Corrective Action Plans

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The Company acknowledges non-compliance with 2 CFR § 200.305 that the entity must minimize the time elapsing between the transfer of funds from the U.S. Treasury or the pass-through entity and the disbursement of funds by the recipient or subrecipient. However, the questioned costs that were transfe...
The Company acknowledges non-compliance with 2 CFR § 200.305 that the entity must minimize the time elapsing between the transfer of funds from the U.S. Treasury or the pass-through entity and the disbursement of funds by the recipient or subrecipient. However, the questioned costs that were transferred in advance were ultimately deemed reasonable because they were disbursed during the grant period for allowable costs as part of the federal contract awarded. The Company will ensure a proper understanding of the compliance requirements for all federal contracts prior to requesting funds and will ensure funds transferred are compliant with the requirement that the Company minimize the time elapsed from the time of transfer and the disbursement of funds in accordance with the grant terms. Contact Person Michael Davis, Chief Financial Officer of Southern Regional Hospital Expected completion date: This will be implemented on new federal contracts awarded subsequent to August 28, 2025.
View Audit 366228 Questioned Costs: $1
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and s...
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and send reminders to the Project Managers no less than 15 days before the reporting deadline.
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and s...
Views of responsible officials and planned corrective actions: The Public Works Department implemented several measures to ensure compliance with grant reporting requirements, including scheduling quarterly meetings with Project Managers, attend training sessions provided by the grant sponsor, and send reminders to the Project Managers no less than 15 days before the reporting deadline.
Finding Number 2024-001 Contact Person(s): Kim Goodman, Finance Director Corrective action planned: The Association acknowledges the audit findings and recognizes the importance of strengthing internal control processes to ensure staff understand the nature of a subrecipient vs a contractor, and t...
Finding Number 2024-001 Contact Person(s): Kim Goodman, Finance Director Corrective action planned: The Association acknowledges the audit findings and recognizes the importance of strengthing internal control processes to ensure staff understand the nature of a subrecipient vs a contractor, and that they ensure that this determination is being reviewed, and clearly communicated in underlying agreements, as part of their internal control processes. The following corrective actions have been taken: • All 23-25 AJA Grantees will be provided agreements with the correct designation of "sub recipient." • All 25-27 AJA and MHFR Grantees will have the designation of "sub recipient." Anticipated completion date: Completed June 30, 2025
Corrective Action Plan: In response to the findings related to the Gramm-Leach-Bliley Act (GLBA) Safeguards Rule compliance at [Institution Name], we have developed the following Corrective Action Plan to address identified deficiencies and strengthen our information security program. • Corrective A...
Corrective Action Plan: In response to the findings related to the Gramm-Leach-Bliley Act (GLBA) Safeguards Rule compliance at [Institution Name], we have developed the following Corrective Action Plan to address identified deficiencies and strengthen our information security program. • Corrective Action: By December 31, 2025, Rockland Community College will complete a comprehensive risk assessment of all systems handling covered financial and student information. Risk assessments will be conducted annually thereafter, with updates documented and reviewed by the Information Security Officer (ISO). • Corrective Action: A revised Written Information Security Program (WISP) will be finalized by July 31, 2026. It will outline administrative, technical, and physical safeguards, as well as roles and responsibilities for maintaining compliance. • Corrective Action: A Qualified Individual responsible for overseeing and enforcing the Safeguards Rule compliance program will be designated by December 31, 2025. • Corrective Action: All vendor agreements will be reviewed and updated by July 31, 2026, to include language requiring providers to safeguard covered data. A vendor management procedure will also be implemented to ensure ongoing oversight. • An annual GLBA training program will be implemented starting July 31, 2026. Training completion will be monitored and documented through the HR compliance system. • Corrective Action: Rockland Community College will implement quarterly testing of safeguards and document results. Findings will be reported to the Executive Cabinet and used to continuously improve protections. All corrective actions will be completed by August 31, 2026. Progress will be tracked by the Information Security Officer and reported quarterly to the Executive Cabinet and the Board of Trustees. We are committed to protecting sensitive financial and student information and ensuring full compliance with the GLBA Safeguards Rule. Please let us know if additional information is required.
2024-003 a. Contact person responsible for corrective action: Steve Reed, Chief Financial Officer b. Description of corrective action to be taken: Management has implemented a staffing plan, established an audit preparation calendar, and added monitoring controls to ensure timely completion of f...
2024-003 a. Contact person responsible for corrective action: Steve Reed, Chief Financial Officer b. Description of corrective action to be taken: Management has implemented a staffing plan, established an audit preparation calendar, and added monitoring controls to ensure timely completion of financial statement audits and submission of the Data Collection Form. The CFO is responsible for oversight, and these procedures were put in place beginning September 2025 to prevent recurrence. c. Anticipated completion date of corrective action: Ongoing.
Finding 2024-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20243445-00, E20243384-00, E20243038-00 Award Year End: Septemb...
Finding 2024-006: Crime Victim Assistance Documented Review and Approval Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20243445-00, E20243384-00, E20243038-00 Award Year End: September 30, 2024 Recommendation: The Organization should establish procedures to require the documented review and approval of all indirect cost calculations, cash management requests for funds, and reports by an individual with adequate skills, knowledge, and experience prior to submission. Action Taken: The Executive Director is now reviewing the bank reconciliation and monitoring cash. The Organization will establish the necessary policies and procedures to require the documented review and approval of all indirect calculations, cash management requests for funds and performance reports on a monthly basis prior to submission with documented approval. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2025.
Finding 2024-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20243445-00, E20243384-00, E20243038-00 Award Year End: Sep...
Finding 2024-005: MATERIAL WEAKNESS—Uniform Guidance Written Internal Control Procedures U.S. Department of Justice Pass-through Entity: Michigan Department of Health and Human Services Assistance Listing Number: 16.575 Award Numbers: E20243445-00, E20243384-00, E20243038-00 Award Year End: September 30, 2024 Recommendation: The Organization should establish and maintain written internal control procedures that cover the required five components of internal control for each area of compliance for each of its federal programs. The Organization should educate all employees working with federal programs of the Organization’s procedures and monitor compliance with them. Action Taken: The Organization will establish the necessary policies and procedures for managing its federal awards in compliance with federal requirements. These policies will be reviewed and updated annually. Managers will be required to familiarize themselves with financial policies annually. Responsible Person and Anticipated Completion Date: The Executive Director will oversee the implementation of this plan by September 30, 2025.
Finding ref number: 2024-003 Finding caption: The District did not have adequate internal controls for ensuring compliance with time-and-effort requirements. Name, address, and telephone of District contact person: Ruby Perez 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corrective action ...
Finding ref number: 2024-003 Finding caption: The District did not have adequate internal controls for ensuring compliance with time-and-effort requirements. Name, address, and telephone of District contact person: Ruby Perez 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corrective action the auditee plans to take in response to the finding: The District acknowledges this finding and has taken steps to address all time-and-effort documentation issues. New procedures are now in place, including formal time-and-effort tracking using the appropriate method—semiannual or monthly—based on program guidelines and funding structure. The District has also implemented a policy that requires all journal entries to include supporting documentation. Each journal entry is reviewed and approved by multiple staff, including Business Office staff and program directors, before posting. These safeguards will ensure accountability, prevent future exceptions, and maintain public trust. Anticipated date to complete the corrective action: August 31, 2025
View Audit 366085 Questioned Costs: $1
Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort requirements. Name, address, and telephone of District contact person: Ruby Perez 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corrective action the a...
Finding ref number: 2024-001 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort requirements. Name, address, and telephone of District contact person: Ruby Perez 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corrective action the auditee plans to take in response to the finding: The District acknowledges the finding and has implemented new procedures to ensure strong internal controls over time-and-effort documentation. This issue primarily occurred during a period of staff turnover. The District has since hired experienced personnel who are now overseeing federal program compliance. We have implemented a compliant time-and-effort tracking system consistent with OSPI and federal requirements. Documentation—whether semiannual certifications or monthly reports, as applicable—is collected, reviewed, and retained in accordance with the type of funding allocation. All documentation is reviewed by both the Business Office and program administrators to ensure accuracy. Monthly monitoring and required training for relevant staff are now embedded into our internal processes. The district is committed to ensuring accuracy and accountability in all federally funded programs. Anticipated date to complete the corrective action: August 31, 2025
View Audit 366085 Questioned Costs: $1
Finding ref number: 2024-002 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort and private school requirements. Name, address, and telephone of District contact person: Ruby Perez 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corr...
Finding ref number: 2024-002 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort and private school requirements. Name, address, and telephone of District contact person: Ruby Perez 1620 S. Pioneer Way Moses Lake, WA 98837 (509) 766-2650 Corrective action the auditee plans to take in response to the finding: The District concurs with the finding. In response, the District has established a regularly updated list of private schools within our boundaries. We will be proactively reaching out to these schools each year to determine interest and eligibility for Title I services, and are documenting all correspondence. In addition, we have strengthened time-and-effort documentation procedures as described in 2024-001. Our new internal controls include multilayered reviews and program director oversight to ensure timely, complete compliance. The District is committed to equity in services and transparency in all federal programming. Anticipated date to complete the corrective action: August 31, 2025
View Audit 366085 Questioned Costs: $1
Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Steps have been taken and implemented on 1/1/2025 to ensure adequate oversight and review takes p...
Management recognizes its compliance requirements for maintaining and implementing sound controls over financial reporting and the potential non-compliance impacts of a lack of such control environment. Steps have been taken and implemented on 1/1/2025 to ensure adequate oversight and review takes place. All reporting requirements and due dates are currently being submitted timely.
The draft audit of June 30, 2024, was completed August 12, 2025. There was not sufficient time to complete the audit and data collection for fiscal year 2024 within the required timeframe, March 31, 2025. The audit of June 30, 2025, will be completed and submitted to the Federal Clearinghouse within...
The draft audit of June 30, 2024, was completed August 12, 2025. There was not sufficient time to complete the audit and data collection for fiscal year 2024 within the required timeframe, March 31, 2025. The audit of June 30, 2025, will be completed and submitted to the Federal Clearinghouse within the required timeframe.
Finding 2024-001 The Project is relatively small with only one administrative staff. Further the Board of Directors is a volunteer board and not a managing board. It does not have the time nor expertise to provide the necessary services to correct the internal control deficiencies noted. The Board o...
Finding 2024-001 The Project is relatively small with only one administrative staff. Further the Board of Directors is a volunteer board and not a managing board. It does not have the time nor expertise to provide the necessary services to correct the internal control deficiencies noted. The Board of Directors has reviewed this issue, and determined there are no additional procedures which can reasonably be done to eliminate these deficiencies. As such, the Board of Directors accepts this finding.
Finding 2024-003 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...
Finding 2024-003 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: Management has requested that the auditor propose certain year-end adjustments to bring the financial statements into conformity with Generally Accepted Accounting Principles (GAAP). For example, cash to accrual adjustments, depreciation calculations and adjustments, adjustments to debt and interest expense, interest subsidy adjustments, etc. Management Response: Management has evaluated the risk that a material misstatement might occur and not be detected in the financial statements. Management believes that the risk of material misstatement is not significant for the following reasons: 1. The entries are standard entries required to be made each year. If an entry was not made it would be obvious in the financial statements. A calculation error that would be material to the financial statements would also be obvious. 2. Management reviews and approves both the proposed adjusting journal entries and the financial statements prior to release. Based upon management’s consideration of the risk of material misstatement, management believes the costs of hiring, training, and monitoring part-time accounting personnel far exceed any potential benefits from implementing additional controls. Status: In progress Anticipated Completion Date: Estimated 2025
Finding 2024-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...
Finding 2024-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2024 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025
Corrective action the auditee plans to take in response to the finding: As reflected in the full text of the finding, the City has controls in place for contracts known to be paid with federal grant dollars. Since 2021 the City has worked to tighten controls over suspension and debarment, includin...
Corrective action the auditee plans to take in response to the finding: As reflected in the full text of the finding, the City has controls in place for contracts known to be paid with federal grant dollars. Since 2021 the City has worked to tighten controls over suspension and debarment, including significant staff training and clarification to the procurement process to include individual staffs’ responsibility over confirming contractor’s suspension and debarment status as well as internal project checklists. Going forward the City will: • Incorporate verbiage into all future contracts requiring contractors to affirm they are not suspended or debarred from receiving grant funding, even if the contract is not expected to be funded by grant funding. • If a similar situation were to arise in the future where an existing contract’s funding source is changed to include grant funding, only funds spent prospectively would be reimbursable with grant funding and only after the contractor is confirmed to not be suspended or debarred.
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Regina D. McIntyre Contact Phone Number and Email Address: 812-376-2595 rmcintyre@columbus.in.gov Views of Responsible Officials...
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Regina D. McIntyre Contact Phone Number and Email Address: 812-376-2595 rmcintyre@columbus.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The City Finance team has added an additional member in 2025 to oversee compliance around grants as well as apply to new grant opportunities. A duty of this position will be to review grant expenditures for compliance, including Suspension and Debarment review requirements on federal funding. Furthermore, this position will develop a specific training program to all departments who receive federal funds (including and especially CCU) as well as train and follow up for competency. The departments will be responsible for first line of review prior to commitment of federal grant expenditures. Should our Grant Writer/Administrator find any failures to perform this review appropriately, additional training and follow up will occur immediately with the department. Evidence of compliance for all expenditures requiring a review for Suspension and Debarment will be stored with the grant paperwork kept centrally in the Finance Dept. Anticipated Completion Date: The anticipated completion date for the review process, the training, and deployment should be complete by the end of October 2025.
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Regina D. McIntyre Contact Phone Number and Email Address: 812-376-2595 rmcintyre@columbus.in.gov Views of Responsible Officials...
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Regina D. McIntyre Contact Phone Number and Email Address: 812-376-2595 rmcintyre@columbus.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The City Finance team has added an additional member in 2025 to oversee compliance around grants as well as apply to new grant opportunities. A duty of this position will be to review grant expenditures for compliance, including Suspension and Debarment review requirements on federal funding. Furthermore, this position will develop a specific training program to all departments who receive federal funds as well as train and follow up for competency. The departments will be responsible for first line of review prior to commitment of federal grant expenditures. Should our Grant Writer/Administrator find any failures to perform this review appropriately, additional training and follow up will occur immediately with the department. Evidence of compliance for all expenditures requiring a review for Suspension and Debarment will be stored with the grant paperwork kept centrally in the Finance Dept. Anticipated Completion Date: The anticipated completion date for the review process, the training, and deployment should be complete by the end of October 2025.
Type of Finding: Material Weakness; Compliance Requirement: Reporting Finding Summary: The totals submitted on the SLFRF Compliance P&E Annual Report did not match the expenditures incurred by the City. The City passed through funds to three subrecipients during the year to be used for preapproved p...
Type of Finding: Material Weakness; Compliance Requirement: Reporting Finding Summary: The totals submitted on the SLFRF Compliance P&E Annual Report did not match the expenditures incurred by the City. The City passed through funds to three subrecipients during the year to be used for preapproved projects allowed under the award. The City reported funds expended by the subrecipients to date, rather than the funds incurred by the City. Responsible Individuals: Ellen Lorraine McCabe, City Manager Corrective Action Plan: The City has had significant turnover in management positions over the past few years. This was also the first year a single audit was required. New procedures will be implemented to controls surrounding federal programs to ensure accurate reporting. The City inquired about amending the report directly with the Treasury Department and is not required to resubmit the report. No further action is necessary. Anticipated Completion Date: August 29, 2025
Accounting has reviewed all projects and Ordinances related to ARPA and has updated reports and records to fully account for ARPA funding. From the Chief Administrative Officer (CAO) and the department responsible for a specific project that has multiple funding sources, confirmation was obtained on...
Accounting has reviewed all projects and Ordinances related to ARPA and has updated reports and records to fully account for ARPA funding. From the Chief Administrative Officer (CAO) and the department responsible for a specific project that has multiple funding sources, confirmation was obtained on what amounts were obligated ARP funds. This strengthens the controls over the report submission process to ensure the reported amounts are accurate and reconciled properly. Person Responsible: Sheila Faour, CFO Anticipated Completion Date: Immediately
Finding 576073 (2024-005)
Material Weakness 2024
We recommend that the subrecipient establish and implement procedures to verify the eligibility of parties involved in Federal awards, subawards, and contracts. This should include regular checks against the System for Award Management (SAM) to ensure compliance with suspension and debarment regulat...
We recommend that the subrecipient establish and implement procedures to verify the eligibility of parties involved in Federal awards, subawards, and contracts. This should include regular checks against the System for Award Management (SAM) to ensure compliance with suspension and debarment regulations. Additionally, the subrecipient should maintain documentation to support the review process, including records of SAM checks and any correspondence related to the verification of eligibility. This documentation will provide evidence of compliance and support any future audits or reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization is implementing formal written procedures to verify the eligibility of all contractors and subrecipients prior to entering into any federally funded agreements. This includes mandatory checks against the System for Award Management (SAM.gov) for each party. In addition, the Organization will maintain documentation of all SAM verification checks, including screenshots or download logs, date of the check, name of the party verified, and results. Any correspondence or follow-up related to eligibility will also be retained in the procurement or grant file. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Finding 576072 (2024-004)
Significant Deficiency 2024
We recommend that the subrecipient implement procedures to ensure that written preapproval is obtained from the Federal awarding entity for noncompetitive procurement. Additionally, the procurement process should be documented thoroughly to indicate the circumstances under which noncompetitive procu...
We recommend that the subrecipient implement procedures to ensure that written preapproval is obtained from the Federal awarding entity for noncompetitive procurement. Additionally, the procurement process should be documented thoroughly to indicate the circumstances under which noncompetitive procurement is justified. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization is updating its procurement policy to explicitly require written prior approval from the Federal awarding agency for all noncompetitive (sole source) procurements, in accordance with federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Kristina Valdez, Chief Executive Officer Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible C...
Finding 2024-004: Written Policies and Procedures • Planned Corrective Action: We will adopt formal policies and procedures that document our current practices and also meet the requirements of the Code of Federal Regulations (CFR). • Anticipated Completion Date: September 30, 2025. • Responsible Contact Person: Rick Smith, Executive Director
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Barrett Dewitt Housing Development Fund...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Barrett Dewitt Housing Development Fund Company, Inc. agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
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