Corrective Action Plans

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Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures to ensure that all required documentation is maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. procedures for tenant inc...
Public and Indian Housing – ALN #14.850 Recommendation: We recommend that management review their procedures to ensure that all required documentation is maintained in the file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. procedures for tenant income and asset verification to ensure that all required third-party documentation is obtained, retained, and reviewed before certifications are finalized. Supervisory review procedures were enhanced to include verification of income documentation, asset calculations, and tenant file completeness. Staff received refresher training on HUD documentation requirements, income and asset verification procedures, and file quality control standards. In addition, ongoing file audits and management review procedures have been implemented to identify and correct documentation deficiencies promptly. Name(s) of the contact person(s) responsible for corrective action: Jason Epperson, Assistant Vice President Planned completion date for corrective action plan: December 31, 2026
SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Caroli...
SIGNIFICANT DEFICIENCY / NONMATERIAL NONCOMPLIANCE Finding 2022-006 Reporting Name of Contact Person: James C Overton, Finance Director Corrective Action: The Town has hired additional staff to improve the accuracy and timeliness of grant reporting. The Town has also contracted with the North Carolina League of Municipalities to provide additional training to the Town ‘s staff. Proposed Completion Date: December 31, 2026.
Audit Finding Reference: 2022-003 Corrective Action Taken or Planned: 1. Formal Documentation and Retention Procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submission ( e.g., email confirmations, screenshots from the federal submission p...
Audit Finding Reference: 2022-003 Corrective Action Taken or Planned: 1. Formal Documentation and Retention Procedures: Going forward, all report submissions will be accompanied by time and date-stamped confirmation of submission ( e.g., email confirmations, screenshots from the federal submission portal, etc.). These confirmations will be retained in a designated compliance folder for each program. 2. Contingency Plan for System Errors: The County will develop a written contingency plan to address delays caused by system outages or data access issues. This plan will include communication protocols with software vendors, documentation of incidents, and immediate outreach to the granting agency when delays are anticipated. 3. Documenting Extensions and Agency Communication: In any case where a reporting deadline cannot be met, staff will immediately request written approval for extensions from the granting agency, and this correspondence will be retained as part of the official reporting record, as applicable and permitted. 4. Training for Program and Compliance Staff: Staff involved in federal reporting will receive training on reporting deadlines, documentation standards, and escalation protocols for delays. This training will be updated annually to reflect current guidance and program requirements. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance
Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentat...
Audit Finding Reference: 2022-002 Corrective Action Taken or Planned: 1. Formalized Record Retention Policies: A formal record retention policy specific to federal grant programs will be implemented to ensure full compliance with 2 CFR 200.334. This policy will apply regardless of whether documentation is stored internally or by third-party systems. Any documentation downloaded or transferred from third-party systems will be subject to a review process to verify completeness and accuracy before being finalized for County retention. The County shall also take steps to ensure that information downloads and exports from third-party systems represent omplete and accurate records. 2. Audit Timing Advocacy and Preparedness: The County will continue to maintain timely documentation and preparedness for audits and will also advocate for timely initiation and completion of future audits. Significant delays in the audit process, through no fault of the County, as observed during the FY2022 audit, substantially impacted the County's ability to access necessary documentation and demonstrate compliance. Although the County made every effort to retain records in accordance with federal requirements, the timing of the audit fieldwork occurred well after the program had concluded in May 2023. Had the audit been conducted in a timely manner, full access to the third-party platform used for program administration would have been available, along with all supporting documentation. However, by the time the audit took place, the program had been closed for over 18 months, and access to the external software system had lapsed in accordance with the expiration of the service agreement. 3. Internal Audit Readiness Reviews: Beginning with FY2025, the County will conduct internal audit readiness reviews shortly after fiscal year-end to ensure all documentation for closed federal programs is centralized, archived, and accessible for future audit purposes, even if conducted years later. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance
Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required...
Audit Finding Reference: 2022-001 Corrective Action Taken or Planned: At the time of compiling the Schedule of Expenditures of Federal Awards (SEF A), the County was unaware that the totals reported in Reports 2 and 3 submitted to the Health Resources and Services Administration (HRSA) were required to be reported under Federal Assistance Listing Number (ALN) 93.498- COVID-19 - Provider Relief Fund. This resulted in an incomplete reporting of federal expenditures under the appropriate ALN. To address this issue, the County will implement the following corrective actions: 1. Training and Guidance: Staff responsible for SEF A preparation will receive additional training regarding federal reporting requirements, including how to align HRSA filings with SEFA reporting and the appropriate identification of Assistance Listing Numbers. 2. Improved Coordination: The County will establish closer coordination between the departments submitting reports to federal agencies (such as HRSA) and those compiling the SEFA to ensure consistency and completeness. 3. Periodic Reconciliations: The County will implement periodic reconciliations of its general ledger and departmental grant records against federal reporting requirements throughout the fiscal year, rather than waiting until year-end. This will support more timely and accurate SEFA preparation. Anticipated Completion Date: October 15, 2025 Contact Person Responsible for Corrective Action: Charles Nickerson, Senior Director of Finance
Audit Finding Reference: 2022-007 Improve Internal Controls and Compliance with Reporting Planned Corrective Action: The Town agrees with the finding and understands each of the issues that have been identified with internal controls and compliance with reporting. There have been personnel changes i...
Audit Finding Reference: 2022-007 Improve Internal Controls and Compliance with Reporting Planned Corrective Action: The Town agrees with the finding and understands each of the issues that have been identified with internal controls and compliance with reporting. There have been personnel changes in the Town Accountant's office and the new Town Accountant will work to ensure general ledger data is reported accurately as well as review prepared reports thoroughly prior to submission. Planned Implementation Date of Corrective Action: Present Day Person Responsible for Corrective Action: Christopher Costello, Assistant Town Administrator/Finance Director
Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to...
Condition/Context: For 3 of the 3 samples selected for testing, the School did not provide support for review and approval of the monthly bank reconciliations Corrective action taken: Quileute Tribal School will establish effective internal controls for the monthly bank reconciliations and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent NOTE: In addition, Quileute Tribal School has engaged an independent CPA firm to assist with account reconciliations and audit readiness to help ensure that financial information is complete, accurate, and properly reported. Implementation Date: July 30, 2026
Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requireme...
Condition/Context: For 1 of the 3 samples selected for testing, the school did not provide support for review and approval of the Character Investigations. Corrective action taken: Quileute Tribal School will establish effective internal controls for the Character Investigations compliance requirement and adhere to the internal controls. Person responsible for corrective action: Bob Harmon, Superintendent Implementation Date: July 30, 2026
2022-005 – Loss of Internal Controls Over Cash Disbursements – Significant Deficiency Auditor Recommendations: The Authority should perform a complete review of HUD and Housing Authority policies over disbursements to ensure compliance with these policies. Response: We will implement reviews of HUD ...
2022-005 – Loss of Internal Controls Over Cash Disbursements – Significant Deficiency Auditor Recommendations: The Authority should perform a complete review of HUD and Housing Authority policies over disbursements to ensure compliance with these policies. Response: We will implement reviews of HUD and Housing Authority policies, in addition to staffing changes, to ensure that this finding will be cleared by the subsequent fiscal year audit. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director
2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the proc...
2022-004 – Deficiencies Noted in Documentation of Controls - Housing Choice Voucher Participant Files - Significant Deficiency Auditor Recommendations: The Authority should establish a checklist for the Housing Choice Voucher Coordinator to use during the recertification process to document the procedures performed to ensure all compliance requirements are met. We recommend a complete review of all Housing Choice Voucher Program tenant file regulations to ensure compliance with these policies. Response: The Executive Director will actively oversee all financial aspects of the agency. Additionally, the director will ensure that finances are current and accurate monthly. A complete review of all Housing Choice Voucher Program tenant file regulations will be performed to ensure compliance with these policies. Timeframe: By completion of the 2027 FYE audit Individual responsible for correction: Mr. Marc Starling, Executive Director
The College is implementing a new version of Jenzabar. The new version will simplify processes and operations. Reports will be easier to access and tracking functions will notify users of missed operations. This will help to ensure that processes are running as required and are timely completed. The...
The College is implementing a new version of Jenzabar. The new version will simplify processes and operations. Reports will be easier to access and tracking functions will notify users of missed operations. This will help to ensure that processes are running as required and are timely completed. The upgrade and improvements are expected to be implemented by December 31, 2024. The party responsible is the Finance Director.
Finding 2022-002 Significant Deficiency in Internal Controls Over Compliance – HOME Investment Partnerships Program Finding: The audit identified a tenant file in which a HOME-assisted unit was not properly identified on the Household Eligibility Certification form, resulting in rental charges that ...
Finding 2022-002 Significant Deficiency in Internal Controls Over Compliance – HOME Investment Partnerships Program Finding: The audit identified a tenant file in which a HOME-assisted unit was not properly identified on the Household Eligibility Certification form, resulting in rental charges that exceeded allowable limits under HOME program requirements. Corrective Action Plan: DNDA agrees with the finding and has implemented procedures to strengthen compliance monitoring and tenant file review processes. To address this finding, management has taken the following actions: o Corrected the identified tenant file and reviewed the circumstances that led to the error. o Implemented additional review procedures for Household Eligibility Certification forms to verify unit designation, household income calculations, and applicable rent restrictions. o Established a secondary review process for HOME-assisted units to ensure compliance requirements are accurately reflected in tenant records. o Provided additional training and guidance to staff responsible for tenant certifications and compliance monitoring. o Incorporated periodic compliance reviews into ongoing property management oversight activities. Responsible Party: Shannon Woodard – Interim Executive Director, Danielle Clark-Burfening – Housing Director, Misty Wilson – Area Supervisor (3rd Party Property Management – United Marketing, Inc.), Bonita Salyers – Regional Portfolio Assistant (3rd Party Property Management – United Marketing, Inc.) Implementation Date: Corrective actions began upon identification of the finding. Expected Completion Date: Implemented December 18, 2025, Quarterly Verification of Compliance by Danielle Clark-Burfening Monitoring: Management will conduct periodic reviews of HOME-assisted tenant files and certification documents to verify continued compliance with HUD and HOME program requirements.
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SAS Material Weakness, Eligibility, management agrees with the findi...
View of Responsible Officials: Management response and corrective action Personnel responsible for corrective action: Evan Heath, CFO Anticipated completion date for corrective action: April 30, 2026 In response to Finding No. 2022-SAS Material Weakness, Eligibility, management agrees with the finding and will design, implement, and maintain policies and procedures to ensure compliance with the Uniform Guidance including eligibility.
2022-010 Inventory Significant Deficiency Recommendation: Management should use a quarterly physical count as a starting point, track purchases and uses of inventory throughout the quarter in order to calculate the inventory balance that should be on hand at the end of the quarter. Management should...
2022-010 Inventory Significant Deficiency Recommendation: Management should use a quarterly physical count as a starting point, track purchases and uses of inventory throughout the quarter in order to calculate the inventory balance that should be on hand at the end of the quarter. Management should then compare the calculated ending inventory against the related quarterly physical count and determine if there are any large variances that require further investigation. Written policies and procedures should be adopted accordingly. Action Taken: The Housing Authority agrees with this finding and will implement this recommendation within 120 days of this audit report
2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at leas...
2022-001 Segregation of Duties – Loan Program Significant Deficiency Recommendation: The Housing Authority’s fiscal policies should be revised to ensure that preventive controls are in place over check disbursements for loan disbursements, such that checks must be signed with live signatures at least the signature of one Tribal Council member. Further, individuals who benefit from the loan program should not have complete discretion over recording and processing of advances and repayment. We recommend a complete list of outstanding balances be presented to the Tribal Council, or its designee, for continued monitoring. Action Taken: The SCCHA discontinued the Loan Program as of November 2019. A complete list of balances owed has been submitted to the Tribal Council with the outstanding balances of those whom had signatory authority forwarded to the St. Croix Tribal Court for further repayment actions.
CORRECTIVE ACTION PLAN (Concerning Finding 2022-007) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board has taken the following actions to address finding 2022-007 The current Town Manager was appointed by...
CORRECTIVE ACTION PLAN (Concerning Finding 2022-007) Contact Person Responsible for Corrective Action: Carrie Castonguay, Town Manager Corrective Action: The Treasurer, Town Manager and Select Board has taken the following actions to address finding 2022-007 The current Town Manager was appointed by the Select Board on August 14, 2023, and had no knowledge of this material weakness. She is an experienced Manager and has drafted a new Procurement Policy that addresses this deficiency. This policy was approved and implemented by the Select Board on January 23, 2024. Anticipated Completion Date: Completed January 23, 2024.
REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget p...
REFERENCE # 2022-005 PERIOD OF PERFORMANCE – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Compliance Supplement Requirement: A non-federal entity may charge only allowable costs incurred during the approved budget period of a federal award’s period of performance and any costs incurred before the federal awarding agency or pass-through entity made the federal award that were authorized by the federal awarding agency or pass-through entity (2 CFR sections 200.308 200.309 and 200.403(h)). A period of performance may contain one or more budget periods. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. The Division’s pass-through Contract requires period of performance and also requires funds must be expended by certain date. Of the Sixty (60) files selected for testing We noted that the Division: • For 4 samples, we noted that Division program expenses were recorded prior to Contract starting date. Questioned Costs: Cannot be determined Recommendation: We recommend Division charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Corrective Action Plan: The Division will charge only allowable costs incurred during the approved budget period of a pass-through award’s period of performance and any costs incurred before the pass-through entity made the federal award that were authorized by the pass-through entity. Step 1 Action Date: Ongoing Final Implementation Date: 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, ...
REFERENCE # 2022-003 OTHER - BASIS OF ACCOUNTING – SIGNIFICANT DEFICIENCY- NONCOMPLIANCE Program Name/ALN Emergency Food and Shelter National Board Program (ALN # 97.024) Criteria: Basis of Accounting —Uniform Guidance states the basis of accounting used may be a special purpose framework. However, it does state that the determination of when an award is expended must be based on when the activity related to the federal award occurs. Uniform Guidance also states for Grants, cost reimbursement contracts, cooperative agreements, and direct appropriation type of contracts, the federal expenditure or expense should be reported when the transaction occurs. Uniform Guidance further states, the auditee should also be able to reconcile amounts presented in the financial statements to related amounts in the schedule of expenditures of federal awards. Condition/Context: Division receive Emergency Food and Shelter National Board Program funds from the U.S. Department Homeland security/FEMA and various pass-through entities. Division report to the pass-through entity on an accrual basis. Division’s schedule of expenditures of federal awards is presented on the accrual basis of accounting. Of the Sixty (60) files selected for testing: • Five (5) prior year expenditures were included in Division’s current year schedule of expenditures of federal awards. Questioned Costs: Cannot be determined Recommendation: We recommend Division report program expenditures in the year expenditures were accrued. Corrective Action Plan: The Division will report program expenditures in the year expenditures were accrued. Step 1 Action Date: Ongoing Final Implementation Date:h 12/31/2023 Name and Phone # Of Person Responsible for Implementation: Jeanne Stromberg, Major, Divisional Finance Secretary (916) 563-3710
Lack of Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss o...
Lack of Internal Controls over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Name of Contact Person: Ross Waddell Corrective Action Plan: The Native Village of Barrow (NVB) experienced significant operational disruption as a result of the COVID-19 pandemic, including the loss of several long-term employees. Due to the limited availability of qualified personnel in the local labor market, these vacancies were difficult to fill, which resulted in delays and backlogs in financial accounting and reporting functions. While efforts to establish a long-term staffing solution remained ongoing during 2022, NVB was required to engage out-of-town contract personnel and implement a transition of accounting and payroll systems during FY 2022, as sufficient internal expertise with the legacy systems was no longer available. For FY 2023, all financial activity was processed using a single accounting and payroll system (QuickBooks). However, FY 2022 required extensive reconciliation and integration of data from two separate systems to ensure accurate financial reporting for grant compliance and audit purposes. As a result of the circumstances described above, audited financial statements for FY 2023 and FY 2024 will not be issued in a timely manner. NVB was able to get grant reporting current by the end of calendar year 2025. Management is actively working to complete the accounting records for FY 2023 through FY 2025 to facilitate the timely completion of the upcoming audits. Proposed Completion Date: December 31, 2025.
Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024
Contact Person Jackie Cordie, Business Manager Corrective Action Plan The District plans to implement the auditor's recommendation. Planned Completion Date for CAP Fiscal year beginning July 1, 2024
Head Start of Lane County has created a timeline in partnership with Wipfli to ensure the completion of delinqunet audits and to ensure timely completion after August 31, 2026
Head Start of Lane County has created a timeline in partnership with Wipfli to ensure the completion of delinqunet audits and to ensure timely completion after August 31, 2026
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while mai...
Finding 2022-018 Eligibility Individual(s) Responsible: Michelle Cadue, Tribal Treasurer and Jonnah McKinney, KTIK IHS Director. Action:Complete patient files will be maintained to document eligibility in accordance with program requirements. Records will be made available for audit review while maintaining confidentiality, i.e., HIPPA. Anticipated Completion Date: March 2026.
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Co...
Finding 2022-016 Program Income Individual(s) Responsible: Tribal Council; Rona Johnson-Murillo, Accounting Director; Program Directors; Enterprise Managers; and Tyce Martin, HR Generalist. Action: Ensure that documentation is available for every item purchased or run through payroll. Anticipated Completion Date: March 2026.
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all ...
Finding 2022-014 Special Tests and Provisions Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Paula Vann, Grants Compliance Officer; and Cheryl DuBois, Head Start Director. Action: Review annual and quarterly reporting to ensure timely filing. Implementation of procedures to ensure all required Head Start facilities documentation is obtained, accurately completed, retained, and readily accessible for review. Resources will be allocated to develop, implement, and monitor policies and procedures that support effective operations, timely reporting, and full compliance with Head Start facilities requirements. Anticipated Completion Date: March 2026.
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monito...
Finding 2022-013 Reporting Individual(s) Responsible: Michelle Cadue, Tribal Treasurer; Rona Johnson-Murillo, Accounting Director; Paula Vann, Grants Compliance Officer; and Program Directors. Action: Reporting requirements will be reviewed with department heads, and submitted reports will be monitored for accuracy and timeliness. To strengthen compliance, a Grants Compliance Officer will be hired to oversee reporting obligations and ensure all required reports are submitted on time. Anticipated Completion Date: March 2026.
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