31, 2026
Finding 2025-002: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 and entity-wide Recommendation: Our auditors recommended that we schedule and hold an annual meeting of the board of directors and document minutes ...
Finding 2025-002: Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects, Federal Assistance Listing Number 14.155 and entity-wide Recommendation: Our auditors recommended that we schedule and hold an annual meeting of the board of directors and document minutes and the annual report of directors. Additionally, they recommended that we adopt a board governance calendar with statutory checkpoints (annual meeting, director elections, policy reviews) and assign responsibility for compliance tracking. Action Taken: Pompei North Apartments has drafted an annual report of directors and are in the process of scheduling an annual meeting. Additionally, Pompei North Apartments has implemented a governance calendar and checklist. Name of Contact Person Responsible for Corrective Action: John Lutz, Vice President of Finance, (315) 424- 1821. Anticipated Completion Date: March 31, 2026
2025-001 – Suspension and Debarment Auditor Description of Condition and Effect. For the four vendors selected for testing, the District was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods or services. As ...
2025-001 – Suspension and Debarment Auditor Description of Condition and Effect. For the four vendors selected for testing, the District was unable to provide evidence that the vendors were not suspended, debarred, or otherwise excluded at the time they were engaged to provide goods or services. As a result of this condition, the District was exposed to an increased risk that disbursements of federal awards could be made to vendors or subrecipients suspended or debarred by the federal government. Auditor Recommendation. We recommend that the District review its written policies and procedures over federal awards with employees responsible for grant compliance to ensure that they are being followed consistently. Responsible Person: Kimberly Worden, Business Manager Corrective Action. The District will implement a process to ensure that, for any covered procurement or nonprocurement transaction, documentation is maintained confirming suspension and debarment verification was completed prior to executing the transaction. Anticipated Completion Date: June 30, 2026
Suspension and Debarment Special Education Cluster (Special Education – Grants to States and Special Education – Preschool Grants) Assistance Listing No. 84.027 and 84.173 Recommendation: Auditors recommend the District revise its policies and procedures to ensure that documentation as to the date o...
Suspension and Debarment Special Education Cluster (Special Education – Grants to States and Special Education – Preschool Grants) Assistance Listing No. 84.027 and 84.173 Recommendation: Auditors recommend the District revise its policies and procedures to ensure that documentation as to the date of the review of suspension and debarment status is maintained with the procurement history of each transaction that requires such a search. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District changed all the requisition/PO groups and any po that comes in for approval over the $25,000 threshold will go to the purchasing department first. The purchasing department will verify the vendor and attach the documentation to the purchase order. The purchase order can then go through the approval process. This process will eliminate any contracts/purchases to go through without being verified first. Name(s) of the contact person(s) responsible for corrective action: Michael Kurtz Planned completion date for corrective action plan: December 4, 2025
Suspension and Debarment Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The organization did not document that Sam.gov was checked prior to entering into a contract with a vendor. Recommendation: We recommend that the organizatio...
Suspension and Debarment Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The organization did not document that Sam.gov was checked prior to entering into a contract with a vendor. Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent practicable, the organization can engage with a third party that will verify any new and existing vendors have not been suspended or debarred on a monthly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management recognizes that even though none of the vendors utilized were suspended, debarred or otherwise excluded, the potential for violations increase if the verification is not done prior to engaging in transactions. For grant expenses with federal funding, LCHC management has implemented mandatory SAM.gov verification for all vendors prior to contract execution, with documentation retained in procurement files. LCHC has held meetings where applicable staff have been informed of compliance requirements. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Nelson Planned completion date for corrective action plan: 7/1/2025 If there are any questions regarding this plan, please call Jeffrey Nelson at 872-588-3033
Procurement Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The Organization did not follow the procedures outlined within its internal policies related to maintaining documentation associated with purchases made via the simplifie...
Procurement Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Program – Assistance Listing No. 93.323 Condition: The Organization did not follow the procedures outlined within its internal policies related to maintaining documentation associated with purchases made via the simplified acquisition method of procurement. Recommendation: We recommend the organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management acknowledges that even though grant objectives were met, procurement procedures must be followed regardless of timeline constraints. Management has implemented enhanced controls to ensure compliance with internal procurement policies, including: (1) mandatory documentation for simplified acquisitions requiring evidence of price reasonableness; (2) staff meetings on procurement requirements; and (3) supervisory review of procurement files prior to grant invoice submission. Name(s) of the contact person(s) responsible for corrective action: Jeffrey Nelson Planned completion date for corrective action plan: 7/1/2025
Management’s Response/Corrective Action Plan (Unaudited): Management concurs with the finding. While procedures for verifying vendor eligibility are in place, KANZA acknowledges that documentation of suspension and debarment checks was not consistently retained during the audit period. Management re...
Management’s Response/Corrective Action Plan (Unaudited): Management concurs with the finding. While procedures for verifying vendor eligibility are in place, KANZA acknowledges that documentation of suspension and debarment checks was not consistently retained during the audit period. Management recognizes the importance of maintaining complete and verifiable documentation in accordance with federal procurement requirements. KANZA will implement the following actions to remediate the identified deficiency and strengthen compliance with suspension and debarment regulations: 1. Revision of Internal Procedures: Procurement policies will be updated to explicitly require suspension and debarment verification for all vendors prior to engagement and annually thereafter. Verification will be completed through SAM.gov. 2. Standardized Documentation Protocol: A standardized verification form will be implemented and required for all vendor files. The form will document the verification method, date, and staff member responsible. 3. Centralized Tracking and Monitoring: KANZA will maintain a centralized log of all suspension and debarment verifications. The log will be reviewed quarterly by the Director of Operations to ensure compliance with established procedures. 4. Staff Training: All staff involved in procurement, purchasing, and vendor management will receive training on suspension and debarment requirements and documentation standards. Training completion will be recorded. 5. Internal Compliance Reviews: Semiannual reviews of vendor files will be conducted to confirm the presence and completeness of required verification documentation. Corrective measures will be taken immediately for any identified deficiencies. Planned Completion Date: March 31, 2026 Contact Person Responsible for Correction Action: Shelby Donahoo, Director of Finance and Operations
The District will stregthen controls to ensure all expenditures charged to federal programs are allowable, properly documented, and comply with the Uniform Guidance (2 CFR Part 200). 1. Policy and Procedure development: Written procedures will be implemented defining allowable costs, budget approval...
The District will stregthen controls to ensure all expenditures charged to federal programs are allowable, properly documented, and comply with the Uniform Guidance (2 CFR Part 200). 1. Policy and Procedure development: Written procedures will be implemented defining allowable costs, budget approval processes, and documentation requirements for federal programs. 2. Pre-approval and Documentation: All expenditures charged to federal awards must receive prior approval from the Program Director and Business Manager, accompanied by invoices, purchase orders, and justification forms referencing the applicable federal cost principle. 3. Monthly Monitoring: The Business Manager will review program expenditures monthly for compliance with allowable cost principles and promptly correct any mischarges. 4. Training: Federal program staff and members of the CSG grants Committee will receive annual training on allowable costs, cost allocation, and time-and effort reporting.
The District Cafeteria Manager, Melanie Pardini, corrected this procedure for fiscal year 2025-26 and has the process in place going forward for each fiscal year.
The District Cafeteria Manager, Melanie Pardini, corrected this procedure for fiscal year 2025-26 and has the process in place going forward for each fiscal year.
Finding 2025-005 Lack of Internal Controls over Activities Allowed or Unallowed, Allowable Costs/Cost Principles Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Invoices will be approved for payment by the person who receives the product and then approved also by th...
Finding 2025-005 Lack of Internal Controls over Activities Allowed or Unallowed, Allowable Costs/Cost Principles Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Invoices will be approved for payment by the person who receives the product and then approved also by the food service coordinator. No unallowable costs will be paid for with food service revenue. Proposed Completion Date: Fiscal Year 2026.
Condition: The School District's internal controls did not effectively identify the required formal solicitation. The School District did not utilize the appropriate competitive procurement methods and did not retain suspended or debarred verification documentation. Planned Corrective Action: The Sc...
Condition: The School District's internal controls did not effectively identify the required formal solicitation. The School District did not utilize the appropriate competitive procurement methods and did not retain suspended or debarred verification documentation. Planned Corrective Action: The School District will ensure that the proper procurement methods are adhered to, prior to executing future contracts. This includes also reviewing to ensure that vendors are not suspended or debarred, prior to awarding the contract. To accomplish this, the School District will use their grant budget process as a control for identifying the population of applicable expenditures that will be subject to procurement compliance requirements for federal programs. Contact person responsible for corrective action: Kyle Jen, Chief Financial and Operations Officer Anticipated Completion Date: 6/30/2026
Finding 2025-002 Lack of Internal Control Over Reporting Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all federal reports are properly prepared and values reflect actual values in the accounting software. Proposed Completion Date: December 31, 2025.
Finding 2025-002 Lack of Internal Control Over Reporting Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all federal reports are properly prepared and values reflect actual values in the accounting software. Proposed Completion Date: December 31, 2025.
Finding 2025-001 Lack of Internal Control Over Procurement Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all procurements follow Board polices relating to bids and procurement, including written documentation for sole source and procurements and exemptions. Proposed Compl...
Finding 2025-001 Lack of Internal Control Over Procurement Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all procurements follow Board polices relating to bids and procurement, including written documentation for sole source and procurements and exemptions. Proposed Completion Date: December 31, 2025.
Management concurs with the finding and will implement procedures to retain evidence of suspension and debarment reviews for all vendors and subrecipients under federally funded programs.
Management concurs with the finding and will implement procedures to retain evidence of suspension and debarment reviews for all vendors and subrecipients under federally funded programs.
The Town will add language to their future contracts to ensure the vendor is not suspended or debarred.
The Town will add language to their future contracts to ensure the vendor is not suspended or debarred.
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