Corrective Action Plans

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Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will...
Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will prepare the monthly SNP Claim for Reimbursement Summary report and compile all supporting meal count documentation. 2. Prior to submission, the Administrative Assistant to the Director of Food Services or another designated individual independent of the preparation process will: a. Review the claim for mathematical accuracy; b. Verify meal counts against supporting documentation; c. Confirm claims are submitted within required timelines; and 3. Evidence of the review and approval will be documented through: a. Signature or electronic approval on the reimbursement summary report; and b. Retention of supporting documentation in accordance with federal and state record retention requirements. 4. A written standard operating procedure (SOP) outlining these review and approval responsibilities will be developed and communicated to applicable personnel. The Business Manager will periodically monitor compliance with the procedure to ensure controls remain effective.
Corrective Action: The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Ro...
Corrective Action: The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
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: The City will establish a centralized grant reporting calendar to monitor federal reporting deadlines; assign responsibility for the timely preparation and submission of required reports; and implement review procedures to ensure compliance with federal reporting requirements. Res...
Corrective Action: The City will establish a centralized grant reporting calendar to monitor federal reporting deadlines; assign responsibility for the timely preparation and submission of required reports; and implement review procedures to ensure compliance with federal reporting requirements. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 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.
The City will establish and document formal subrecipient-monitoring procedures consistent with 2 CFR §200.332. The audit found that the City did not document its review of the subrecipient's Single Audit report, evaluate whether the subrecipient's audit finding related to City-provided funds, or fol...
The City will establish and document formal subrecipient-monitoring procedures consistent with 2 CFR §200.332. The audit found that the City did not document its review of the subrecipient's Single Audit report, evaluate whether the subrecipient's audit finding related to City-provided funds, or follow up on discrepancies in the subrecipient's Schedule of Expenditures of Federal Awards. 1. Maintain a complete inventory of all federal subawards, including the subrecipient, federal program, Assistance Listing Number, award amount, period of performance, and applicable compliance requirements. 2. Require each subrecipient to submit its annual Single Audit report or written confirmation that it was not subject to the Single Audit requirement. 3. Review each applicable Single Audit report and the Federal Audit Clearinghouse for findings that could relate to City-funded subawards. 4. Compare subaward information reported by the subrecipient on its Schedule of Expenditures of Federal Awards to the City's accounting and grant records. 5. Investigate and resolve any reporting discrepancies, including missing pass-through entity information, incorrect Assistance Listing Numbers, or omitted federal expenditures. 6.. Use a standardized monitoring checklist and retain all supporting documentation in the applicable grant file. Responsible Officials Anticipated Completion Date The revised monitoring checklist will be completed by September 30, 2026. Review and follow-up concerning the identified subrecipient will be completed by December 31 , 2026. Monitoring will continue throughout the duration of each subaward. Contact Person Responsible for the Corrective Action Plan Cynthia Smith, Finance Director City of Chicago Heights 1601 Chicago Road Chicago Heights, Illinois 60411
Finding #2025-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: Management of the System has reviewed the financial statements and schedule of expenditures of federal awards (SEFA) ...
Finding #2025-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: Management of the System has reviewed the financial statements and schedule of expenditures of federal awards (SEFA) prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the System. Management and the Board of Directors has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Anticipated Completion Date: Ongoing
Finding 1224785 (2025-001)
Material Weakness 2025
Ecotrust is strengthening its controls over federal financial reporting to ensure required SF‑425 Federal Financial Reports are submitted (in a timely manner) in accordance with 2 CFR 200.328 and applicable award terms. Approximately three years ago, following turnover, Ecotrust shifted grantee and ...
Ecotrust is strengthening its controls over federal financial reporting to ensure required SF‑425 Federal Financial Reports are submitted (in a timely manner) in accordance with 2 CFR 200.328 and applicable award terms. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub‑grantee management from a centralized model to a distributed model in which program managers assumed responsibilities for which tools and training were insufficient. To correct the underlying deficiency, Ecotrust is taking the following specific actions: • Assigning clear, documented responsibility for the preparation and timely submission of all federal financial reports (including the SF‑425), with a designated primary preparer and a backup to ensure continuity of reporting during staff absences or turnover. • Establishing a federal reporting calendar that tracks all federal financial report due dates, with proactive advance reminders shared across the finance and program teams. • Providing periodic training to finance and program staff to reinforce awareness of federal financial reporting requirements and deadlines. • Engaging an outside consultant, Jennifer Hutton, who has grantee‑management experience gained at Mercy Corps and other non‑profits, to work with the finance team and program managers to develop the supporting processes, tools, and accountability measures.
Finding #2025-002 – Material Weakness and Material Noncompliance. U. S. Department of Housing and Urban Development, Community Development Block Grants/Entitlement Grants, Assistance Listing #14.218, Passed through the City of Houston, Contract year: 11/07/23 – 10/31/26. Condition and context: Manag...
Finding #2025-002 – Material Weakness and Material Noncompliance. U. S. Department of Housing and Urban Development, Community Development Block Grants/Entitlement Grants, Assistance Listing #14.218, Passed through the City of Houston, Contract year: 11/07/23 – 10/31/26. Condition and context: Management failed to include a federally funded contract on the SEFA for the last two years totaling $522,014. Omitting these expenditures from the SEFA resulted in incorrectly reported federal expenditures. Recommendation: Develop policies and procedures to identify and reflect all federal programs on the SEFA and reconcile the federal expenditures to the federal program revenue on a routine basis. Planned corrective action: The Vice President of Finance and Administration will be provided with all funding agreements to identify any new federal grants. Additionally, the project management team and the Vice President of Finance and Administration will now meet bi-weekly to discuss new funding agreements in order to identify any new funding that is federally sourced and would require inclusion on the SEFA. Responsible officer: Michele Nezi Marvin, Vice President of Finance and Administration. Estimated completion date: July 1, 2026.
FINDING 2025-002 This is Department of Family and Support Services’ first Single Audit where FFATA reporting was reviewed under Sam.gov rather than FSRS.gov. The Sam.gov system does not keep records of historical changes/ updates to published reports. Every time a report is modified, the date of sub...
FINDING 2025-002 This is Department of Family and Support Services’ first Single Audit where FFATA reporting was reviewed under Sam.gov rather than FSRS.gov. The Sam.gov system does not keep records of historical changes/ updates to published reports. Every time a report is modified, the date of submission is updated to reflect the current date. Effective August 1, 2026, DFSS will track and document changes or updates made to a FFATA report by using screenshots. Additionally, DFSS will update FFATA reports when the original contract and budget allocation is modified. DFSS will submit separate FFATA reports for each program funded by contract number. The FFATA reports will be delineated in Sam.gov by the purchase order number and the release number using the new Subaward ID format “PO#_Release#.” Chief Research Analyst Kaur from DFSS’ Grants unit will be responsible for ensuring the changes are implemented for FFATA reporting. Deputy Commissioner of Contracts, IT, and Programmatic Monitoring Givens will be responsible for providing oversight and monitoring the process with the Department of Family and Support Services (DFSS) Contracts staff to add the sub awardee’s UEI to the contract for all future amendments and new contracts is implemented by August 1, 2026.
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.
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
The Department of Community Development will implement the following corrective measures using existing systems, including exploring the capabilities of Amplifund, the City’s grant management software, to address the finding and to establish a durable compliance framework for all federal grant repor...
The Department of Community Development will implement the following corrective measures using existing systems, including exploring the capabilities of Amplifund, the City’s grant management software, to address the finding and to establish a durable compliance framework for all federal grant reporting obligations: 1. Designation of a Federal Grants Compliance Officer;2. Staff Training and Cross-Training;3. Grants Management and Reporting Calendar Reminders;4. Federal Portal Access Redundancy and Technical Escalation Protocol; and5. Internal Compliance Audits.
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
The Administration of HONOR acknowledges the condition identified in the 2025 Financial Audit concerning the lack of allocation documentation. The following response outlines the steps the HONOR Administration, and Management will take to address these issues and prevent recurrence. During the 2025 ...
The Administration of HONOR acknowledges the condition identified in the 2025 Financial Audit concerning the lack of allocation documentation. The following response outlines the steps the HONOR Administration, and Management will take to address these issues and prevent recurrence. During the 2025 audit process, RBT identified the following condition: “Allocation of allowable costs were not properly documented.” HONOR Chief Financial Officer, along with the Finance Director, reviewed the condition and implemented the following corrective measure: -Ensure source documents are documented with G/L code, cost center and allocation method, if one is used. Documentation will be reviewed for completeness by the Staff Accountant. This will add an additional layer of documentation review prior to month end close. HONOR’s Chief Financial Officer along with the finance team take this audit finding seriously and are committed to strengthening internal controls to prevent future incidents. The steps outlined above will help us maintain compliance and ensure the proper use of resources. HONOR thanks RBT for their due diligence in bringing this matter to our attention.
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
The Organization is aware that their staff does not have a process to prepare financial statements, schedule of expenditures of federal awards, and related notes in accordance with GAAP. The Organization will continue to make this decision on a cost/benefit basis and have auditors assist in preparin...
The Organization is aware that their staff does not have a process to prepare financial statements, schedule of expenditures of federal awards, and related notes in accordance with GAAP. The Organization will continue to make this decision on a cost/benefit basis and have auditors assist in preparing the financial statements and related notes. Management does review the financial statements and the schedule of expenditures of federal awards and compares to the Organization’s financial records for completeness and accuracy and accepts responsibility for those financial statements and schedule of expenditures of federal awards.
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
We agree with the auditors' recommendations, and the following action will be taken to improve the timeliness of the financial reporting process. Management will consult with the audit firm and outside CPA firm to develop an agreed upon schedule for the FY 2026 financial reporting process and relate...
We agree with the auditors' recommendations, and the following action will be taken to improve the timeliness of the financial reporting process. Management will consult with the audit firm and outside CPA firm to develop an agreed upon schedule for the FY 2026 financial reporting process and related audit to meet the Financial Audit Clearinghouse reporting requirement. We will also identify additional training for departmental staff to improve skills and address identified deficiencies. Finally, Management will review capacity constraints and development solutions to improve capacity.
The Single Audit was not completed and submitted within the required timeframe due to a combination of factors, including delays in submitting supporting documentation, and staffing constraints due to implementing new payroll software during the audit. Management has completed the FY2025 audit and i...
The Single Audit was not completed and submitted within the required timeframe due to a combination of factors, including delays in submitting supporting documentation, and staffing constraints due to implementing new payroll software during the audit. Management has completed the FY2025 audit and issued the financial statements. To prevent recurrence the city has established earlier deadlines for the completion of year end close, federal award schedules, and supporting documentation along with periodic progress reviews with external auditors. Effectiveness will be measured by timely issuance of audited financial statements in accordance with all regulatory and stakeholder requirements beginning with the FY2026 audit cycle. Angela Middaugh, the Director of Finance of the City, will be responsible for monitoring progress and allocating the necessary resources for timely issuance.
Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2024 - October 31, 2025 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2025-001 Corrective Action Plan The Organization acknowledges a...
Name of auditee: Columbia Opportunities, Inc. TIN: 14-1627038 Name of audit firm: EFPR Group, CPAs, PLLC Period covered by audit: November 1, 2024 - October 31, 2025 CAP prepared by: Tina Sharpe tsharpe@columbiaopportunities.org Finding 2025-001 Corrective Action Plan The Organization acknowledges and is aware of this finding. Management and fiscal departments are responsible for timely reporting. Management will follow its comprehensive policies and procedures and complete reporting submissions on time for future periods.
Moving to Work Demonstration Program ALN: 14.881 Description: The Authority's fiscal year ended September 30, 2025. The unaudited Financial Data Schedule (FDS) was required to be submitted electronically to HUD's Real Estate Assessment Center (REAC) through the Financial Assessment Subsystem (FASS-P...
Moving to Work Demonstration Program ALN: 14.881 Description: The Authority's fiscal year ended September 30, 2025. The unaudited Financial Data Schedule (FDS) was required to be submitted electronically to HUD's Real Estate Assessment Center (REAC) through the Financial Assessment Subsystem (FASS-PH) no later than December 31, 2025 (60 days after fiscal year end). The Authority did not submit the unaudited FDS until May 29, 2026 -approximately five months after the required due date. Planned Corrective Action: The Authority concurs with the finding regarding late submission of the unaudited FDS. Establish a regulatory reporting calendar; assign responsibilities and supervisory review; and accelerate year-end closing procedures to support timely FDS submissions.
The Authority's unaudited Financial Data Schedule (FDS) for the fiscal year ended September 30, 2025 was submitted on April 27, 2026, approximately four months after the HUD-required deadline of 60 days following fiscal year end (November 29, 2025). Planned Corrective Action: The Authority will esta...
The Authority's unaudited Financial Data Schedule (FDS) for the fiscal year ended September 30, 2025 was submitted on April 27, 2026, approximately four months after the HUD-required deadline of 60 days following fiscal year end (November 29, 2025). Planned Corrective Action: The Authority will establish a financial reporting calendar with assigned responsibility and interim deadlines to ensure the unaudited Financial Data Schedule (FDS) is prepared, reviewed, and submitted to HUD within 60 days of fiscal year end. The Authority will perform timely monthly general ledger reconciliations to support a timely year-end close.
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.
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