Corrective Action Plans

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Reference Number: 2024-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspec...
Reference Number: 2024-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Housing Choice Cluster Federal Catalog Number: 14.871 and 14.879 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspections) Classification of Finding: Significant Deficiency in Internal Control over Compliance Instance of Noncompliance Authority’s Response & Actions Taken The Authority has made considerable progress in addressing the backlog of annual inspections that resulted from restricted unit access and the temporary implementation of HUD waivers during the COVID-19 national pandemic. These necessary public health measures, while appropriate at the time, contributed to delays in fulfilling Housing Quality Standards (HQS) inspection requirements. The Authority acknowledges that additional progress is still needed and remains actively engaged with its third-party Housing Choice Voucher (HCV) contractors to ensure timely completion of all outstanding inspections. The Authority is fully committed to ensuring that all units under contract meet and exceed HUD’s standards for safe, decent, and sanitary housing, in accordance with HQS and the Authority’s Administrative Plan. All five annual inspections with exceptions noted during the audit were inspected after the required timeframes and ultimately passed inspection with the units determined to be in full compliance with HUD requirements. The Authority uses the Emphasys Elite software to check against HUD's PIH Information Center (PIC) system to identify units with outstanding Housing Quality Standards (HQS) Inspections. The Authority has scheduled HQS Inspections for the units identified to be out of compliance. Key strategies and controls in place are as follows: Project-Based Program: For the PBV program, the Authority has already implemented the following procedures to result in timely HQS inspections of all units. 1. Matching data between the Emphasys Elite system of records to ensure the most overdue inspections are scheduled. 2. A bulk inspection process was implemented effective November 1, 2024. Through this process, all units for a particular PBV site are scheduled for their annual inspections in the same month each year. This ensures that all units are inspected annually. The scheduling process includes: a. Posting the bulk inspection schedule on the website. This is an annual schedule which identifies properties, property management, and the month the project will be inspected. b. Providing notice to the applicable site owner/manager of the inspection date and the units to be inspected. The notice will include information on how to prepare for the inspection, a request to have site staff accompany the inspector, and a reminder to notify residents so access can be gained even if no one is home. c. Sending individual inspection notices to the owner and participant for each scheduled inspection. For the PBV portfolio, staff will work directly with property management and developers to ensure access to units is continuously granted. Upcoming bulk inspections are also discussed on calls with owners. This allows for increased planning and respect for noticing timelines. Tenant-Based Program: • Review the report of outstanding HQS Inspections on a weekly basis. • Schedule outstanding HQS Inspections in order of aging date. • Conduct HQS Inspections prior to the anniversary date of previously completed inspection. • Running a monthly report of failed inspections and comparing them with future scheduled inspections to ensure that a second inspection has been scheduled. • Running a monthly report to identify units with two failed inspections to ensure all have been abated correctly. • Implement weekly monitoring to ensure all units are properly abated and lifted timely when units pass inspections and contracts are properly terminated after being in abatement for 180 days without a cure. The Authority has worked with Emphasys to identify the best ways to sort aged HQS inspections due and generate/schedule in bulk, as well as maximize the Inspector’s workday by routing the tenantbased units in a way that flows in a clear and orderly manner. Similar to the handling of delinquent annual reexaminations, the Authority is checking the data in PIC with the system of records and processing 50058 corrections where inspections have been completed but rejected in PIC due to out of sequence effective dates and any other fatal errors that require corrective action. The procedures for the project-based and tenant-based programs are already in effect, and the backlog of inspections has been substantially reduced as illustrated by a reporting rate of 99% for SEMAP Indicator 12 annual HQS inspections as of May 31, 2025. Monthly performance reports are also reviewed by management to ensure inspection timeliness is maintained. Anticipated Implementation Date September 30, 2025 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractors Kendra Crawford, Director of Housing Operations
2024-003- Significant Deficiency, Data Collection Form (Repeat Finding 2023-003) Audit Finding; The Town did not submit the 2024 or 2023 federal reporting packages with the Federal Audit Clearinghouse within the required timeline of either 30 days after receipt of the auditor’s reports or nine (9) m...
2024-003- Significant Deficiency, Data Collection Form (Repeat Finding 2023-003) Audit Finding; The Town did not submit the 2024 or 2023 federal reporting packages with the Federal Audit Clearinghouse within the required timeline of either 30 days after receipt of the auditor’s reports or nine (9) months after the end of the Town’s fiscal year as required by CFR 200.512(a)(1). Corrective Action Taken: We agree with this audit finding, resulting from turnover at the BOE. The delays should not reoccur in the future. Name and Phone # of Person Responsible for Implementation Mr. Peter Mynarski, Comptroller 203-622-2226
Finding Number: 2024-003: Allowable Costs – 3 of the 25 payroll transactions tested, the time and effort charged to the grant did not agree to the employee’s timesheet. The amount of time charged to the grant was greater than what was approved to be charged to the grant per the employee’s timesheet ...
Finding Number: 2024-003: Allowable Costs – 3 of the 25 payroll transactions tested, the time and effort charged to the grant did not agree to the employee’s timesheet. The amount of time charged to the grant was greater than what was approved to be charged to the grant per the employee’s timesheet hours and grant budget allocations, and additional fringe benefits were charged that were not consistent with the other charges to the grant. Planned Corrective Action: The Turning Point has enhanced training on completing Grant Activity Reports through individualized one-on-one training during NEO and posted how to videos for continued education. The Grant Activity Reports will be audited monthly by comparing the hours to what was billed to grants and the Allocation Spreadsheet. Completion Date: October 1, 2024 Responsible Contact Person: Tana Rice, Director of Finance
Finding Number: 2024-001: Allowable Costs – 2 out of the 38 samples tested included charges that were either unsupported or refunded back to the Organization and not corrected to return those funds to the grantor. Planned Corrective Action: The Turning Point has updated policies that include a proce...
Finding Number: 2024-001: Allowable Costs – 2 out of the 38 samples tested included charges that were either unsupported or refunded back to the Organization and not corrected to return those funds to the grantor. Planned Corrective Action: The Turning Point has updated policies that include a process for managing refunds and crediting them back to grants. We also updated our Expense Reimbursement and Credit Card policies in 2024 to simplify our payment process which includes both the Finance Director and Executive Director checking all expenses have the proper documentation prior to paying the statements/invoices and submitting to payors (funders) for reimbursement. Completion Date: June 1, 2025 Responsible Contact Person: Tana Rice, Director of Finance
Finding #2024-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Assistance Listing #66.456, National Estuary program, Passed through Texas Commission on Environmental Quality: Contract period: 09/01/23 – 08/31/25, Contract numb...
Finding #2024-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Assistance Listing #66.456, National Estuary program, Passed through Texas Commission on Environmental Quality: Contract period: 09/01/23 – 08/31/25, Contract number: 582-24-50165. Condition and context: We reviewed one of the two subrecipient awards for the required information described in the criteria above and noted such provisions were not included in the subrecipient agreement. Recommendation: Policies and procedures should be implemented to ensure all required information is included in the subrecipient agreement before issuance. Planned corrective action: Management agrees with the finding and would like to provide additional context to this situation. This agreement occurred during the early implementation phase of a multi-year grant in 2023, when the Foundation was still establishing internal processes for managing subawards under federal funding requirements. At the time of this transaction: The federal award had not yet been formally executed, though the federal agency provided authorization to begin incurring expenses. The subrecipient, a partner organization, drafted and issued the agreement using their standard contract template. Since that time, the Foundation has updated its procedures for subsequent subrecipient agreements to include the required Uniform Guidance information as outlined in 2 CFR §200.331(a). This was an isolated incident during a transitional period, and management is confident that current processes address this issue. To prevent recurrence, the Foundation will: Continue to follow updated subrecipient agreement templates, which include all required award and federal compliance language. Provide refresher training to staff involved in grant and contract administration on subrecipient vs. vendor classifications and associated federal requirements. Perform an annual compliance review of all subrecipient agreements to ensure ongoing adherence. Responsible officer: Dawn Asbury, Controller. Estimated completion date: July 31, 2025.
2024-002 – REPORTING Other Matter/Significant Deficiency Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the year-end financial statements will be prepared and submitted timely and formalized guidelines for fina...
2024-002 – REPORTING Other Matter/Significant Deficiency Auditee’s Response and Planned Corrective Action The Authority hired a new Executive Director in November 2023. Under new management, the year-end financial statements will be prepared and submitted timely and formalized guidelines for financial reporting will be created. New controls over financial close process will ensure more accurate financial reporting prior to the audit. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Kayla Potter, Executive Director
Finding 2024-001: North American Wetlands Conservation Fund Assistance Listing Number: 15.623 U.S. Department of Interior Pass-through: N/A Compliance Requirement: Reporting Grant No.: N/A Type of finding: Internal Control Over Complian...
Finding 2024-001: North American Wetlands Conservation Fund Assistance Listing Number: 15.623 U.S. Department of Interior Pass-through: N/A Compliance Requirement: Reporting Grant No.: N/A Type of finding: Internal Control Over Compliance (significant deficiency) and Compliance (noncompliance) Recommendation: The Organization should strengthen its internal with adopted policies and procedures that include evaluation of grant terms and conditions to ensure compliance with reporting requirements. Action Taken: FFATA reports were completed in May 2025 for any funds withdrawn for the years 2024 and 2025 and the Trust is awaiting guidance on reporting retroactively for previous years. Rio Grande Headwaters Land Trust added a step to our ASAP.gov withdrawal instructions: Ensure to file a FFATA report on Sam.gov immediately if the funds drawn down are pass through (or schedule a reminder on your calendar for prior to the end of the next calendar month). The Executive Director is now the sole grant reviewer and signer on grant agreements, as well as the only ASAP.gov and SAM.gov admin which will allow the Land Trust to ensure compliance with reporting requirements in the future. If there are questions regarding this plan, please call the responsible party listed below. Sincerely yours, Laura Cusick Executive Director Rio Grande Headwaters Land Trust
Planned Implementation Date of Corrective Action: July 2025 Person Responsible for Correctove Action: Krishonna Murray, Executive Director I. 2024-001 Eligibility Rent Calculation Other Matter/Significant Deficiency The Authority had instances of missing income verifcation. Gardner Housing Au...
Planned Implementation Date of Corrective Action: July 2025 Person Responsible for Correctove Action: Krishonna Murray, Executive Director I. 2024-001 Eligibility Rent Calculation Other Matter/Significant Deficiency The Authority had instances of missing income verifcation. Gardner Housing Authority has establised a system of internal control over the participant recertification process that meets HUD's requirements. Seven (7) to ten (10) files will be reviewed fiscally for quality assurance.
The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal...
The Company acknowledges the importance of accurately documenting key personnel requirements in support of federal contract compliance. The audit noted one contract with two projects where the individual listed as key personnel did not match the most current contract documentation. However, internal “load sheets” and program communications consistently reflected the correct personnel assignments, and there was no impact on contract performance or deliverables. Given the isolated nature of these discrepancies and their lack of effect on program execution or financial reporting, the Company does not consider this matter to be material. Nonetheless, to strengthen internal controls, the Contracts Department now records and maintains all key personnel data directly in Costpoint. Additionally, the Controller performs a quarterly internal review of these records to verify accuracy and completeness. These measures provide added assurance that the Company remains fully compliant with federal award requirements. Director of Contracts/Elena Einstein now oversees this control which was put into place as of April 2025.Notwithstanding these findings, management is confident that the accompanying financial statements present fairly, in all material respects, the Company’s financial position for the fiscal year ended September 30, 2024.
Finding 568861 (2024-003)
Significant Deficiency 2024
The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financ...
The Mayor's Office is fully committed to addressing the audit finding and the requirement per the grant agreement to develop and implement a fiscal sustainability plan as of 06/10/2025 on any futhter awarded funds. The corrective actions outlined in this plan reflect the importance of prudent financial management and forward-thinking strategies to safeguard the financial future of our community. Anticipated Completion Date: 6/10/2025 James A. Sullivan, Mayor.
Finding 568859 (2024-002)
Significant Deficiency 2024
Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor
Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor
Internal Control over compliance - reporting. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to carefully review grant agreements and ensure that grants personnel are familiar with the grant compliance requitements for reporting. We slo recommend the C...
Internal Control over compliance - reporting. Non-compliance with reporting compliance requirements. Recommendation: We recommend the Center to carefully review grant agreements and ensure that grants personnel are familiar with the grant compliance requitements for reporting. We slo recommend the Center to update its grant policies and procedures for the FFATA reporting requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: All grant agreements will be carefully reviewed for compliance requirements for reporting. The Center has taken steps to familiarize applicacle staff with the compliance reports for FFATA reporting, and progress has been made in the requirement to report subawards granted under FFATA reporting. We will also update our grants policies and procedures to specifically include a section for FFATA reporting of subawards.
Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and...
Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and approved by the NWIFC Grants Program Manager and submitted to PSFMC. Effective immediately, the NWIFC grants program manager will increase internal controls by including documentation of internal review and approval prior to progress reports being submitted to PSMFC. Anticipated completion date: July 2025.
Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written ...
Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written policy and implement a documented process for the preparation and review of federal drawdowns, including clear evidence of review such as signoffs or electronic approvals. Responsible Individual: Andres Chavarro, Finance Manager Planned Completion date: 07/01/2025
The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...
The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director
The Division will ensure evidence of review is maintained for the inventory worksheets. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director
The Division will ensure evidence of review is maintained for the inventory worksheets. This was also reviewed during the NW Division’s Social Service conference in April 2025. Anticipated Completion Date: 10/1/25. Responsible Contact Person: Julie Luft, NW Social Services Director
The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of re...
The Division will enhance controls to ensure timely submission of reports and that there is segregation of duties between the report preparer and reviewer. Reports will be reviewed prior to submission and the review and submission of reports to granting agencies will be documented. A schedule of reports will be added to the TSAMM during the review and approval of new contracts. We will also work with our funders to extend reporting due dates. Anticipated Completion Date: 12/31/25. Responsible Contact Person: Yohannes Gedlu, NW Divisional Finance Director & Julie Luft, NW Social Services Director
1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Contro...
1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Controls over Compliance were already in place during the audit period. These policies were reviewed by the Board of Directors on 6/11/25 and found to align with the best practices and compliance requirements. Following the audit, we have also taken steps to reinforce the adherence and ensure consistent implementation across all relevant areas. Responsible Parties: Brandi Senters, Finance Director, will be responsible for implementation, with oversight from Interim Executive Director, Bernie Jackson.
Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during t...
Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during the audit period. To strengthen documentation access and retention, the Organization has transitioned to NetSuite, where backup documentation for transactions is now stored centrally on the cloud and can be easily accessed by headquarters staff. This change enhances our ability to ensure timely review, approval, and audit readiness, regardless of field conditions. We remain committed to continuous improvement of our internal controls and documentation practices. Responsible Person: Country Finance Directors
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 . Name of the contact person responsible for corrective action: Carli Taylor, Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Carli Taylor, Chief Financial Officer at 660.385.8716 .
CORRECTIVE ACTION PLAN Name of auditee: Bellflower Oak Street Manor Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: October 1, 2023 through September 30, 2024 CAP prepared by: Name: Sean Calendar Position: Director of Accounting Telephone: (916) 357-5300 Comments: Man...
CORRECTIVE ACTION PLAN Name of auditee: Bellflower Oak Street Manor Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: October 1, 2023 through September 30, 2024 CAP prepared by: Name: Sean Calendar Position: Director of Accounting Telephone: (916) 357-5300 Comments: Management agrees with the 2024-001 finding. Actions: Management will implement policies and procedures to ensure the monthly deposit to the replacement reserve is made in accordance with HUD regulations. Additionally, management will fund $19,824 of additional reserve deposits to make the account whole; $9,912 for the current period’s unfunded deposits and an additional $9,912 for unfunded deposits from prior period, as reported in finding 2023-01.
Finding 2024-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting ...
Finding 2024-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Cynthia Beatus, IGAP Coordinator Corrective action plan: The IGAP Coordinator will ensure that the annual federal financial report (FFR) will be submitted within the 120 day timeframe of the end of the project period. Proposed Completion Date: September 30, 2025
Finding 567929 (2024-002)
Significant Deficiency 2024
Corrective Action Plan (CAP) Date: June 23, 2025 From: Dallas County Health & Human Services (DCHHS) Subject: Response and CAP to Finding 2024-002: Reporting – Significant Deficiency in Controls over Compliance and Noncompliance - ALN # 14.871 & 14.879 – Housing Voucher Cluster – Contract # TX559 ...
Corrective Action Plan (CAP) Date: June 23, 2025 From: Dallas County Health & Human Services (DCHHS) Subject: Response and CAP to Finding 2024-002: Reporting – Significant Deficiency in Controls over Compliance and Noncompliance - ALN # 14.871 & 14.879 – Housing Voucher Cluster – Contract # TX559 – Section 8 Housing Choice Vouchers (“HCV Program”). Responsible Party - Thomas Lewis, Assistant Director of Housing Services - Ganesh Shivaramaiyer, Deputy Director of Finance and Operations Implementation Date: July 01, 2025 Cause - The HCV Program did not have controls in place to compare all electronic HUD-50058 forms against the original related hard copy form. DCHHS Response: The hard copy HUD Form 50058 included in each file is a printed version of the corresponding electronic submission sent to HUD. Program Monitors review this same form during their file assessments. Current Practice – HUD Form 50058 Submission Process: To support timely compliance with HUD reporting requirements, the Dallas County Housing Authority (DCHA) Housing Choice Voucher Program (HCVP) follows a structured and efficient process for the submission of HUD Form 50058 Family Reports. Case Managers complete the transaction upon verification of all required documentation in the client file. At this point, the Data Analyst gathers the batch file and submits the HUD Form 50058 Family Reports electronically. The Data Analyst generates error reports and forwards the report to the Case Manager Supervisor. The Supervisor assigns the error report along with a designated correction and return deadline to the appropriate Case Manager. This structured workflow ensures timely submission and resubmission of any current or rejected reports. The current model balances timeliness and quality control, aligning with HUD’s programmatic and compliance expectations. Proposed Process - HUD Error Reports or Rejections: To improve the efficiency of resolving rejected or erroneous HUD Form 50058 submissions, DCHHS will implement an additional layer of oversight. Program Monitors will now have access to the "History" section within the Housing software HAPPY, to verify the submission dates of HUD Form 50058 Family Reports. This process serves as a checks-and-balances system, ensuring alignment between the submission date and the effective date, and provides a secondary review to confirm that the appropriate transaction code is submitted within HUD’s 60-day window from the effective date noted on the form.
The City does not concur. The City submitted their report to the Department of the Treasury on April 30, 2025 which covered the time period from January 1, 2022 through December 31, 2024. The Department of the Treasury allowed for this reporting deadline and the City maintains it filed the reports w...
The City does not concur. The City submitted their report to the Department of the Treasury on April 30, 2025 which covered the time period from January 1, 2022 through December 31, 2024. The Department of the Treasury allowed for this reporting deadline and the City maintains it filed the reports within the acceptable time requirements.
The Conservancy District has implmenented controls and processes to ensure that the required reports are prepared and submitted timely.
The Conservancy District has implmenented controls and processes to ensure that the required reports are prepared and submitted timely.
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