Corrective Action Plans

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This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, ...
This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding in conjunction with Finding 2024-005 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. The new Finance Team leadership have reinstated use of the class system in our general ledger to allocate direct costs to specific programs and clearly separate non-reimbursable expenses. Monthly reconciliations will be performed to ensure qualifying costs align with cash draw requests. Accounting staff have or will receive targeted training on cost allocation principles and documentation standards to support this effort.
Filing of Data Collection Form and Reporting Package Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete the filing of data collection form and reporting package on a timely b...
Filing of Data Collection Form and Reporting Package Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete the filing of data collection form and reporting package on a timely basis. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over filing and reporting on the Data Collection Form and has reviewed the policies and procedures with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely filing. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
Improve Controls over the Preparation of the Schedule of Expenditures of Federal of Awards Department’s Response: Management is in agreement with the recommendation and has updated their policy subsequent to year-end. Views of Responsible Offices and Corrective Action Plan: Management agrees with th...
Improve Controls over the Preparation of the Schedule of Expenditures of Federal of Awards Department’s Response: Management is in agreement with the recommendation and has updated their policy subsequent to year-end. Views of Responsible Offices and Corrective Action Plan: Management agrees with this and will implement the below to its financial policies and procedures manual: Post-Award Procedures - After an award has been made, the following steps shall be taken: 1.Verify the specifications of the grant or contract. The finance department shall review the terms, time periods, award amounts and expected expenditures associated with the award. A CFDA (Catalog of Federal Domestic Assistance) number shall be determined for each award. All reporting requirements under the contract or award shall be summarized. 2.Create new general ledger account numbers. New accounts shall be established for the receipt and expenditure categories in line with the grant or contract budget. 3.Gather documentation. A file is established for each grant or contract. The file contains the proposal, all correspondence regarding the grant or contract, the final signed award document and all reports submitted to the funding sources. 4.Management will prepare a SEFA and share with the auditor to determine when the schedule is presented fairly in all material respects in relation to the financial statements as a whole. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors...
Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors will be adjusted each period to ensure that account and ledger totals are properly maintained and recorded. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over bank reconciliations, accounts payable and grants receivable. Controls and the policies and procedures have been reviewed with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely reconciliations. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026
2024-004—Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are co...
2024-004—Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: May 31, 2026
We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.
We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.
2024-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The School did submit their audit for the fiscal year ending June 30, 2024 timely. The audit was submitted May 1, 2026, which was 396 days past the March 31, 2025 deadline. Action plan in response to the finding: The Pr...
2024-004: Reporting Type of Finding: Noncompliance, Material Weakness Condition: The School did submit their audit for the fiscal year ending June 30, 2024 timely. The audit was submitted May 1, 2026, which was 396 days past the March 31, 2025 deadline. Action plan in response to the finding: The Principal will ensure that all required audit documentation is organized, complete, and readily available to the auditors upon request. This includes maintaining updated financial records, supporting documents, reconciliations, and schedules throughout the fiscal year so that materials can be provided promptly during the audit process. To support timely completion of the annual audit, the Principal will formally request the 2025 audit to be completed by August 30, 2026. This timeline allows adequate opportunity for fieldwork, review, and finalization of the audit report. The Principal will monitor progress, respond quickly to auditor inquiries, and verify that the final audit report is submitted within the required timeframe. The 2026 Audit Request for Proposal will be submitted at the End of April 2026 for School Board approval. Repeat Finding: No. Planned completion date for a corrective action plan: June 30, 2026 Name of the contact person responsible for corrective action: Marie Rose, Principal | Lynnette Greyeyes, Business Manager
Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit...
Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit for the year ended December 31, 2024 within the required nine month deadline under 2 CFR 200.512. As of September 30, 2025, no single audit report has been issued or filed, resulting in noncompliance with federal audit requirements. Views of Responsible Officials and Corrective Action Plan: Management has developed and implemented corrective actions to address this finding. As of January 1, 2026, formal procedures for FAC submission have been established, including defined roles, internal deadlines, and review protocols. A compliance tracking system has been implemented to monitor key reporting deadlines, and staff have received training on federal requirements. Management will continue to monitor adherence to these procedures to ensure timely submission in future reporting periods. Implementation date: January 1, 2026
Finding No.2024-002: Maintain Supporting Documentation for Required Federal Reports Finding: During our testing of 24 reporting samples, we identified two (2) instances wherein Quarterly Expenditure Reports related to the grant of Council on American Islamic Relations, San Francisco Bay Area Office ...
Finding No.2024-002: Maintain Supporting Documentation for Required Federal Reports Finding: During our testing of 24 reporting samples, we identified two (2) instances wherein Quarterly Expenditure Reports related to the grant of Council on American Islamic Relations, San Francisco Bay Area Office (CAIR-SFBA), including the evidence of submission (e.g. confirmation emails or system-generated receipts), were not available for review. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already implemented reporting procedures to include the retention of submission confirmations as part of its grant documentation. Because the organization’s first single audit in FY2023 was conducted concurrently with the FY2024 single audit, there was limited opportunity for these procedural improvements to be reflected in the FY2024 single audit testing cycle. As a result, the impact of these changes will be more fully reflected in the FY2025 single audit, which is scheduled to commence this year. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Implementation date: October 31, 2025.
Finding No. 2024-001 Implement System-Based Tracking of Federal Expenditures Finding: During our review of the SEFA, we noted that CAIR-CA utilizes workbooks outside of its accounting software to track federal expenditures. The workbooks do not reconcile directly with the general ledger (GL), so man...
Finding No. 2024-001 Implement System-Based Tracking of Federal Expenditures Finding: During our review of the SEFA, we noted that CAIR-CA utilizes workbooks outside of its accounting software to track federal expenditures. The workbooks do not reconcile directly with the general ledger (GL), so management performs a separate reconciliation to support the SEFA amounts. This approach was similarly observed in the prior year's audit. Views of Responsible Officials and Corrective Action Plan: Management concurs with the finding and has already updated the accounting system to incorporate grant-specific tracking codes to further align with federal reporting standards. Because the organization’s first single audit in FY2023 was conducted concurrently with the FY2024 single audit, there was limited opportunity for these procedural improvements to be reflected in the FY2024 single audit testing cycle. As a result, the impact of these changes will be more fully reflected in the FY2025 single audit, which is scheduled to commence this year. As part of a layered approach to internal controls, excel worksheets will continue to be used as a supplementary monitoring tool, providing an additional cross-check to the system-generated reports. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Implementation date: November 20, 2025
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this material weakness and has considered adding additional personnel to assist in the monthly reconciliations and financial statement preparation. Management reviews and approves the monthly inte...
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this material weakness and has considered adding additional personnel to assist in the monthly reconciliations and financial statement preparation. Management reviews and approves the monthly interim financial statements and uses the knowledge that management and the Board of Directors has of operations by having them review certain accounting records and reports. Also, management monitors the effectiveness of the above actions and makes changes as considered appropriate.
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this significant deficiency and addresses it by obtaining the auditor's assistance in the preparation of the Organization’s annual financial statements. Management reviews and approves the complet...
Views of Responsible Officials and Planned Corrective Actions The Organization’s management is aware of this significant deficiency and addresses it by obtaining the auditor's assistance in the preparation of the Organization’s annual financial statements. Management reviews and approves the completed statements and distributes them to the users.
Corrective Action Plan: Management acknowledges the delay in submission of the audited financial statements, which was partly due to this being the organization’s first Single Audit and delays in completing the year-end close process. To address this, the organization will implement a structured yea...
Corrective Action Plan: Management acknowledges the delay in submission of the audited financial statements, which was partly due to this being the organization’s first Single Audit and delays in completing the year-end close process. To address this, the organization will implement a structured year-end closing timeline, including a detailed checklist, assigned responsibilities, and internal deadlines to ensure all reconciliations and journal entries are completed prior to the audit. Management will also establish a pre-audit review process and coordinate closely with auditors to ensure timely completion and submission to the Federal Audit Clearinghouse within required deadlines. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: December 31, 2025
Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual acco...
Corrective Action Plan: Management acknowledges that federal grant revenue was recorded based on reimbursement timing rather than when related expenditures were incurred. To address this, the organization will implement procedures to ensure grant revenue is recognized in accordance with accrual accounting principles, aligning revenue with the period in which eligible expenditures are incurred. A year-end cutoff review will be performed to identify and record any receivables for incurred but unreimbursed costs. Additionally, grant tracking schedules and reconciliation processes will be enhanced to ensure accurate and timely revenue recognition. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: December 31, 2025
CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all requi...
CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all required deadlines. • Assign a designated preparer and reviewer for each reporting cycle. • Provide training on the Treasury reporting portal. • Implement a pre-submission checklist to ensure completeness and accuracy. • Conduct semiannual internal reviews of reporting processes and documentation. Responsible Staff Chief Financial Officer (CFO) Target Completion Date July 31, 2026
Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with ...
Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026
CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be t...
CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be taken: • Developing written procedures for PR28 and CAPER preparation and submission. • Implementing a compliance calendar with required reporting deadlines. • Assigning both primary and secondary preparers to ensure redundancy. • Providing HUD IDIS training to relevant staff. • Conducting supervisory review prior to submission. • Hired a Grants Compliance Specialist to support ongoing compliance.(10/2025) Responsible Staff Grants Administrator Target Completion Date August 31, 2026
Views of Responsible Officials Management agrees with the federal award finding identified in the audit. The System Fund will file the audit reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with audit partner and frequently...
Views of Responsible Officials Management agrees with the federal award finding identified in the audit. The System Fund will file the audit reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline.
Name of Auditee: Town of Potsdam, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Marty Miller, Supervisor Telephone: (315) 265-4310 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2024-0...
Name of Auditee: Town of Potsdam, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended December 31, 2024 CAP Prepared by: Marty Miller, Supervisor Telephone: (315) 265-4310 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Finding 2024-003 Management’s Response: Management will develop policies and procedures, and anticipates starting and completing the audit more timely in order to meet the required filing deadlines. Persons Responsible for Implementation: Marty Miller, Town Supervisor Implementation Date - December 31, 2026
Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for ...
Finding 2024-001 Allowable Cost Principles and Activities Allowed or Unallowed Material Weakness in Internal Control Over Compliance Assistance Listing Number 21.029 While Wabash currently maintains informal procedures for coding and reviewing invoices and payroll records, we recognize the need for a formalized, written policy governing expenditures charged to federal awards. To address identified material weaknesses, Wabash is committed to implementing a comprehensive written policy by June 30, 2026. This policy will formalize the coding, review, and reporting processes for all federal expenditures. Key improvements will include: • Enhanced Internal Controls: We will establish a clear segregation of duties to ensure oversight and accuracy. • Timely Reporting: We are refining our payroll allocation process. Previously, payroll expenditures were withheld pending budget verification, which occasionally led to reporting delays. New controls will ensure that all expenditures, including payroll, are reported within the required quarterly timeframes. • Monitoring: The Controller will oversee the development of these procedures and remain responsible for ongoing monitoring and compliance. These steps will ensure our financial practices meet federal standards and provide rigorous oversight of project funds. Contact person(s): Cheryl Gaither, Controller Justin Gephart, Chief Operating Officer
Finding 2024-012 - Single Audit Reporting Auditee's Response and Planned Corrective Action The Town will work with the accounting department, fee accountant, and audit fmn to file the required reports timely. Planned Implementation Date of Corrective Action: January 2026 Person Responsible for Corre...
Finding 2024-012 - Single Audit Reporting Auditee's Response and Planned Corrective Action The Town will work with the accounting department, fee accountant, and audit fmn to file the required reports timely. Planned Implementation Date of Corrective Action: January 2026 Person Responsible for Corrective Action: Fred Costello, Town Supervisor
CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and acknowledges that these issues have continued through our March 31, 2024 and March 31, 2025 fiscal year ends. We continue to make every effort to get our filings up to date by our March 31, 2026 year end due date of...
CORRECTIVE ACTION: Management is in agreement with the auditor’s recommendations and acknowledges that these issues have continued through our March 31, 2024 and March 31, 2025 fiscal year ends. We continue to make every effort to get our filings up to date by our March 31, 2026 year end due date of December 31, 2026.
CORRECTIVE ACTION PLAN March 13, 2026 Chickahominy Indian Tribe - Eastern Division respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonbur...
CORRECTIVE ACTION PLAN March 13, 2026 Chickahominy Indian Tribe - Eastern Division respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent public accounting firm: Brown, Edwards & Company, L.L.P. 1909 Financial Drive Harrisonburg, VA 22801 Audit period: December 31, 2024 The findings from the December 31, 2024 Schedule of Findings and Questioned Costs (the "Schedule" ) are discussed below. The findings are numbered consistently with the number assigned in the Schedule. FINDINGS- FINANCIAL STATEMENT AUDIT 2024-001: Payroll Tracking and Allocation (Material Weakness) Condition The client was unable to provide a payroll allocation by fund that agreed to the payroll registers. Criteria Payroll allocations were not supported by adequate documentation and were not consistent with methods used in the prior year. Cause The prior CFO had created an allocation method in which the existing employees could not follow . After the CFO's departure, emailed allo cat ions were sent which only specified which funding source the payroll expendit ures would be paid from, not the fund the expenditures were incurred in. Effect Material audit adjustments were required. Recommendation We recommend that payroll allocations be supported by a logical method and be allocated by fund. Corrective Action The Tribe has implemented corrective actions to strengthen internal controls over payroll allocations including: • Development and implement ation of a standardized payroll allocation model beginning with payrolls processed from September 2024 forward. • Preparation of documented allocation schedules for each pay period reconciling payroll costs to payroll registers and accounting records. • Use of standardized spreadsheet templates to support calculation and documentation of payroll allocations across funding sources . • Direct upload of payroll allocation entries into the accounting system to reduce manual entry and improve reconciliation accuracy. These procedures have established a consistent and supportable methodology for allocating payroll expenditures by fund and maintaining documentation sufficient to support financial reporting and audit requirements. The payroll allocation model was implemented beginning September 2024 and was further refined during 2025. The corrective action is considered implemented. 2024-002: Material Audit Adjustments (Material Weakness) Condition In fiscal year 2022, the Tribe elected to convert from the cash basis of accounting to governmental accrual accounting. During 2024, the Tribe continued to function on a cash basis and did not record most accruals. Criteria Financial information provided shou ld be accessible and materially correct. Cause Tribe has not consistently used the accounting software and has relied on program­ specific spreadsheets. The Tribe did not fully switch to accrual basis for internal reporting. Effect Material audit adjustments were required. Recommendation We recommend that monthly reports be generated from Abila and reviewed for accuracy. Any discrepancies between Abila reports and program-specific spreadsheets should be reconciled or adjusted. These reports should be reliable and able to be used to present to Council as part of monthly financial reporting. Corrective Action The Tribe has taken steps to strengthen the use of the accounting system as the primary source of fi nancial reporting and to improve the reliability of financial reports generated for internal management purposes including: • Continued use of the accounting system (Abila/ M IP) as the system of record for all financial t ransact ions. • Development and implementation of a revised chart of accounts structure to improve financial reporting and fund tracking. • Comprehensive review and correction of historical accounting activity to improve data integrity within the accounting system. • Use of spreadsheets as supplemental tools for monitoring estimated fund balances and grant acti vit y where necessary. • Ongoing efforts to customize financial reports generated direct ly from the accounting system so they align with the reporting format requested by Tribal leadership. The Tribe is currently working to finalize customized accounting system reports that will allow monthly financial reports to be generated directly from the accounting system in the format required for Tribal Council repo rt ing. Substantial improvements were implemented during 2025. Full implement atio n of customized accounting system reporting will be completed in the second quarter of 2026. 2024-003 : Budget Approval and Adherence (Material Weakness) Condition The budget was not approved until February 2024 and did not contain sufficient detail nor was it an accurate reflection of financial operations. Criteria Budgets should be developed with sufficient detail to track organizational performance throughout the year. Budgets should be approved by Council prior to the start of the fiscal year. Cause Unqualified staff or lack of attention to the budgeting process. Effect A budget was approved after the fiscal year and was not measured to actual performance during the year. Recommendation A thorough and detailed budget should be developed at the fund and entity level and adopted by Council prior to the start of the fiscal year. We also recommend Council meetings include a formal discussion of budget to actual results, thus giving Council an opportunity to question variances. Corrective Action The Tribe has taken steps to strengthen its budgeting process and improve financial oversight by Tribal leadership including: • Development of a detailed fiscal year 2025 operating budget at the fund and entity level to improve monitoring of financial activity across funding sources. The FY2025 budget was adopted by Tribal Council on February 8, 2025. • Development of a detailed fiscal year 2026 operating budget at the fund and entity level. This budget was presented to Tribal Council on December 19, 2025 and formally adopted with minor revisions at the January 12, 2026 Council meeting very near the start of the fiscal year. • Implementation of enhanced monthly financial reporting for Tribal leadership to support improved financial monitoring and oversight. • Ongoing development of budget-to-actual comparison reporting to support regular review of financial performance by Tribal Council. Budget development improvements were implement ed during fiscal years 2025 and 2026. Full implementation of budget-to-act ual repo rting will becompleted in the second quarter of 2026. 2024-004: Segregation of Duties (Material Weakness) Condition Certain key financial operational responsibilities are not sufficiently segregated. Criteria Proper segregation of duties shou ld be in place detect of irregulariti es in a timely manner. Cause Small staff size combined with significant turnover. Effect Segregation of duties could not be maintained in several signi fi cant rol es during the year. Recommendation Management should review the current process and implement changes to better separate responsibilities so that no one individual is responsible for a transaction cycle. Where proper segregation is not possible, mitigating controls can be put into place to detect errors. Corrective Action The Tribe recognizes the importance of segregation of duties as an internal control and has taken steps to strengthen oversight and implement mitigating controls where full segregation is not feasible due to staffing limitations including: • Increased oversight of financial transactions and accounting activit y by the Director of Finan ce. • Implementation of improved documentation and reconciliation procedures for key accounting processes. • Development of standardized processes and templates to improve consistency and transparency in financial transactions. • Implementation of enhanced financial reporting to Tribal leadership to support independent review offinancial activity. • Ongoing review of financial responsibilities and workflows to identify opportunities for improved separation of duties as staffing capacity permits. Where complete segregation of duties is not possible due to organizational size, the Tribe will continue to rely on management review and reconciliation procedures as compensating controls that have proven effective in detecting errors and irregularities. Mitigating controls were implemented during late 2024 and throughout 2025 and will continue to be refined as staffing capacity allows. 2024-005: Grant Tracking and Reporting (Material Weakness) Condition Poor financial record keeping and lack of thorough grant expenditure and status tracking. Criteria Grant funding should be recorded in separate GL accounts and be reconciled to any ext ernal spreadsheets or drawdown requests and grant reporting. Cause Turnover and unqualified staff. Effect Some grant funding sources were drawn down without documentation of qualifying expenditures, while others appear to have had qualifying expenditures that did not have matching drawdowns. Recommendation Accounting systems should be properly uti lized to track expenditures incurred under each grant and be reconciled to external reporting and spreadsheets. Once a grant is fully expended, the grant shou ld be closed out by ensuring revenues match expenditures. If expenditures are greater than the revenue provided by the grant, a transfer from the general fund would be needed. If revenues are greater than expendit ures , it could be an indication of improper drawdowns or expenditures have not been properly recorded. Corrective Action The Tribe has taken steps to strengthen grant financial management and improve reconciliation between accounting records, grant expenditures, drawdown activity, and monitoring of fund balances including: • Implementation of a revised chart of accounts structure to improve tracking of grant revenues and expenditures within the accounting system. • Continued use of the accounting system as the system of record for all financial transactions associated with grant programs. • Review and reconstruction of grant financial records to ensure expenditures, drawdow ns, and grant balances are properly documented and reconciled. • Use of standardized tracking spreadsheets as supplemental tools to monitor grant activity and reconcile grant balances to the accounting system. • Implementation of improved financial reporting and reconciliation procedures to ensure grant revenues, expenditures, drawdo wns, and balances are reviewed on a regular basis. Beginning in 2026, the Tribe has established a process to perform grant drawdowns monthly to ensure that drawdowns are aligned with recorded expenditures and that grant balances are monitored on an ongoing basis. Corrective actions began during late 2024 and continued throughout 2025. Monthly grant drawdown and reconciliation procedures were implemented in the first quarter of 2026. FINDINGS AND QUESTIONED COSTS - MAJOR FEDERAL AWARD PROGRAM AUDIT 2024-006: Bureau of Indian Affairs -105(1) Leases ALN 15.048 and Pandemic Relief Activities: Local Food Purchase Agreements with States, Tribes, and Local Governments ALN 10.182, Late filing of Data Collection Form Condition The Tribe did not file the data collection form for the years ended December 31, 2022, 2023, or 2024 timely. Criteria Under the requirements of the Uniform Guidance and the Office of Management and Budget (0MB), all entities are required to file the annual data collection form with the Federal Audit Clearinghouse the earlier of 30 days after the issuance of the entity's annual audit or nine months after the entity's fiscal year-end. Management did not complete and certify the auditee portion of the form before the deadline. Questioned Cost N/A Repeat Finding Yes RecommendationManagement should take steps to ensure that the form is filed timely Corrective ActionThe Tribe has taken steps to ensure timely completion and submission of the annual data collection form going forward including: • Assignment of responsibility for preparation, review, and submi ssion of the auditee portion of the data collection form to the Director of Finance. • Establishment of a formal process to complete and certify the annual data collection form immediately upon completion of the annual audit. • Implementation of internal tracking procedures to monitor audit timelines and ensure compliance with Federal Audit Clearinghouse submission requirements. • Coordination with external auditors to ensure timely communication regarding audit completion and reporting deadlines. This corrective action has been implemented and the tribe anticipates comp liance in all future audit reporting periods beginning with FY202 5. 2024-007: Bureau of Indian Affairs -105(1) Leases ALN 15.048, Lack of Approvals (Material Weakness) Condition Criteria Cause Questioned Cost Repeat Finding Perspective Information Recommendation Corrective Action There were several instances of lack of approvals for disbursements. Federal grant recipients are required to maintain effective internal controls over federal awards, as out li ned in 2 CFR §200.303. Turnover and inadequate staffing. N/A N/A Nine of 27 tested. All disbursements should have one approval and ensure the expenditure is eligible under the grant. The Tribe has taken steps to strengthen internal controls over disbursement approvals and ensure that all expenditures are properly reviewed and documented including: • Establishment of a standardized disbursement approval process requiring documented approval prior to payment for non-routine/recurring expenditures. • Implementation of procedures to ensure all disbursements are reviewed for allowability under applicable grant requirements before payment is issued. • Maintenance of supporting documentation, including approval evidence, within the accounting records. • Ongoing review of disbursement procedures to ensure compliance with internal control requirements under 2 CFR §200.303. These measures are designed to ensure th at all disbursements are properly authorized, documented, and compliant with applicable grant requirements. Corrective actions began implementation during throughout 2025. These procedures are currently in place and will continue to be refined as part of ongoing internal control improvements. If the Federal Audit Clearinghouse has questions regarding this plan, please call Tim Emery, Director of Finance at 804-488-9392. Respectfully submitted, r Chief
Due in part to delays from the Organization’s prior auditor addressed in the Corrective Action Plan for the June 30, 2023 audit, the 2024 and 2025 audits were significantly delayed. Management has already taken steps to strengthen controls for year-end closing and audit preparation procedures to ens...
Due in part to delays from the Organization’s prior auditor addressed in the Corrective Action Plan for the June 30, 2023 audit, the 2024 and 2025 audits were significantly delayed. Management has already taken steps to strengthen controls for year-end closing and audit preparation procedures to ensure timely submission of the federal single audit reporting package. These steps included replacing the Chief Financial Officer and engaging an accounting firm to assist with the closing process. Furthermore, the Organization is working quickly to complete the 2025 audit to bring federal reporting fully up to date. Lastly, the Organization is updating its accounting procedures manual to reflect these improved practices.
Management acknowledges that a formalized process to identify and track federal expenditures for SEFA preparation was not in place during the audit period. Steps have since been taken to improve tracking and reporting of federal expenditures throughout the year. With a stable accounting team in plac...
Management acknowledges that a formalized process to identify and track federal expenditures for SEFA preparation was not in place during the audit period. Steps have since been taken to improve tracking and reporting of federal expenditures throughout the year. With a stable accounting team in place since September 2024, management has increased oversight and accountability for grant coding and federal award identification. Additionally, the implementation of Blackbaud Financial Edge in FY2027 will allow for more precise tracking of funding sources, including the ability to segment federal and non-federal expenditures within programs and generate SEFA-ready reports. These improvements will enable the Organization to prepare a complete and accurate SEFA prior to the start of future audits and ensure compliance with Uniform Guidance requirements. Actions Taken - Established internal processes to identify and track federal expenditures throughout the fiscal year - Increased review procedures over grant coding and funding source classification - Assigned responsibility for SEFA preparation and review prior to audit fieldwork - Initiated implementation of Blackbaud Financial Edge to automate and enhance federal reporting capabilities
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