Corrective Action Plans

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The auditor compares being a beneficiary to being a sub-recipient instead of is the secondary institution a contractor or a sub-recipient. The organization agrees that policies and procedures should be put in place in the event that funds are going to be passed-through. In addition, the organization...
The auditor compares being a beneficiary to being a sub-recipient instead of is the secondary institution a contractor or a sub-recipient. The organization agrees that policies and procedures should be put in place in the event that funds are going to be passed-through. In addition, the organization feels that it was able to show the funds that were passed-through to the contractor. Responsible Individual: Chief Financial Officer– Scott Korba Estimated Completion Date
Under the state of Pennsylvania, contractors doing home repairs in excess of $5000 a year must register with the state of Pennsylvania and receive their Home Improvement Contractor Certification. Applications are reviewed by the Attorney General’s Office , anyone who is debarred is not issued and HI...
Under the state of Pennsylvania, contractors doing home repairs in excess of $5000 a year must register with the state of Pennsylvania and receive their Home Improvement Contractor Certification. Applications are reviewed by the Attorney General’s Office , anyone who is debarred is not issued and HIC Certification. In addition, the Program Director has a list of debarred contractors that he reviews periodically to ensure that contractors are not on the list. The organization will take the auditors recommendation of copying the debarred alphabetical page indicating that the contractor is not on the debarred or suspended listing and placing it in the contractors file. Responsible Individual: Energy Director Zack Porrecca and Housing Director Vickie Bucker Estimated Completion Date: September 30, 2026
2025-004 – Lack of Written Policies and Procedures Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have bee...
2025-004 – Lack of Written Policies and Procedures Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and drafts of formal written policies covering the above items that address all of the area required by the Uniform Guidance have been developed, these policies have not yet been formally approved and adopted by the Organization. As a result of this condition, the Organization did not fully comply with the Uniform Guidance applicable to the above noted grants. Auditor Recommendation. We recommend that the Organization review and approve the draft policies as soon as practical, but no later than the end of fiscal year 2026. Corrective Action. The Organization has prepared a policies and procedures manual for the federal grant programs, which will be approved by the Board of Directors before the end of fiscal year 2026. Responsible Person. Rob Rafson, Executive Director Anticipated Completion Date: December 2026
2025-005 – Lack of Documentation for SAM.gov Exclusion Checks Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Organization did not retain documentation to support that the exclusion checks...
2025-005 – Lack of Documentation for SAM.gov Exclusion Checks Auditor Description of Condition and Effect. Although the Organization has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Organization did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Organization verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Organization retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Organization will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Rob Rafson, Executive Director Anticipated Completion Date: December 2026
Condition Summary: The institution's procedures and controls for determining and reporting withdrawal dates to NSLDS were not operating effectively to ensure that the actual effective date of withdrawal was reported accurately and that enrollment status changes were reported timely. Of the forty stu...
Condition Summary: The institution's procedures and controls for determining and reporting withdrawal dates to NSLDS were not operating effectively to ensure that the actual effective date of withdrawal was reported accurately and that enrollment status changes were reported timely. Of the forty student records tested for NSLDS withdrawal reporting, we identified the following: • One student where the effective date of withdrawal was reported as the end of the semester rather than the student's actual withdrawal date. • Six students where the effective date of withdrawal was reported as the date the student was notified rather than the actual effective withdrawal date. • One student where the student's withdrawal was not reported timely and was not included on the first enrollment roster following the withdrawal. Management Response / Corrective Action Plan: Management concurs with this finding. Turnover within the Financial Aid office resulted in a breakdown in the process for timely and accurate submission of reporting enrollment changes within NSLDS. Staff previously responsible for this function are no longer employed at the institution, and the engaged consulting firm has assumed interim responsibility for identifying enrollment status changes and completing NSLDS reporting within the required 60-day period. Responsible Party - Raymond Nault, Interim Director of Student Financial Services Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
Condition Summary: 2 of 3 students selected for verification lacked evidence that required verification procedures were performed, and controls to track verification completion were not operating during the academic year. Management Response / Corrective Action Plan: Management concurs with this fin...
Condition Summary: 2 of 3 students selected for verification lacked evidence that required verification procedures were performed, and controls to track verification completion were not operating during the academic year. Management Response / Corrective Action Plan: Management concurs with this finding. The University has directed the engaged consulting firm to complete a full review of 2025-2026 verification activity, obtain and document outstanding verification records, and complete any required corrections to FAFSA data. A dedicated verification tracking log, maintained by the consulting firm, now records each selected student's status from selection through completion. Staff previously responsible for monitoring verification completion are no longer employed at the institution. Responsible Party - Raymond Nault, Interim Director of Student Financial Services Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
Condition Summary: The Data Collection Form was submitted to the Federal Audit Clearinghouse after the required deadline, with no documented extension obtained. Management Response / Corrective Action Plan: Management concurs with this finding. The University has implemented a compliance calendar, m...
Condition Summary: The Data Collection Form was submitted to the Federal Audit Clearinghouse after the required deadline, with no documented extension obtained. Management Response / Corrective Action Plan: Management concurs with this finding. The University has implemented a compliance calendar, maintained by the engaged consulting firm, that tracks all federal reporting deadlines, including the DCF submission date, with milestone reminders beginning 60 days in advance of each deadline. Responsibility for final submission has been assigned to the consulting firm for the current cycle to ensure the deadline is met while the University's internal compliance-monitoring function is rebuilt. Responsible Party - Michael DeWees, Vice-President for Finance and Administration Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
Condition Summary: 5 of 40 credit balance refunds were processed outside the required 14-day timeframe, controls over review and approval were not operating for the full year, and the University could not produce a report distinguishing Title IV credit balances from other funding sources. Management...
Condition Summary: 5 of 40 credit balance refunds were processed outside the required 14-day timeframe, controls over review and approval were not operating for the full year, and the University could not produce a report distinguishing Title IV credit balances from other funding sources. Management Response / Corrective Action Plan: Management concurs with this finding. As part of the University's full review of 2025-2026 cash management activity, a revised credit-balance workflow has been established requiring supervisory approval and a system-generated report that separately identifies balances attributable to Title IV funds. Staff associated with the prior lapse in controls are no longer employed at the institution, and the engaged consulting firm is providing interim monitoring of the 14-day refund requirement, with weekly exception reporting until the control is demonstrated to be operating effectively on a sustained basis. Responsible Party - Ebony Martin, Associate Director of Student Accounts Title - Interim oversight: Engaged Consulting Firm Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
Condition Summary: Customer data was not encrypted, periodic data inventories were not performed for a portion of the year, and elements of the annual risk assessment were not satisfactorily implemented. Management Response / Corrective Action Plan: Management concurs with this finding. The absence ...
Condition Summary: Customer data was not encrypted, periodic data inventories were not performed for a portion of the year, and elements of the annual risk assessment were not satisfactorily implemented. Management Response / Corrective Action Plan: Management concurs with this finding. The absence of adequate internal controls and monitoring procedures left gaps in the University's information security program required under the GLBA Safeguards Rule. To remediate this finding and safeguard the institution from further harm, the University has engaged an outside consulting firm with information-security expertise to complete a full review of 2025-2026 data-security practices, implement encryption of customer data at rest and in transit, reinstate periodic data inventories, and close the gaps identified in the prior risk assessment. Personnel previously responsible for information security oversight are no longer employed at the institution, and the consulting firm is providing interim GLBA program management, including board-level reporting, while a permanent qualified individual is identified. Responsible Party - Candice Santell, CampusWorks, Ray Nault, Interim Director of Student Financial Services Title - Interim oversight: Engaged Consulting Firms Anticipated Completion Date - August 24, 2026 Note: Because the corrective actions described above were substantially implemented during and after the fiscal year 2025 audit period, management anticipates that this condition, or elements of it, may continue to be identified as a finding in the University's fiscal year 2025-2026 single audit. Full operating effectiveness of the revised controls will not be demonstrable until they have been in place for a complete testing cycle.
Finding Type: Immaterial Noncompliance / Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program: Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategi...
Finding Type: Immaterial Noncompliance / Significant Deficiency in Internal Control over Compliance (Subrecipient Monitoring). Program: Coronavirus State and Local Fiscal Recovery Funds; U.S. Department of Treasury; ALN 21.027, Small Business Support Hubs Program passed through the Michigan Strategic Fund. Auditor Description of Condition and Effect: Although there were improvements in the monitoring process from the prior year, during testing in the current year of seven subrecipients, it was determined: 1) The Assistance Listing Number (ALN) for the grant was not included in the subgrant agreement. All other applicable program information was noted, 2) Searches at www.sam.gov performed by management were not timely reviewed and no certification of eligibility was present in the subgrant agreements. As a result of this condition, the Organization did not fully comply with the requirements of the Uniform Guidance. Questioned Costs: No costs were required to be questioned as a result of this finding inasmuch as our testing did not identify any unallowed costs. Auditor Recommendation: We recommend that management become familiar with the subrecipient monitoring requirements and draft policy and procedures that provide reasonable assurance that future subrecipient arrangements will be in compliance with the Uniform Guidance. Management's Acknowledgment Management acknowledges that the recurrence of this finding — albeit at a reduced severity level compared to the FY2024 material weakness designation — reflects incomplete implementation rather than absence of policy. The ALN omission in subgrant agreement templates is a straightforward technical correction that should have been applied uniformly once identified. The corrective actions below are procedural in nature and largely already embedded in the updated SOP; the remaining work is one of consistent execution and documentation. Corrective Action Plan (See CAP for Table)
Finding Reference Number: 2025-003 Description of Finding: IYT submitted its Audited Financial Statements and Single Audit Report to the Federal Audit Clearinghouse in August 2026, approximately five months after it was due. IYT was required to submit it no later than March 31, 2026; nine months aft...
Finding Reference Number: 2025-003 Description of Finding: IYT submitted its Audited Financial Statements and Single Audit Report to the Federal Audit Clearinghouse in August 2026, approximately five months after it was due. IYT was required to submit it no later than March 31, 2026; nine months after the June 30, 2025 fiscal year-end, in accordance with 2 CFR 200.512. Federal awarding agencies may deny future federal awards or subject IYT to additional cash monitoring requirements. Statement of Concurrence or Nonconcurrence: We concur with the audit finding. Corrective Action: This finding is a repeat of prior-year finding 2024-004. IYT's prior corrective action committed to on-time submission but did not establish the controls needed to make that commitment hold: it relied on the intent to submit on time rather than on a dated, back-scheduled calendar with an owner for each step and a checkpoint to catch slippage early. When the FY24-25 audit timeline slipped, there was no interim milestone to surface the delay while it could still be recovered, and the report was again submitted late. IYT acknowledges and accepts the responsibility for late submission. Meeting the FAC deadline is IYT's responsibility and remains so even where individual steps sit with the audit firm or with governance. IYT will establish a compliance calendar built by working backward from the Federal Audit Clearinghouse (FAC) statutory deadline, with defined interim milestones and an owner assigned to each by position: engagement of the audit firm and confirmation of fieldwork dates; completion of the year-end close; delivery of the prepared-by-client (PBC) list; fieldwork; draft report; management review; Finance Committee and Board review; and final FAC submission and certification. IYT's timeline depends on inputs from the audit firm (scheduling, fieldwork and reporting turnaround, and draft-review cycles) and from governance (Audit Committee and Board review windows). IYT manages these inputs to the deadline rather than treating them as outside its control: target dates are agreed with the auditors and committee chairs in advance and confirmed in writing, and if any party is at risk of missing a date, IYT escalates and adjusts immediately rather than absorbing the delay. Progress against every milestone is monitored by management and reported to the Audit Committee as a standing agenda item, so slippage is identified and escalated early rather than discovered near the deadline. Name of Contact Person: Macarena O'Brien, Chief Financial & Administrative Officer macarena@improveyourtomorrow.org | (480) 993-4764 Projected Completion Date: March 31, 2027
CORRECTIVE ACTION PLAN — Finding 2025-001 Compliance Finding – Special Tests and Provisions | Community Services Block Grant (ALN 93.569) Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | Pass-Through Entity: State of Vermont Department for Children and Families | Cognizant Federal Agenc...
CORRECTIVE ACTION PLAN — Finding 2025-001 Compliance Finding – Special Tests and Provisions | Community Services Block Grant (ALN 93.569) Entity: Southeastern Vermont Community Action, Inc. (SEVCA) | Pass-Through Entity: State of Vermont Department for Children and Families | Cognizant Federal Agency: U.S. Department of Health and Human Services | CAP Contact: Joshua Davis, Executive Director, JDavis@sevca.org 1. Summary of Finding Finding 2025-001 identified that, as of the September 24, 2025 board meeting, SEVCA’s 13-member Board of Directors did not meet the required CSBG tripartite composition: four participant-sector members, five private-sector members, and four public-sector members, leaving neither the participant nor the public sector at one-third. SEVCA returned to compliance the following month by seating the additional members needed to restore the required composition, recruited and seated through SEVCA’s established board-selection process. No questioned costs were identified. 2. Management’s Response SEVCA concurs with the finding. The tripartite structure is fundamental to community action agency governance and to meaningful representation of low-income individuals and families, public officials, and private-sector members. Management and the Board have strengthened monitoring of Board composition and are maintaining a continuing pipeline of prospective members in each required sector. 3. Root Cause Board-member turnover created a temporary imbalance among the three required sectors. The underlying control gap was the absence of a documented composition matrix, a recurring compliance review, and a formal escalation procedure triggered when a departure caused—or was expected to cause—a sector to fall below its required representation. Because members must be seated through SEVCA’s established selection procedures, vacancies cannot always be filled immediately, making proactive succession planning and sector-specific recruitment necessary. 4. Corrective Actions 1. Provide Board training on CSBG tripartite composition requirements and each member’s role in maintaining a compliant Board — Executive Director / Board Chair; completed and incorporated into ongoing Board education. 2. Maintain a Board composition matrix identifying each member’s sector, term dates, appointing or selecting authority, applicable public-official status, and current or anticipated vacancies — Executive Director / Board Secretary; completed and maintained ongoing. 3. Review the composition matrix at each regular Executive Committee meeting, include it in the monthly Board meeting materials, and document the review in the minutes — Board Chair / Executive Director; ongoing. 4. Maintain an all-Board recruitment pipeline of qualified candidates for each required sector through public advertising, community partnerships, and direct outreach, beginning recruitment as early as possible when a departure is anticipated — Board of Directors / Executive Director; implemented and ongoing. 5. Adopt written requirements that vacancies affecting tripartite compliance be filled within 90 days where reasonably possible, with immediate escalation of any current or anticipated imbalance to the Board Chair and governance committee, together with contingency procedures for declined appointments, failed elections, or mid-year changes in Board size — Executive Committee; within 90 days of plan approval. 6. Obtain an annual certification by the Board Chair or governance committee confirming tripartite composition compliance and documentation of member-selection procedures — Board Chair / Governance Leadership; annually, beginning with the next governance review. 5. Anticipated Completion Date Restoration of tripartite compliance, Board training, and the composition matrix are complete. Written vacancy, escalation, and contingency requirements will be completed within 90 days of approval of this plan. Recruitment, succession planning, composition monitoring, and annual certification continue as ongoing governance responsibilities. 6. Monitoring The Executive Director and Board Chair will monitor the composition matrix, review it at each regular Executive Committee meeting, and include it with the monthly Board meeting materials. Progress toward filling affected seats will be reported to the full Board until compliance is restored, and the Board Chair or Executive Committee will complete the annual composition certification.
Onvida Health will establish an echelon of staff for reporting in the grant policies and procedures manual that will cover gaps when turnover happens to key staff assigned. Multiple staff will and have been assigned to each grant portal to ensure that communication efforts and deadlines between gran...
Onvida Health will establish an echelon of staff for reporting in the grant policies and procedures manual that will cover gaps when turnover happens to key staff assigned. Multiple staff will and have been assigned to each grant portal to ensure that communication efforts and deadlines between grantee and YRMC/Onvida Health allow for multiple communication to be received in the event of any staffing changes and reporting can still be completed without delays. The Federal financial report was submitted as soon as access was given by HRSA. No correspondence came from HRSA to reference a late filing. Onvida Health is in the process of changing over the project director assigned to this grant on the HRSA EHB site for the performance reports. Only HRSA staff can update these records/access to individual grants. We have been delayed in this process due to a government furlough in place, no response to numerous Onvida Health emails to HRSA grant awarding agency contacts and phone messages were left for return correspondence. Responsible Official: Dana Alexander, Controller Completion Date: Any outstanding items not already completed that are listed in the corrective action plan, will be completed by an estimation date of October 1, 2026.
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current ...
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-002: The Corporation paid entity costs of $7,680 from operating cash. Comments on the Finding and Each Recommendation: The Sponsor should reimburse the Corporation $7,680 or management should request HUD approval for funds to be reimbursed from the reserve for replacement. Action(s) taken or planned on the finding: Management requested reimbursement from the reserve for replacement. HUD approval was received on February 25, 2026.
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current ...
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2025 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2025-001: As of December 31, 2025, deposits to the reserve for replacements account of $27,908 had not been made. Comments on the Finding and Each Recommendation: Management should make a deposit to the reserve for replacements for $27,908 for the delinquent deposits. In future periods, management should fund the reserve for replacements on an annual basis as required by the regulatory agreement. Action(s) taken or planned on the finding: Management made the delinquent deposit on March 11, 2026.
Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number: SFLRP0201 • Fiscal Year of Initial Finding: 2024 •...
Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number: SFLRP0201 • Fiscal Year of Initial Finding: 2024 • Name(s) of the contact person: Kenneth Stiles, Interim Administrative Services Director • Corrective Action Plan: The City will implement controls to ensure timely quarterly reporting. Specifically, the City will: 1. Establish a reporting calendar with internal deadlines. 2. Assign primary and backup staff for report preparation. 3. Implement a review process prior to submission. 4. Use tracking tools to monitor deadlines and status. • Anticipated Completion Date: September 2026
Finding #SA2025-002: Subrecipient Monitoring Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number: SFLRP...
Finding #SA2025-002: Subrecipient Monitoring Assistance Listing Number: 21.027 Assistance Listing Title: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Name of Federal Agency: Department of the Treasury Pass Through Entity: County of San Mateo Federal Award Identification Number: SFLRP0201 • Fiscal Year of Initial Finding: 2024 • Name(s) of the contact person: Kenneth Stiles, Interim Administrative Services Director • Corrective Action Plan: The City will strengthen its subrecipient monitoring practices to comply with 2 C.F.R. § 200.332. Specifically, the City will: 1. Conduct a suspension and debarment check on SAM.gov prior to awarding subrecipient agreements. 2. Update its standard subrecipient agreement template to include a requirement that subrecipients notify the City of any noncompliance or misuse of federal funds. 3. Require subrecipients to submit quarterly programmatic and financial reports to demonstrate proper use of funds and progress toward performance goals. 4. For subrecipients expending $750,000 or more in federal funds, obtain and review their Single Audit reports annually. If below the threshold, request and retain a written statement confirming the subrecipient is not subject to Single Audit requirements. 5. Maintain all documentation related to subrecipient monitoring for a minimum of five years and use a standardized checklist to track compliance. • Anticipated Completion Date: September 2026
Management concurs with the findings. Management is in the process of implementing formal procedures to strengthen oversight of HUD regulatory requirements, including the preparation, review, and timely execution of surplus cash calculations and related residual receipts deposits. These procedures w...
Management concurs with the findings. Management is in the process of implementing formal procedures to strengthen oversight of HUD regulatory requirements, including the preparation, review, and timely execution of surplus cash calculations and related residual receipts deposits. These procedures will include clearly assigning responsibility, incorporating the requirement into a year‑end compliance checklist, and documenting management review. Name of Responsible Person: Peyton Vang, Director of Finance Name of Contact: John Reilly Anticipated Completion Date: August 2026
The District concurs with the finding. Following the 2024 Single Audit, the District assigned separate report preparation and review responsibilities and implemented a report review checklist. However, the procedures did not include a comprehensive mechanism for tracking recurring, final, and closeo...
The District concurs with the finding. Following the 2024 Single Audit, the District assigned separate report preparation and review responsibilities and implemented a report review checklist. However, the procedures did not include a comprehensive mechanism for tracking recurring, final, and closeout reports or a requirement to resolve uncertain reporting obligations sufficiently in advance of the deadline. The District will take the following actions: 1. Establish and maintain a Grant Reporting Requirements Matrix and calendar for each federal award and pass-through grant. The matrix will identify each recurring, final, and closeout report; the applicable grant provision; reporting period; due date; submission method; assigned preparer; assigned reviewer; and evidence of submission. 2. Set documented reminder dates in advance of each deadline and require the assigned preparer to confirm, for every reporting period, whether a report is required. Final and closeout reporting requirements will be reconfirmed before project completion. When a requirement is uncertain, the District will request written clarification from the grantor or passthrough entity as soon as the uncertainty is identified. Unless written confirmation is received that a report is not required, the District will prepare and submit the report. 3. Require the Finance Manager or designated supervisory reviewer to review the reporting calendar at least monthly while an award is active and to verify completion of each required submission. 4. Retain the completed review checklist, approved report, supporting documentation, correspondence concerning reporting requirements, and proof of timely submission in the grant file. 5. Incorporate these controls into written grant-reporting procedures and provide training to staff assigned to federal award administration. Person Responsible for Corrective Action: William Clayton, Finance Manager Anticipated Completion Date for Corrective Action: September 30, 2026. The reporting matrix, advance reminders, and supervisory monitoring will be used immediately for all open federal and pass-through awards, with written procedures and staff training completed by this date.
2025-013 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen internal controls and procedures to ensure that all subrecipient monitoring checks are performed and documented. Such procedures should include identify...
2025-013 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen internal controls and procedures to ensure that all subrecipient monitoring checks are performed and documented. Such procedures should include identifying subrecipients subject to Single Audit requirements, obtaining and reviewing applicable Single Audit Reports, documenting the results of the review, retaining evidence of the review, and tracking any required follow-up or corrective action related to findings impacting the Federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  CIP will create a Standard Operating Procedure for ensuring ARPA subrecipients are appropriately monitored, who is responsible for monitoring, and how documentation will be retained on file. Name(s) of the contact person(s) responsible for corrective action:  Chelcie Pinsonneault, Community Grants Manager Planned completion date for corrective action plan:  Planning and Community Development will ensure the implementation of this corrective action plan is completed by October 31, 2026.
2025-011 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its written policies, procedures, and internal controls to require suspension and debarment verifications before entering into Federally funded contract...
2025-011 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its written policies, procedures, and internal controls to require suspension and debarment verifications before entering into Federally funded contracts and that verification be readily available for audit. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Soundthinking LLC – Police Department  The Manchester Police Department will follow its SOP - Sam.gov Verification for Subrecipients and Vendors Standard Operation Procedure (enclosed) confirming Entity Registration Status (Active / Inactive), Exclusion Status (Suspended, Debarred, Ineligible), and the Expiration Date of all vendors. This process will be completed by the Grant Coordinator in coordination with the Project Manager (if applicable). All documentation will be maintained within the official electronic grant file complying with federal retention dates. Name(s) of the contact person(s) responsible for corrective action:  Whitney Dade, Grant Coordinator, MPD Action taken in response to finding:  Environmental Partners – DPW-Highway: 712522 – DPW agrees with findings and will create a prequalification SOP to complete and record SAM.gov queries on suspensions and debarment verifications prior to entering into contracts. This will be completed within 90 days of today.  Denisco Electric - DPW-Highway: 71222 – DPW agrees with findings and will create a prequalification SOP to complete and record SAM.gov queries on suspensions and debarment verifications prior to entering into contracts. This will be completed within 90 days of today.  GMI Asphalt LLC - DPW-Highway: 712522 – DPW agrees with findings and will create a prequalification SOP to complete and record SAM.gov queries on suspensions and debarment verifications prior to entering into contracts. This will be completed within 90 days of today.  All future prequalification packages will include a requirement for Manchester DPW to complete the SAM.gov verification in addition to the other assertions already made by the contractor/engineering firm.  In addition an SOP will be created to detail how the SAM.gov verification will be conducted prior to contract and where this info for each entity will be archived for a minimum of 3 years following the end of the program. Name(s) of the contact person(s) responsible for corrective action:  Caleb Dobbins – Chief Highway Engineer, DPW Planned completion date for corrective action plan:  9/30/2026 Action taken in response to finding:  39 Beech Street LLC – Mayor’s Office / Fire Department - agrees with the finding and will create a prequalification SOP to complete, record SAM.gov queries on suspensions and debarment verifications as part of a checklist prior to entering into contracts. Name(s) of the contact person(s) responsible for corrective action:  Mayors office - Kathleen Pelissier, Grants Coordinator  Fire Department – Melissa Paulhamus, Administrative Services Manager Planned completion date for corrective action plan:  9/30/2026
2025-010 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its internal controls over procurement and contract documentation for Federal awards. Such procedures should require that complete contract files, inclu...
2025-010 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that the City strengthen its internal controls over procurement and contract documentation for Federal awards. Such procedures should require that complete contract files, including executed agreements, procurement method documentation, vendor selection support, approvals, and other required supporting documentation, be retained in a centralized location and reviewed for completeness. The City should also establish monitoring procedures to ensure documentation is maintained in accordance with Federal requirements and is available timely for audit or other oversight review. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Soundthinking LLC – Police Department  The Manchester Police Department will follow the City’s procurement policy as well as its own internal Procurement Standard Operating Procedure (enclosed). Complete contract files will be maintained to include executed agreements, procurement method documentation, vendor selection support, approvals, and other required supporting documentation. Documentation will be kept in the official electronic grant file and reviewed for completeness by the Business Services Manager, Project Manager (if applicable), and Grant Coordinator. Name(s) of the contact person(s) responsible for corrective action:  Kristy Goodman, Business Services Manager and  Whitney Dade, Grant Coordinator. Planned completion date for corrective action plan:  09/30/2026 Explanation of disagreement with audit finding:  Environmental Partners – DPW-Highway: 712522 – DPW DOES NOT CONCUR with these findings. Request for documentation of Environmental Partners contract was not clearly understood by contracting agency (DPW) and was not submitted.  Requested contract documentation for the Environmental Partners contract attached. This will also be included in the CAP to be provided later to have a single document with all information. Name(s) of the contact person(s) responsible for corrective action:  Caleb Dobbins – Chief Highway Engineer, DPW
2025-007 Community Development Block Grants/Entitlement Grants - Assistance Listing Number 14.218 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that all required subawards are reported timely and accurately no later than the end of the month following th...
2025-007 Community Development Block Grants/Entitlement Grants - Assistance Listing Number 14.218 Recommendation: We recommend the City strengthen procedures and internal controls to ensure that all required subawards are reported timely and accurately no later than the end of the month following the month of issuance of each subaward. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:  Planning and Community Development’s Community Improvement Program (CIP) will update the CIP Procedures Manual to ensure that FFATA reporting is identified as a required step when providing subawards. Additionally, a Standard Operating Procedure (SOP) will be created on how, when and why to complete FFATA reporting, who will be responsible, and how we will ensure the required reporting is completed. Name(s) of the contact person(s) responsible for corrective action:  Chelcie Pinsonneault, Community Grants Manager Planned completion date for corrective action plan:  Planning and Community Development will ensure the implementation of this corrective action plan is completed by October 31, 2026.
Finding 2025-004 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: The Hospital does not have an internal control policy in place to ensure covered transactions are with vendors that are not suspended or de...
Finding 2025-004 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: The Hospital does not have an internal control policy in place to ensure covered transactions are with vendors that are not suspended or debarred, and no evidence was retained regarding ensuring the vendor was not suspended or debarred. Corrective Action Plan: For Finding 2025-004, the Hospital has implemented corrective actions to address the lack of internal controls related to suspended and debarred vendor verification. The Hospital revised its Capital Request Form to require documented verification that vendors involved in federally funded procurements are not suspended or debarred prior to contract award or purchase. Additionally, the Federal Procurement Policy and Procedure was updated to establish formal internal controls for screening vendors against applicable federal exclusion lists and retaining evidence of the verification process. Effective immediately, no procurement involving federal funds will be approved until suspended and debarred status verification has been completed and documented. Management will provide education to all managers on August 5, 2026, regarding the revised requirements and documentation standards. Hospital leadership will conduct ongoing monitoring and review of procurement files to ensure compliance with federal regulations and to prevent recurrence of this finding. Responsible Individuals: Wesley Babers, Chief Executive Officer and Ashley Jaramillo, Chief Financial Officer Anticipated Completion Date: August 2026
Corrective Action Plan for Finding 2025-002 U.S Department of Agriculture Rural Broadband Access Loans (AL# 10.886) Criteria: Quarterly financial reports are required to be submitted to the United State Department of Agriculture no more than 30 days after the end of the quarter. Internal controls sh...
Corrective Action Plan for Finding 2025-002 U.S Department of Agriculture Rural Broadband Access Loans (AL# 10.886) Criteria: Quarterly financial reports are required to be submitted to the United State Department of Agriculture no more than 30 days after the end of the quarter. Internal controls should provide reasonable assurance of compliance with reporting requirements of the Rural Broadband Access Loans program. Cause/Condition: Quarterly reports for all 4 quarters of the year under audit were not submitted timely. Effect: The County was not in compliance with the reporting requirements of the Rural Broadband Access Loans program. Perspective Information: We tested all 4 quarterly financial reports due relating to the fiscal year ending December 31, 2025. All 4 quarterly reports were submitted late, subsequent to 30 days after quarter end. Questioned Costs: None noted. Recommendation: We recommend the County design and implement internal controls over compliance to ensure that all reports required under the Uniform Guidance are submitted to the appropriate government agency timely. Documentation to support the effectiveness of the controls should be retained. Management’s Response: Management agrees with the finding and recommendation. To address this issue, we will implement procedures to better monitor reporting deadlines and assign responsibility for preparing, reviewing, and submitting required reports. We will also maintain documentation to verify reports are completed and submitted timely. These improvements will help ensure compliance with the reporting requirements of the Rural Broadband Access Loans program going forward. Corrective Action Plan for Finding 2025-002 (Continued) Expected Completion: December 31, 2026 Responsible Official: Lou Anne Randall, Director of Finance
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