Corrective Action Plans

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We are taking steps to address the ongoing issue by coordinating with department heads and the Treasurer to ensure all grant paperwork is properly received and documented.
We are taking steps to address the ongoing issue by coordinating with department heads and the Treasurer to ensure all grant paperwork is properly received and documented.
FINDING 2024-001: Audit Report Deadline (Repeated 2023-001) Response: Following turnover in the City Manager (June 2024) and Finance Director (November 2024) positions, city staff have been actively working to ensure compliance regarding the delayed audit submission. The Finance Director, who joined...
FINDING 2024-001: Audit Report Deadline (Repeated 2023-001) Response: Following turnover in the City Manager (June 2024) and Finance Director (November 2024) positions, city staff have been actively working to ensure compliance regarding the delayed audit submission. The Finance Director, who joined the city in November 2024, postponed issuing RFPs to audit firms until the new City Manager assumed the role in April 2025. By July 2025, the City Manager and Finance Director engaged Nexus to complete the 2024 audit in the fall of 2025. To ensure compliance, the city will work with Nexus to have the 2025 Audit completed by March of 2026.
The SEFA information needed for this finding was from the 2025 budget. The 2025 budget can be amended up to 12/31/2025. Even though the ARPA funds in question were not reported on the SEFA page of the 2025 budget, it was reported within the budget within its own fund, which would show actual expendi...
The SEFA information needed for this finding was from the 2025 budget. The 2025 budget can be amended up to 12/31/2025. Even though the ARPA funds in question were not reported on the SEFA page of the 2025 budget, it was reported within the budget within its own fund, which would show actual expenditures of the year ended December 31, 2024. Going forward the County Clerk will have the Treasurer review the SEFA report for accuracy.
Inadequate Grant Recordkeeping The County will work to improve grant documentation and will consider having someone review grant reports prior to their submission. In the absence of necessary knowledge and expertise, the County will continue to rely on the auditors to assist with prepration of the S...
Inadequate Grant Recordkeeping The County will work to improve grant documentation and will consider having someone review grant reports prior to their submission. In the absence of necessary knowledge and expertise, the County will continue to rely on the auditors to assist with prepration of the Schedule of Expenditures of Federal Awards and reconciling the financial records to the Consolidated Year-End Financial Report.
Insufficient Grant Monitoring The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to the grant reports that are filed.
Insufficient Grant Monitoring The County will work to improve grant documentation and will consider implementing a review process to ensure the grant records agree to the grant reports that are filed.
Insufficient Subrecipient Monitoring The Health Department will establish procedures for subrecient monitoring.
Insufficient Subrecipient Monitoring The Health Department will establish procedures for subrecient monitoring.
Scotland County’s response for issues found: 1. We will double check to make sure we didn’t miss something for the SEFA report. 2. We will update the 2024 SEFA for the corrected amounts. 3. The Highway Planning and Construction (MODOT Intermodal) included the railroad bridge that no one could tell u...
Scotland County’s response for issues found: 1. We will double check to make sure we didn’t miss something for the SEFA report. 2. We will update the 2024 SEFA for the corrected amounts. 3. The Highway Planning and Construction (MODOT Intermodal) included the railroad bridge that no one could tell us where the money was coming from. This accounted for $1,228,104.64. We will correct this on the SEFA. 4. The ARPA was the interest received in 2024. We didn’t receive any more money from the state in 2024. We will get this added to the SEFA. 5. The HAVA Election Security Grant was missed when we were putting them in the report. We will get this added to the SEFA.
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Special Tests and Provisions Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assis...
FA 2024-001 Strengthen Controls over Expenditures Compliance Requirement: Special Tests and Provisions Internal Control Impact: Material Weakness Compliance Impact: Material Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425U - American Rescue Plan Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425U210012 (Year: 2021) Questioned Costs: None Description: Construction-related weekly payroll timesheets were not produced to satisfy the Wage Rate Requirements according to the Davis-Bacon Act. Corrective Action Plans: The School District will review and update the current procedures to ensure that the Wage Rate requirements are met. Estimated Completion Date: June 30, 2025 Contact Person: Daisy M. Prather, Finance Director Telephone: (478) 836-3131, extension 5007 Email: daisy.prather@crawfordschools.org
Condition and Context: The County does not have a complete set of written cash management policies and procedures required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Managemen...
Condition and Context: The County does not have a complete set of written cash management policies and procedures required by the Uniform Guidance. The lack of written procedures did not result in any material noncompliance, fraud or abuse with respect to the major program. Recommendation: Management should determine the scope of written policies needed for compliance with all federal programs and develop policies and procedures to comply with the Uniform Guidance. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and recommendation. The County’s existing policies are currently under review by management and staff to determine what updates/changes are necessary in order to meet the Uniform Guidance requirements. Once any updates/changes are drafted, the policy will be presented to the Governing Body for review and approval.
Condition and Context: During our audit of the Public Safety Partnership and Community Policing Grant (CFDA 16.710), we were unable to obtain a copy of the required SF-425 (Federal Financial Report) submitted by the County. Recommendation: We recommend that the County implement procedures to ensure ...
Condition and Context: During our audit of the Public Safety Partnership and Community Policing Grant (CFDA 16.710), we were unable to obtain a copy of the required SF-425 (Federal Financial Report) submitted by the County. Recommendation: We recommend that the County implement procedures to ensure that copies of all required federal reports are retained in accordance with federal record retention requirements and made available for audit purposes. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will establish procedures to ensure that all required federal reports are retained and readily available for future monitoring and audits.
Finding 2024-002 – Subrecipient Monitoring (Significant Deficiency) Recommendation: We recommend that procedures be implemented to ensure all subrecipients are notified of subaward requirements as outlined in 2 CFR 200.332(b) and the County implement a process to ensure all subrecipients audits are ...
Finding 2024-002 – Subrecipient Monitoring (Significant Deficiency) Recommendation: We recommend that procedures be implemented to ensure all subrecipients are notified of subaward requirements as outlined in 2 CFR 200.332(b) and the County implement a process to ensure all subrecipients audits are reviewed and deficiencies be followed up on. We also recommend that the County perform annual risk assessments for all subrecipients. The Area Agency on Aging failed to conduct the required annual risk assessment prior to disbursing funds. Corrective Action: • All divisions within the Department of Human Services (excluding Gracedale) will conduct an annual risk assessment for each provider during the contracting process. • DHS Policy 300.8 will be revised to include a standardized, department-wide risk assessment form for use across all divisions. The County did not ensure that all Foster Care Title IV-E and aging subrecipients were notified via contract or letter of their subaward Assistance Listing Number (ALN) and the amount paid during the year. Corrective Action: When issuing contracts, the County will include a notification letter to each provider indicating whether they have the potential to be a subrecipient of federal funds. If applicable, the letter will also include the relevant Assistance Listing Number (ALN). After the close of each fiscal year, the County will issue a summary letter to all subrecipients detailing the total amount of federal, state, and county funds paid to them. The portion of federal funding will be clearly identified and accompanied by the corresponding ALN. Cindy Smith, Financial and Information Systems Director for the Department of Human Services and her staff will be responsible for the corrective actions for finding 2024-002. The Department of Human Services began issuing notification letters in fall 2025 to vendors identified as potential subrecipients of federal funding. These notifications apply to fiscal year 2025–2026. In addition, summary letters informing vendors of federal award amounts are currently being distributed for fiscal year 2024–2025.
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contra...
Condition: Suspension and debarment compliance was not verified for four covered transactions. Corrective Action Planned: The Town will implement procedures to include a suspension and debarment certification in all federal contracts that are considered covered transactions to ensure that the contractors are eligible to receive federal funds and not excluded or disqualified from doing business. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawy...
Condition: The Town has not documented in writing its policies regarding federal awards. Corrective Action Planned: The Town will formally document procedures in writing to support compliance with applicable federal awards requirements. Anticipated Completion Date: March 31, 2026 Contact: Bryan Sawyer, Town Administrator
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project...
Federal Program Information Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health; Not Applicable Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24; Not Applicable Awards: Assistance Listing 93.917 – HIV Emergency Relief Project Grants; Assistance Listing 93.918 – Grants to Provide Outpatient Early Intervention Services with Respect to HIV Disease Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025; May 1, 2023 to April 30, 2024; May 1, 2024 to April 30, 2025 Type of Finding: Significant Deficiency in Internal Control Over Compliance Description: Timely Application of Program Income Prior to Requesting Additional Cash Payments Recommendation: During the latter part of the fiscal year and as a result of prior year audit findings, IJP implemented various checkpoints in their monthly processes to ensure that program income was disbursed prior to requesting cash reimbursements. IJP should continue to assess existing policies and procedures to ensure the program income balance is spent timely. HRSA recommends that recipients and subrecipients strive to proactively secure and estimate the extent to which program income will be accrued. View of responsible officials: Management concurs with the finding and has implemented procedures to ensure appropriate and timely application of program income. Corrective Action Planned: Inova Grants Accounting and Inova Juniper Program (IJP) directors will work collaboratively to disburse funds available from program income prior to requesting additional cash payments from RWHAP funds. Inova implemented a Program Income from Sponsored Programs policy in February 2025. Inova will assess this written procedure and revise as necessary to ensure that program income is applied before requesting federal reimbursement. Inova will review federal grant requirements related to program income and identify sources of program income during kickoff meetings for new awards. Mandatory training will be conducted for program and finance staff responsible for the administration of these awards. (2 CFR 200.307 and 200.305) Inova will require a monthly reconciliation of program income earned and expenditures by grant. Program income tracking will also be included in monthly grant variance reports. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
View Audit 372193 Questioned Costs: $1
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award P...
Federal Program Information: Federal Agencies: Department of Health and Human Services (“HHS”) Pass-Through Entity: Virginia Department of Health Pass-Through Entity Number: INORWB611-GY23; INORWB611-GY24 Awards: Assistance Listing Number 93.917 – HIV Emergency Relief Project Grants (Part B) Award Periods: April 1, 2023 to March 31, 2024; April 1, 2024 to March 31, 2025 Description: Timely Completion of the 24-month Eligibility Screening Type of Finding: Significant Deficiency in Internal Control Over Compliance Recommendation: Management should continue to implement procedures to ensure completion of the eligibility screening prior to the end of the 24-month eligibility period including steps to ensure the eligibility date aligns with the supporting documentation. View of responsible officials: Management concurs with the finding and will continue to implement further procedures to ensure that timely documentation is received with regard to eligibility. Corrective Action Planned: Inova will comply with VDH's 24-month eligibility rule, ensuring that services are not provided to RWHAP clients who miss their reassessment. To prevent gaps in service, Inova will continue to maintain monthly expiring eligibility tracking sheet to ensure clients will receive reminders 30–45 days before their eligibility period ends. CAR reviews will continue periodically throughout the 24 month timeframe. Inova will transition to HRSA’s CareWare system for eligibility management and tracking. Inova will continue 100% internal monthly eligibility audits and peer reviews, as well as implement a 10% chart review by a team member outside of the Juniper Program. Clients who do not submit the required reassessment documents will be removed from the program. Planned Completion Date for Corrective Action Planned: Ongoing with completion date of December 31, 2025.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Mrs. Clark (the County Clerk) didn’t realize she hadn’t included the number of monies in the SEFA report from ARPA monies. The correction was made when auditors were here.
Finding 1162353 (2024-002)
Material Weakness 2024
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Report...
This Finding is related to the failure to correctly report grant funds being expended and to the lack of a Department’s filing one quarterly report timely related to the SLFRF Funds. The Department has been contacted and is carefully reviewing guidance for all future remaining reports. Future Reports are expected to be filed correctly and timely, with future education being sought as needed.
Finding 1162350 (2024-001)
Material Weakness 2024
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. ...
This Finding is related to the Failure of a Department to timely file one quarterly status report. The employee in charge of quarterly reporting realized the omission herself in less than a week and corrected the action immediately, months before it was noticed and reported by the State Audit Team. The Director reports several calendaring mechanisms are in place and the reports are being tracked by duplicative methods since that error.
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action wi...
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action with a Target Completion Date of December 31, 2025: The Town will draft and present a formal policy addressing this finding to the Board of Selectmen for review and approval prior to December 31, 2025. Responsible Party: Tammy Penny, Finance Director 6 Village Green Pelham, NH 03076 Phone: 603-508-3072 Email: TPenny@Pelhamweb.com Implementation of this policy will ensure that the Town is in compliance with applicable requirements and will prevent recurrence of the cited issue in future audits.
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.
The City of Royal City is committed to meeting all federal grant requirements and thanks SAO for providing guidance regarding this matter. We will proceed with developing written procurement procedures for purchases, services and public works contracts. It is our goal to ensure all stipulations are ...
The City of Royal City is committed to meeting all federal grant requirements and thanks SAO for providing guidance regarding this matter. We will proceed with developing written procurement procedures for purchases, services and public works contracts. It is our goal to ensure all stipulations are met for solicitation and award of Architectural and Engineering Services and Public Works contracts as required by state and federal granting agencies.
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