Corrective Action Plans

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Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael El...
Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will implement formal Section 3 policies and procedures for applicable CDBG projects. The policies will identify applicable projects, assign responsibility for compliance monitoring, establish worker certification and documentation requirements, and provide for documentat...
Corrective Action: The City will implement formal Section 3 policies and procedures for applicable CDBG projects. The policies will identify applicable projects, assign responsibility for compliance monitoring, establish worker certification and documentation requirements, and provide for documentation retention and periodic review procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated October 2026.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Finding 2025-002: Community Development Block/Grants/ State's Program and Non-Entitlement Grants in Hawaii Assistance Listing No. 14.228 Compliance Requirement: Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Compliance (material nonco...
Finding 2025-002: Community Development Block/Grants/ State's Program and Non-Entitlement Grants in Hawaii Assistance Listing No. 14.228 Compliance Requirement: Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The City should establish and implement formal policies and procedures requiring weekly certified payrolls be obtained and reviewed against the applicable Davis-Bacon wage requirment before contractor payment. The review should be documented and include evidence of comparison of labor classifications, wage rates, fringe benefits, and reviewer approval. Action Taken: Management will establish comprehensive, formal policies and procedures to ensure strict compliance with Davis-Bacon regulations alongside all applicable federal and state grant requirments. If there are questions regarding this plan, pleasecall the responsible parties listed below. Sincerely yours, Heather Sanchez City Manager City of Alamosa, Colorado Emily Martinez Finance Director City of Alamosa, Colorado
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environm...
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environment. The Foundation maintains controls designed to ensure that expenditures charged to federal awards are reviewed for allowability, properly supported, and approved before submission for reimbursement. In this instance, a subsequent reimbursement from the lender was not identified through the Foundation's normal monitoring process. Management contacted the grantor and resolved the matter by applying other allowable expenditures to the federal award, thereby eliminating any duplicate recovery of federal funds. To further strengthen existing controls, the Foundation has enhanced its procedures to specifically track expenditures submitted for reimbursement under federal programs and monitor any subsequent refunds, credits, rebates, or reimbursements received from vendors or other third parties related to those expenditures. In addition, management will document a post-submission review process to identify vendor credits or recoveries received after reimbursement requests have been submitted and determine whether any adjustment to future reimbursement requests or repayment to the granting agency is required.
The Center for Advanced Defense Studies (C4ADS) acknowledges the finding related to disbursement approvals and the instance where required pre-disbursement authorization was not documented in the system. Existing C4ADS policy requires the approval of the budget manager before finance team approval o...
The Center for Advanced Defense Studies (C4ADS) acknowledges the finding related to disbursement approvals and the instance where required pre-disbursement authorization was not documented in the system. Existing C4ADS policy requires the approval of the budget manager before finance team approval on all credit card transactions — this sequence ensures that someone with operational authority verifies necessity and project relevance before charges are recorded. The accounting manager, as the administrator of the credit card online portal, has the ability to override/approve out of sequence with approval from the Senior Director of Operations. Due to staff turnover, the accounting manager inadvertently approved a charge out of cycle. Divvy does not permit retroactive correction of approval order and the accounting manager failed to appropriately document the event. As a result of this finding, C4ADS has implemented the following corrective actions: ● Strengthen Approval Controls: C4ADS added an additional review step where the Director of Finance and the Senior Director of Operations review all credit card charges to ensure all charges have two approvers. In cases where the charge has one approver, the Director of Finance confirms with the Senior Director of Operations that the final coding is appropriate prior month ending billing and month end reporting. ● Enhance Documentation and Monitoring: To demonstrate review, the Director of Finance communicates any anomalies to the Senior Director of Operations via Monday.com, C4ADS’ online ticket and tracking system. The Senior Director of Operations approval, or rejection, is logged in that system. ● Staff Training and Reinforcement: Additional training has been provided to the accounting department related to the approval override system and the appropriate documentation. These measures have been implemented and incorporated into ongoing financial processes to ensure all disbursements are properly authorized and documented.
2025-004 Uniform Guidance Audit Submission CONTACT PERSON: Cing Huai, Treasurer ANTICIPATED COMPLETION DATE: June 30, 2027 VIEW OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a...
2025-004 Uniform Guidance Audit Submission CONTACT PERSON: Cing Huai, Treasurer ANTICIPATED COMPLETION DATE: June 30, 2027 VIEW OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facilitate a timely audit submission as set forth in the Uniform Guidance.
Finding No.: 2025-003 Condition: During our testing of expenditures submitted for reimbursement under the Special Education Grant, we noted that expenditures included in reimbursement requests were difficult to reconcile to supporting documentation and the District's accounting records. Specifically...
Finding No.: 2025-003 Condition: During our testing of expenditures submitted for reimbursement under the Special Education Grant, we noted that expenditures included in reimbursement requests were difficult to reconcile to supporting documentation and the District's accounting records. Specifically, amounts recorded within the general ledger for certain purchased services and supplies and materials expenditures were incomplete and could not independently support the amounts claimed for reimbursement. District personnel were required to provide additional grant tracking schedules and other supporting records to reconcile the expenditures reported for reimbursement. Plan: Management agrees with the finding and will strengthen grant tracking and reconciliation procedures to ensure expenditures submitted for reimbursement are fully supported, accurately recorded in the general ledger, and readily traceable to the underlying documentation. Anticipated Date of Completion: 6/30/2027 Name of Contact Person: Scott, Assistant Superintendent for Business Services/CSBO Management Response: N/A
Management Response: Management agrees with the finding. The reporting package and Data Collection Form were not submitted by the required deadline. While the delay was primarily the result of significant staffing shortages within the Finance Department during the reporting period, management recogn...
Management Response: Management agrees with the finding. The reporting package and Data Collection Form were not submitted by the required deadline. While the delay was primarily the result of significant staffing shortages within the Finance Department during the reporting period, management recognizes that it remained the City's responsibility to ensure timely compliance with federal reporting requirements. To address this issue, the City will implement a formal tracking process for all federal reporting requirements, maintain a compliance calendar, clearly assign responsibility for monitoring submission deadlines, and require management review prior to submission. These procedures are expected to strengthen internal controls, improve oversight of compliance deadlines, and ensure timely submission of future reporting packages in accordance with Uniform Guidance requirements. Anticipated Completion Date: 06/30/2026 Responsible Person: Mandy Kellogg, Administrative Services Director
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Supplemental Nutrition Assistance Program Cluster & Medical Assistance Assistance Listing Numbers: 10.561 and 93.778 Federal Award Identification Numbers and Years: 252MN101S2514 – 2025 & 2505MN5ADM – 2025 Passed Thro...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Supplemental Nutrition Assistance Program Cluster & Medical Assistance Assistance Listing Numbers: 10.561 and 93.778 Federal Award Identification Numbers and Years: 252MN101S2514 – 2025 & 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55250010 & H58260061 & H55255048 Compliance Requirement: Allowable Activities Award Period: 2025 Recommendation: We recommend that the County review its procedures and control to ensure all RMS listings sent to the State properly exclude those necessary individuals no longer working in the programs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will increase coordination with human resources to obtain data on employee turnover as timely as possible and also ensure that the listings are reviewed prior to submission going forward. Name of the contact person responsible for corrective action: Tiffinie Miller, Deputy Director of Employment & Economic Assistance Planned completion date for corrective action plan: December 31, 2026
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Numbers: 93.778 Federal Award Identification Numbers and Years: 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55255048 Comp...
Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Medical Assistance Assistance Listing Numbers: 93.778 Federal Award Identification Numbers and Years: 2505MN5ADM – 2025 Passed Through Entity: Minnesota Department of Human Services Pass Through Number: H55255048 Compliance Requirement: Special Provisions Award Period: 2025 Recommendation: We recommend that the County reviews its polices and controls to ensure there is a formally documented control that ensures all required training of LCTS fiscal site contacts is completed and the documentation of the completions of the training is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will share the Minnesota DHS previously recorded “LCTS Fiscal & Cost Schedule” training video with all new Fiscal Site Contacts that prepare cost schedules. County staff will then follow-up with the new Fiscal Site Contacts with a brief quiz to ensure they watched the training video and know how to capture only applicable costs in the cost schedule reports. Then, the LCTS Training Verification Form will be completed, signed by the applicable parties, and emailed to the LCTS Project Manager at Minnesota DHS. The communications sharing the training video, responses to the brief quiz, and LCTS Training Verification Form will be maintained as documentation of the completion of the required trainings. Name of the contact person responsible for corrective action: Lucas Chase, Audit Manager Planned completion date for corrective action plan: December 31, 2026
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully t...
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebecca Holden Planned completion date for corrective action plan: 6/30/2026
Finding 2025-002: Financial Reports and Recognition of Grant Revenue Plan: NERHA originally contracted with a partner to provide financial services with the understanding that there were industry-standard systems and policies in place that were sufficient to manage and account for transactions from ...
Finding 2025-002: Financial Reports and Recognition of Grant Revenue Plan: NERHA originally contracted with a partner to provide financial services with the understanding that there were industry-standard systems and policies in place that were sufficient to manage and account for transactions from multiple federal and state funders. The true magnitude of the gap between the financial services provider’s financial policies and controls and NEHRA’s complex funding streams only became apparent during this audit period. The lack of financial reporting and the errors in grant invoicing (budgeted vs. actual allocations) stemmed from the number of transitions in accounting software systems and payroll systems during this period in the process of remedying the previous year’s findings and the third-party accounting provider's inability to deliver monthly financial packages during this period due to the requirement for reconciliation and adjustments to opening balances and deferred program accounts. To remediate this, management has implemented the following controls under the new Managed Service Agreement: • Timely Reporting: Once the Audit adjusting journal entries have been completed in the accounting software, GAAP-compliant monthly financial reports will be run within 15 days of month-end close process for management and board review. • Actual Cost Invoicing: Management will discontinue tracking grant expenditures using historical spreadsheet methods vulnerable to human error. Payroll and non-payroll allocations are now integrated into the accounting software and the General Ledger expenditures will be used for payroll expenses, ensuring grant invoicing is driven strictly by actual, documented expenditures rather than budgeted amounts. • Management Review: The COO will perform a monthly reconciliation of actual payroll logs against general ledger allocations prior to grant reimbursement submissions and double-verify that payroll logs match planned and worked hours. • Resolution of Overbilled Funds: Regarding the $17,104 in overbilled grant revenue, management is actively coordinating with the respective pass-through and federal granting agencies to either apply these excess amounts as a credit against current invoices or return the funds directly. Expected Completion Date: December 2026 Contacts: Ann Marie Day, Chief Operating Officer, and Andy Lowe, Executive Director New England Rural Health Association 207-228-5966 amday@newenglandrha.org andy@newenglandrha.org
Program Name: Emergency Housing Voucher (EHV) Program (Housing Voucher Cluster) 14.EHV During the audit of the financial statements for the year ended September 30, 2025, testing of Emergency Housing Voucher (EHV) program activity identified that approximately $90,317 of EHV funds were used for acti...
Program Name: Emergency Housing Voucher (EHV) Program (Housing Voucher Cluster) 14.EHV During the audit of the financial statements for the year ended September 30, 2025, testing of Emergency Housing Voucher (EHV) program activity identified that approximately $90,317 of EHV funds were used for activities outside of the EHV program - specifically, within the Moving to Work (MTW) Demonstration Program - without a waiver or approval from HUD. EHV funds are restricted to activities allowable under the EHV program and are not subject to MTW funding fungibility; any application of MTW administrative flexibilities to EHV vouchers requires HUD approval before implementation. The Authority did not maintain adequate controls to ensure EHV funds were restricted to allowable EHV expenditures or to verify that appropriate HUD approval was obtained prior to using EHV funds for non-EHV activities. As a result, federal funds may have been expended for purposes not authorized under the EHV program, resulting in noncompliance with federal requirements and questioned costs of $90,317. This condition represents noncompliance and a significant deficiency in internal control over compliance. Questioned Costs: $90,317 The Authority concurs with the finding and questioned costs of $90,317. The Authority will strengthen controls over federal program expenditures to ensure EHV funds are used solely for allowable EHV activities; establish procedures to obtain and retain documentation of any HUD approvals or waivers before applying MTW flexibilities to EHV vouchers or using EHV funds outside of their intended purpose; work with HUD to resolve the questioned costs; and provide staff training on EHV program eligibility and allowable-cost requirements.Timeline for completion: 3 months
Compliance Deficiencies Identified in HUD Monitoring Review (Repeat of Finding 2024-006) Program Name: N/A ALN: N/A Description: The compliance deficiencies identified in the U.S. Department of Housing and Urban Development (HUD) Compliance Monitoring Review conducted June 24-28, 2024 (formalized in...
Compliance Deficiencies Identified in HUD Monitoring Review (Repeat of Finding 2024-006) Program Name: N/A ALN: N/A Description: The compliance deficiencies identified in the U.S. Department of Housing and Urban Development (HUD) Compliance Monitoring Review conducted June 24-28, 2024 (formalized in HUD's letter dated March 24, 2025) remained unresolved as of September 30, 2025. The open items span multiple program areas, including governance and internal controls, HoJsing Choice Voucher (HCV) program compliance, Project-Based Voucher (PBV) documentation, Public Housing operations, ROSS grant administration, Violence Against Women Act (VAWA) policy, and Section 3 compliance. This condition is a repeat of prior year finding 2024-006. Planned Corrective Action: The Authority concurs with the finding and acknowledges it is a repeat of finding 2024-006. Maintain a remediation tracker; implement corrective actions identified by HUD; conduct training and file reviews; submit required certifications; and provide progress updates until all items are closed. Timeline for completion: 6 months
During testing of the MTW Demonstration Program - Capital Fund Program (CFP), four eLOCCS drawdown vouchers were identified for which funds were drawn down but not disbursed within a reasonable timeframe (ranging from 7 to 36 days after deposit), contrary to the federal immediate-disbursement ("just...
During testing of the MTW Demonstration Program - Capital Fund Program (CFP), four eLOCCS drawdown vouchers were identified for which funds were drawn down but not disbursed within a reasonable timeframe (ranging from 7 to 36 days after deposit), contrary to the federal immediate-disbursement ("just-in-time") requirement. Planned Corrective Action: The Authority will implement a process to ensure that Capital Fund Program drawdowns are requested only when funds are needed for immediate disbursement, consistent with federal ca􀀉h management ("just-in-time") requirements. Drawdowns will be reconciled to disbursements, the elapsed time between each drawdown and the related disbursement will be monitored, and any excess cash held will be returned or interest remitted to HUD as required.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District only charge costs that are allowable under the grant agreement. We also recommend that the District contact ISBE to discuss if the District will need to return the funds reimbursed by the Illinois Sch...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District only charge costs that are allowable under the grant agreement. We also recommend that the District contact ISBE to discuss if the District will need to return the funds reimbursed by the Illinois School Board of Education for these unallowed expenditures. Corrective Action: The District will ensure that all costs charged to the Title I grant are allowable per the grant agreement going forward.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the Superintendent approves all timesheets and the approval is documented and maintained. Corrective Action: The Superintendent will begin to document his approval for all timesheets. Proposed Completion Date: Imm...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the Superintendent approves all timesheets and the approval is documented and maintained. Corrective Action: The Superintendent will begin to document his approval for all timesheets. Proposed Completion Date: Immediately.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-a...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-annual certifications of time and effort distribution records. Proposed Completion Date: Fiscal year 2026.
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes th...
2025-002: Missing Supporting Documentation Action Taken/Planned: Management acknowledges the instance identified in which supporting documentation for a federal award disbursement could not be located at the time of audit. While this appears to be an isolated occurrence, the University recognizes the importance of maintaining complete and readily accessible documentation to support all federal expenditures in accordance with institutional policy and federal compliance requirements. The University will reinforce documentation and record retention requirements with all relevant personnel, including finance staff, grant administrators, and principal investigators. Additionally, management will implement enhanced controls to ensure that all required supporting documentation is properly maintained and centrally accessible. This will include transitioning toward a more standardized and, where feasible, electronic document management process to reduce the risk of missing records. Furthermore, periodic monitoring procedures will be established, including routine reviews of disbursement files to confirm the presence of required supporting documentation. Any identified deficiencies will be promptly addressed, and corrective actions will be taken to prevent recurrence. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
Finding 1224391 (2025-002)
Material Weakness 2025
Fraser
MN
Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: During testing there was an instance identified were an unallowed payroll item in the amount of $761.08 was submitted for reimbursement. In addition, there was no documented review of the reimbursement reques...
Cash Management Significant Deficiency in Internal Control over Compliance Finding Summary: During testing there was an instance identified were an unallowed payroll item in the amount of $761.08 was submitted for reimbursement. In addition, there was no documented review of the reimbursement request prior to submission. Responsible Individuals: Jim Strickland, Jim Olson Corrective Action Plan: We have designated a member of management to review more extensively reimbursement requests at a more detailed level prior to submission. Anticipated Completion Date: Already in place
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