Corrective Action Plans

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Finding 2024-004: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Lead-Based Paint Hazard Reduction Grant Program Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principle...
Finding 2024-004: Material Weakness and Noncompliance Finding- Procurement and Suspension, and Debarment - Verification Against the System for Award Management (SAM) Program: Lead-Based Paint Hazard Reduction Grant Program Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. When a non-federal entity enters a covered transaction with an entity at a lower tier, the non-federal entity must verify that the entity, as defined in 2 CFR section 180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded from participating in the transaction. Without documented evidence verifying whether the City was following its policy, the City could not provide evidence of this control being completed for federally funded projects. There were no standard forms or templates that were used to document verification that parties are not suspended or debarred. Corrective Actions Taken: 1. Establish Documentation Protocols: The City is implementing standard templates and procedures for verifying suspension and debarment status, including documentation requirements. 2. System Integration and Workflow Updates: These procedures will be integrated into procurement workflows and reviewed regularly to ensure consistency across all federally funded contracts. 3. Monitoring and Oversight: A designated staff member will perform periodic reviews to confirm verification procedures are being followed and properly documented. Contact: Malinda Figueroa, Purchasing Director, Anticipated Completion Date: December 2025
Finding 567561 (2024-002)
Significant Deficiency 2024
Finding 2024-002: Significant Deficiency and Noncompliance Finding, Reporting-Annual Program: Lead-Based Paint Hazard Reduction Grant Program Finding: Under the Lead-Based Paint Hazard Reduction Grant Program Terms and Conditions issued by the U.S. Department of Housing and Urban Development, Cit...
Finding 2024-002: Significant Deficiency and Noncompliance Finding, Reporting-Annual Program: Lead-Based Paint Hazard Reduction Grant Program Finding: Under the Lead-Based Paint Hazard Reduction Grant Program Terms and Conditions issued by the U.S. Department of Housing and Urban Development, Cities were required to submit an annual race and ethnic data reporting form HUD-27061 covering the period from July 1, 2022, to June 30, 2023, by January 10, 2024. Based on our testing of the required quarterly and annual reports we determined the annual report was not submitted as required. Corrective Actions Taken: 1. Centralized Compliance Tracking: A comprehensive Grant Policy has been implemented with centralized tracking to monitor grant reporting deadlines and prevent missed submissions. 2. The Office of Management, Policy, and Grants is establishing a Grant Management Team to conduct a secondary review of all reporting-related entries and ensure timely submissions. These actions will be implemented by the end of the next fiscal year, with all policy updates and training completed by October 31, 2025. 3. Health Department: The Health Department and the City’s Internal Auditor are creating Standard Operation Procedures and will train staff by December 31, 2025. 4. Contacts: Shannon McCue, Director of Management, Policy, and Grants; Maritza Bond, Health Director, Anticipated Completion Date: January 2026
Our current protocol requires conducting SAM.gov exclusion checks on or before the date of hire. However, due to a recent administrative transition, some records from 2025 and prior were found to be unavailable. To address this gap, we have re-verified SAM.gov checks for all new hires in 2025 and wi...
Our current protocol requires conducting SAM.gov exclusion checks on or before the date of hire. However, due to a recent administrative transition, some records from 2025 and prior were found to be unavailable. To address this gap, we have re-verified SAM.gov checks for all new hires in 2025 and will continue performing monthly exclusion checks moving forward. All SAM.gov results will be stored electronically to ensure ongoing compliance and proper documentation.
The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an issue in the future.
The audit for the year ended June 30, 2023 was not submitted to the Federal Audit Clearinghouse due to issues with the UEI numbers not being renewed timely on the Academy's side. The Finance Director is now responsible for the renewals going forward, and this will not be an issue in the future.
Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...
Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We will ensure all reporting is filed on a timely basis.
Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...
Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • All Federal draws will have supporting documents that are reviewed, approved, and certified before funds are requested.
2024-002 – REPORTING Auditee’s Response and Planned Corrective Action The Executive Director will work with the Fee Accountant in order to review and enhance year end close processes to ensure accuracy and timeliness of reporting. Planned Implementation Date of Corrective Action: June 30, 2025 Per...
2024-002 – REPORTING Auditee’s Response and Planned Corrective Action The Executive Director will work with the Fee Accountant in order to review and enhance year end close processes to ensure accuracy and timeliness of reporting. Planned Implementation Date of Corrective Action: June 30, 2025 Person Responsible for Corrective Action: Anne Marie Burns, Executive Director
Finding 567384 (2024-001)
Significant Deficiency 2024
Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Part...
Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Party: Cynthia Rogers-Ellickson, Director – Housing & Community Development Planned Implementation Date: June 13, 2025
View Audit 360057 Questioned Costs: $1
Identifying Number: 2024-001 – Federal Funding Accountability and Transparency Act Reporting (Significant Deficiency) Finding: Reports in compliance with the Federal Funding Accountability and Transparency Act (FFATA) were not completed in a timely manner. Name of contact person ...
Identifying Number: 2024-001 – Federal Funding Accountability and Transparency Act Reporting (Significant Deficiency) Finding: Reports in compliance with the Federal Funding Accountability and Transparency Act (FFATA) were not completed in a timely manner. Name of contact person and title: David Chimahusky, CFO, GLCAP Anticipated completion date: June 30, 2025 Great Lakes Community Action Partnership’s response: Concur Great Lakes Community Action Partnership agrees with this finding and provides the following response and corrective actions: Corrective Action Taken or Planned: Management has procedures in place to evaluate awards for FFATA reporting applicability and will continue to employ and refine these procedures to ensure reporting is submitted in a timely and complete manner. Record of subaward review and FFATA submission dates will be maintained for regular review. Person(s) Responsible for Implementation: David Chimahusky, CFO
Finding Reference Number: 2024-009 – COVID-19 - Coronavirus State and Local Recovery Funds. Compliance Requirement: Internal Control noncompliance - Reporting. Name of Contact Person: Jim Conklin. Views of Responsible Officials: Management acknowledges the finding and understands the need to complet...
Finding Reference Number: 2024-009 – COVID-19 - Coronavirus State and Local Recovery Funds. Compliance Requirement: Internal Control noncompliance - Reporting. Name of Contact Person: Jim Conklin. Views of Responsible Officials: Management acknowledges the finding and understands the need to complete and submit timely any required reporting to federal grantors as outlined by the notice of award, federal regulations, and/or grant agreement. Planned Corrective Action: The Organization will provide training to staff involved in grants management about importance of completion and timely submission of required reports. We will review any future federal grant agreements obtained for required reporting and prepare a calendar to track the appropriate due dates. This calendar will be shared with and monitored by a member of management and all required reports will be reviewed to evidence internal control over reports submitted to grantors. Anticipated Completion Date: 6/30/2025.
2024-002 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that none of the semi-annual financial reports selected for testing included documentation that they were subjecte...
2024-002 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that none of the semi-annual financial reports selected for testing included documentation that they were subjected to an independent review and approval prior to submission in order to detect and correct potential errors or omissions. As a result of this condition, the Township was exposed to an increased risk that the reports filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation: We recommend that the Township establish procedures to ensure that all reports are subject to review and approval by an independent employee prior to submission, and that the review and approval is adequately documented.   Corrective Action: We acknowledge the finding of significant deficiency in internal controls over compliance. While the matter is not considered to be material to the overall compliance requirements, we recognize the importance of maintaining robust internal controls to ensure full adherence to applicable regulations and policies. The Township is in the process of ensuring relevant personnel are informed and adequately trained on updated compliance processes. We will also increase periodic reviews and monitoring activities to ensure sustained compliance and timely identification of potential issues. Responsible Person: Tracy Watkins, Finance Director Anticipated Completion Date: December 31, 2025
NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS, AIRPORT IMPROVEMENT PROGRAM, CFDA NO. 20.106, CONTRACT NO. AIP-3-30-0068-014-2022 Name of contact person: Board of County Commissioners Corrective Action: The Board will take a more active role in insuring that all grant terms and conditions are being...
NONCOMPLIANCE WITH GRANT TERMS AND CONDITIONS, AIRPORT IMPROVEMENT PROGRAM, CFDA NO. 20.106, CONTRACT NO. AIP-3-30-0068-014-2022 Name of contact person: Board of County Commissioners Corrective Action: The Board will take a more active role in insuring that all grant terms and conditions are being adhered to. Proposed Completion Date: Immediately.
Corrective Action Plan for CDBG – Entitlement Grants Cluster: Reporting – Finding 2024-001 We are in receipt of the Findings Required to be Reported by the Uniform Guidance, specifically finding 2024-001 regarding failure to submit the required report in FSRS for the year ended December 31, 2024 for...
Corrective Action Plan for CDBG – Entitlement Grants Cluster: Reporting – Finding 2024-001 We are in receipt of the Findings Required to be Reported by the Uniform Guidance, specifically finding 2024-001 regarding failure to submit the required report in FSRS for the year ended December 31, 2024 for a first-tier subaward resulting in an obligation of $36,000. View of Responsible Officials and Planned Corrective Actions Management agrees with the finding. The City experienced turnover at the end of the fiscal year leaving less time for preparation and review of required reporting. As a result, internal controls and review processes were not in place or were not followed to ensure all required reporting was completed accurately and timely. Overall, we will increase compensating controls by introducing additional management oversight and review for the processes in this area. We will develop a process for reviewing and tracking the reporting of subaward obligations in FSRS to ensure that reporting is in compliance with Department of Housing and Urban Development, CFR, and FAR rules and regulations. Ember Strange, Chief Financial Officer, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.
City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal con...
City of Panama City Beach, Florida Management’s Corrective Action Plan For the Fiscal Year Ended September 30, 2024 Finding Numbers: 2024-001 Finding 2024-001 Lack of Documented Review of Annual Project and Expenditure Report The City acknowledges the importance of maintaining strong internal controls. While the report was prepared with diligence and care, we recognize that the absence of documented independent review poses a risk for potential errors and noncompliance with federal requirements. To address this issue, the City has established a formal process to ensure that future reports undergo an independent review before submission. A qualified staff member who is not involved in preparing the report will conduct the review, and both the preparer and the reviewer will sign and date the report to provide evidence of oversight. This documentation will be retained in the grant file for compliance and audit purposes. Staff involved in the reporting process have been informed of these new procedures to ensure consistency moving forward. The revised procedures have been adopted and will be applied to the next reporting cycle. Documentation of the review process will be retained and made available for future audits. The City is committed to maintaining compliance with all applicable federal regulations and improving internal controls to ensure the integrity and accuracy of all grant-related reporting. Anticipated Completion Date: June 2025 Responsible Contact Person: Debra Gibson
Finding: 2024-001 Condition: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordan...
Finding: 2024-001 Condition: In accordance with Section 330(k)(3)(G) of the Public Health Services Act (42 U.S. Code § 254b), as an FQHC, the Organization must have a sliding fee discount program in which the Organization’s fee schedule is discounted based on a patient’s ability to pay. In accordance with their policy, the Organization will monitor the accuracy of the discounts provided to patients by a monthly random audit of 15 visits where a sliding fee discount adjustment was received. Individual(s) Responsible for Corrective Action: Kimberly Garca, Director of Patient Accounts Planned Corrective Action: 1. Complete Q1 2025: Complete internal audit/monitoring for January, February and March. 2. Establish a Formal Monitoring Calendar: Develop and maintain a documented monitoring calendar that includes monthly deadlines and responsible personnel for completing the required audits. This calendar should be reviewed and approved by supervisory staff and integrated into regular compliance reporting. 3. Assign Backup Personnel: Designate and train at least one backup staff member to perform sliding fee discount audits during periods of high workload or staff absences. This ensures continuity and timely completion of required monitoring activities. 3. Monthly Oversight Review: Require supervisory review and sign-off on the completion of each monthly audit to verify that the monitoring activities were conducted and documented appropriately. Anticipated Completion Date: • Corrective Action #1 has been completed as of 4/28/2025. • Corrective Action #2 has been completed as of 5/5/2025. • Corrective Action #3 will be completed by August 2025.
Condition: The Office of the Advocate for the Elderly requires the monitoring process of 100% of the population of the subrecipients of federal funds, at least once a year. During the year ended September 30, 2024, the OAE distributed federal funds to 118 subrecipients. However, the subrecipients s...
Condition: The Office of the Advocate for the Elderly requires the monitoring process of 100% of the population of the subrecipients of federal funds, at least once a year. During the year ended September 30, 2024, the OAE distributed federal funds to 118 subrecipients. However, the subrecipients subjected to formal monitoring were only fifty one (51) or 43%. Corrective Action Plan: The Office has changed its procedures for conducting monitoring visits. These are now based on a risk-based monitoring approach. This was implemented during 2024, and we have observed an increase in the number of monitoring visits conducted, compared to the finding from 2023, when only 11% of sub-recipients were monitored. During the audited period, this figure increased to 43% of sub-recipients who received monitoring. We expect that for the 2025 Self-Assessment, this issue will no longer be a finding, thereby meeting the required standards. Lead Person for Action Item Completion: Miguel Padilla Vázquez Budget Director Marie M Marrero Garcia Administration Director
Management implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate it's controls regarding current federal awards and requirements to ensure accurate information captured, reported and maintained.
Management implemented changes to the preparation and review process for grant reporting. Management will continue to evaluate it's controls regarding current federal awards and requirements to ensure accurate information captured, reported and maintained.
Management will continue to evaluate their controls concerning current federal awards and requirements to ensure accurate information captured and reported.
Management will continue to evaluate their controls concerning current federal awards and requirements to ensure accurate information captured and reported.
2024-003 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payme...
2024-003 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payment standard. Cause: Human error in the entry of payment standard which affected the assistance payment. Effect: The cost of the assistance may be disallowed. Context: A sample of grants totaling $29,234 was selected for audit from a population of $12,361,012. The test found questioned costs totaling $212. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: Housing counselors have been instructed to double check that the computer system is pulling in the correct payment standard and document if they override it and why. A new transaction check list has been created with a spot where they have to note the payment standard they are using in the transaction. Anticipated completion date: 9/30/25 Responsible party: Michelle Worthington, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.
View Audit 359820 Questioned Costs: $1
2024-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payme...
2024-001 U.S. Department of Housing and Urban Development Housing Voucher Cluster - 14.871 Section 8 Housing Choice Vouchers and 14.879 Mainstream Vouchers - Material Weakness Condition and Criteria: An assistance payment was calculated incorrectly due to error in data entry, specifically the payment standard. Cause: Human error in the entry of payment standard which affected the assistance payment. Effect: The cost of the assistance may be disallowed. Context: A sample of grants totaling $29,234 was selected for audit from a population of $12,361,012. The test found questioned costs totaling $212. Our sample was a statistically valid sample. CORRECTIVE ACTION PLAN RESPONSE: Housing counselors have been instructed to double check that the computer system is pulling in the correct payment standard and document if they override it and why. A new transaction check list has been created with a spot where they have to note the payment standard they are using in the transaction. Anticipated completion date: 9/30/25 Responsible party: Michelle Worthington, Section 8 Housing Director Please contact Vicky Pritchett, Finance Director at 573-213-4811 extension #10102 with questions regarding this plan.
View Audit 359820 Questioned Costs: $1
The District will establish policies and procedures surrounding the administration of federal grants. The District will use the template developed by the Massachusetts Association of School Business Officials with updates made that are specific to the King Philip Regional School District. Documentat...
The District will establish policies and procedures surrounding the administration of federal grants. The District will use the template developed by the Massachusetts Association of School Business Officials with updates made that are specific to the King Philip Regional School District. Documentation will include procedures to ensure identification of federal grant programs, review and documentation of annual compliance requirements of all grants received, and centralized monitoring and reporting. Grants Managers will be involved in the ongoing monitoring of each grant with the School Business Official to ensure that activity is charged appropriately. Funds will be drawn down on a reimbursement basis.
The instances identified in this finding represent individuals who, in several cases, were processed in the same batches ( e.g., COD date 9/28/23, disbursement date on ledger 10/3/23, and COD date 11/3/23, disbursement date 11/8/23). CMN recognizes the importance of disbursing funds to student accou...
The instances identified in this finding represent individuals who, in several cases, were processed in the same batches ( e.g., COD date 9/28/23, disbursement date on ledger 10/3/23, and COD date 11/3/23, disbursement date 11/8/23). CMN recognizes the importance of disbursing funds to student accounts on the date that funds are stated to be disbursed through COD. While there have been instances of funds not being available in COD in a timely manner, the financial aid coordinator and bursar will work together to ensure these disbursements are completed on the same date in order to remain compliant with stated CMN policy.
The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for all three students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Studen...
The College has identified that the dates of Return of Title IV Calculations and amounts (in one case) were out of compliance. The return calculations for all three students identified through this audit have been completed and corrected to reflect the correct return amounts, if appropriate. Student 1: After changing from an attendance-taking institution to a non-attendance taking institution, this student was identified during the audit as a student who may not have completed the term due to all F/NP grades. Calculation was completed and a return was made based on the midpoint date of the spring term. Student 2: After changing from an attendance-taking institution to a non-attendance taking institution, this student was identified during the audit as a student who may not have completed the term due to all F /NP grades. Calculation was completed and a return was made based on the midpoint date of the spring term. Student 3: Student officially withdrew but withdrawal was not processed until the end of the term. Since the withdrawal was not processed in a timely manner, the enrollment status (as noted in fmding 2024-001) and subsequent R2T4 calculation was delayed. Calculation was completed and a return was made based on the date indicated in the official withdrawal documents. Due to delayed calculations on these three students, CMN will continue to work with fmancial aid staff and the registrar's office to streamline communication on withdrawals and students who complete the term with all F/NP grades, as indicated in CMN policy. CMN has already worked with Anthology (student information system)'to provide electronic triggers to the fmancial aid office when a student status changes from active to drop/withdrawal. Additionally, Enrollment Management notifies all faculty by email at the beginning of the term and again prior to fmal grades being submitted that electronic notification must be sent by the faculty to financial aid in order to alert the fmancial aid office of the date oflast academic engagement for students who earn an For NP grade. For the current audit period, the Director of Enrollment Management and the Financial Aid Coordinator work together to review a final grade report for all students and identify those who need R2T4 calculations based on that review. Both the director and coordinator sign the working documents to indicate that it has been reviewed by both parties. We will continue with this process and will refme as necessary, but we anticipate that this will resolve the issue of calculations not having been performed on students with all F /NP grades at the end of the term.
The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (102 days and 69 days). The statuses of both students are correct with NSLDS. Student 1: Student officially withdrew but withdrawal was not pro...
The College has identified that the dates of enrollment submissions and status changes for the two students identified in the audit were out of compliance (102 days and 69 days). The statuses of both students are correct with NSLDS. Student 1: Student officially withdrew but withdrawal was not processed until the end of the term. Since the withdrawal was not processed in a timely manner, the enollment status and subsequent R2T4 calculation (as noted in finding 2024-002) was delayed. Student 2: Student graduated, and status was updated with NSLDS at 69 days. Due to delayed communication and delayed reporting to NSLDS, CMN will revise institutional policy to clearly define the process and timeline for enrollment status changes. Financial aid staff will seek additional training in enrollment reporting through FSA and/or NSFAA. To further monitor compliance, CMN has already worked with Anthology (student information system) to provide electronic triggers to the financial aid office when a student status changes from active to drop/withdrawal. This electronic, automatic process will provide an additional layer of notification to the financial aid office when a student status change requires further attention.
Finding 566908 (2024-001)
Significant Deficiency 2024
Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director
Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director
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