Corrective Action Plans

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Finding 2025-004: Special Test – Reasonable Rent Housing Choice Vouchers View of responsible officials: The City agrees with the finding. Corrective action plan: The City will determine that the rent to owner is reasonable prior to approving the lease and executing the HAP contract. Implementation d...
Finding 2025-004: Special Test – Reasonable Rent Housing Choice Vouchers View of responsible officials: The City agrees with the finding. Corrective action plan: The City will determine that the rent to owner is reasonable prior to approving the lease and executing the HAP contract. Implementation dates: September 30, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
Finding 2025-003: Reporting – SEMAP Housing Choice Vouchers View of responsible officials: The City agrees with the finding. Corrective action plan: SEMAP certifications must be formally approved by the City’s governing board and signed by appropriate management prior to submission. Implementation d...
Finding 2025-003: Reporting – SEMAP Housing Choice Vouchers View of responsible officials: The City agrees with the finding. Corrective action plan: SEMAP certifications must be formally approved by the City’s governing board and signed by appropriate management prior to submission. Implementation dates: September 30, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
Finding 2025-002: Reporting – HUD 50058 Housing Choice Vouchers View of responsible officials: The City agrees with the finding. Corrective action plan: Management acknowledges that the filings with HUD were not timely. Staff will work to ensure filings take place within 60 days of the effective dat...
Finding 2025-002: Reporting – HUD 50058 Housing Choice Vouchers View of responsible officials: The City agrees with the finding. Corrective action plan: Management acknowledges that the filings with HUD were not timely. Staff will work to ensure filings take place within 60 days of the effective date. Implementation dates: September 30, 2026 Responsible person: Lola Ogunremi, Chief Financial Officer
Provide funder-led training sessions for management and staff, maintain current budget tracking incorporated federal program compliance into relevant staff performance evaluations, implement a dual-storage documentation methodology combining a shared drive and a document management system (DMS) and ...
Provide funder-led training sessions for management and staff, maintain current budget tracking incorporated federal program compliance into relevant staff performance evaluations, implement a dual-storage documentation methodology combining a shared drive and a document management system (DMS) and update the Finance Manual.
Provide all management staff with annual training on federal grant requirements, perform periodic internal reviews and a final year-end reconciliation, maintainall grant-related records on a shared organizational drive accessible to all responsible staff, provide formal onboarding and off boarding p...
Provide all management staff with annual training on federal grant requirements, perform periodic internal reviews and a final year-end reconciliation, maintainall grant-related records on a shared organizational drive accessible to all responsible staff, provide formal onboarding and off boarding procedures for federal grant management, and update the Finance Manual .
Lynsey Darragh – Administrative Services Director and Lucas Mayo – Grant Administrator will develop procedures to obtain and review certified payrolls for construction projects to ensure compliance with the wage rate requirements. Anticipated completion date is July 31, 2026.
Lynsey Darragh – Administrative Services Director and Lucas Mayo – Grant Administrator will develop procedures to obtain and review certified payrolls for construction projects to ensure compliance with the wage rate requirements. Anticipated completion date is July 31, 2026.
Lynsey Darragh - Administrative Services Director, Lucas Mayo – Grant Administrator and Tony Pumphrey – Finance Director will develop procedures to ensure that all program reports have documented reviews; are submitted timely and that are reconciled to the accounting records before submission. Antic...
Lynsey Darragh - Administrative Services Director, Lucas Mayo – Grant Administrator and Tony Pumphrey – Finance Director will develop procedures to ensure that all program reports have documented reviews; are submitted timely and that are reconciled to the accounting records before submission. Anticipated completion date is July 31, 2026.
Finding 2025-003: Section 232 Loan – Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Loan, ALN 14.129 Anticipated Completion Date: November 20, 2025 Recommendation: It was recommended the related parties reimburse Cheney Care Commun...
Finding 2025-003: Section 232 Loan – Mortgage Insurance Nursing Homes, Intermediate Care Facilities, Board and Care Homes and Assisted Living Facilities Loan, ALN 14.129 Anticipated Completion Date: November 20, 2025 Recommendation: It was recommended the related parties reimburse Cheney Care Community for the expenditures paid on their behalf. In addition, it was recommended management review the disbursements made during the periods of turnover to confirm there were no other unallowable payments made. It was also recommended management of Cheney Care Community review their internal controls over the cash disbursement process with the necessary individuals involved in the process to ensure the controls are consistently performed going forward. Action Taken: The related parties reimbursed Cheney Care Community for the expenditures paid on their behalf. Since the new accounts payable clerk started in the Summer of 2025, they have been reviewing all of the supporting documentation for disbursements made during the period of turnover, and accumulating any additional corrections that need to be made. They will continue this process for all disbursements from the period of turnover. The Executive Director/Administrator and Accountant will review the process and procedures in place with the new accounts payable clerk, and implement controls to ensure the appropriate facility and general ledger account coding are made going forward. In addition, they will review the review and monitoring controls in place and revise as needed to ensure the proper checks are in place to catch errors.
Finding 2025-004: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: June 11, 2026 Recommendation: It was recommended the related parties reimburse Sessions Village 202 for the expenditures paid on their beh...
Finding 2025-004: Section 202 Supportive Housing for the Elderly, Capital Advance and Project Rental Assistance Contract, ALN 14.157 Anticipated Completion Date: June 11, 2026 Recommendation: It was recommended the related parties reimburse Sessions Village 202 for the expenditures paid on their behalf. In addition, it was recommended management review the disbursements made during the periods of turnover to confirm there were no other unallowable payments made. It was also recommended management of Sessions Village 202 review their internal controls over the cash disbursement process with the necessary individuals involved in the process to ensure the controls are consistently performed going forward. Action Taken: The related parties reimbursed Sessions Village 202 for the expenditures paid on their behalf. Since the new accounts payable clerk started in the Summer of 2025, they have been reviewing all of the supporting documentation for disbursements made during the period of turnover, and accumulating any additional corrections that need to be made. They will continue this process for all disbursements from the period of turnover. The Executive Director/Administrator and Accountant at the management agent will review the process and procedures in place with the new accounts payable clerk, and implement controls to ensure the appropriate facility and general ledger account coding are made going forward. In addition, they will review the review and monitoring controls in place and revise as needed to ensure the proper checks are in place to catch errors.
Finding 2025-003 Congressionally Mandated Projects / Suspension and Debarment Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed...
Finding 2025-003 Congressionally Mandated Projects / Suspension and Debarment Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
Finding 2025-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part ...
Finding 2025-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
Finding 2025-001 Congressionally Mandated Projects / Reporting Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the...
Finding 2025-001 Congressionally Mandated Projects / Reporting Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
Management will strengthen controls over federal reporting by establishing documented procedures for the preparation, review, certification, and submission of all required federal reports. Responsibility for report preparation and certification will be formally assigned, with designated backup personn...
Management will strengthen controls over federal reporting by establishing documented procedures for the preparation, review, certification, and submission of all required federal reports. Responsibility for report preparation and certification will be formally assigned, with designated backup personnel identified to ensure continuity during staffing transitions. A reporting calendar and tracking system will be maintained to monitor filing deadlines, and all reports will be subject to documented review and approval by an authorized individual prior to submission. Management will periodically review compliance with reporting requirements to ensure reports are submitted accurately and timely.
Please accept this correspondence as the Alfred Saliba Family Services Center, Inc. 's formal corrective action response to Finding 2025-001: Reporting, related to the review and documentation process for Federal Financial Reports, including SF-425 reports. During the prior audit cycle, management b...
Please accept this correspondence as the Alfred Saliba Family Services Center, Inc. 's formal corrective action response to Finding 2025-001: Reporting, related to the review and documentation process for Federal Financial Reports, including SF-425 reports. During the prior audit cycle, management became aware of deficiencies related to the review and documentation process for Federal Financial Reports. While the 2024 audit was occurring and these deficiencies were being identified, the previous Grants Manager was relieved from her position. Following that personnel change, the Alfred Saliba Family Services Center undertook a reorganization of fiscal management responsibilities to strengthen oversight, accountability, and internal controls. As part of this corrective action, the organization reviewed, rewrote, and codified its Fiscal Policies and Procedures, which were formally adopted by the Board of Directors. These revised policies clarified reporting responsibilities, strengthened the review and approval process, and established clearer expectations for documentation, supervisory review, and retention of records related to grant reporting. The revised fiscal policies also include a new Federal Financial Report (SF-425) Review & Approval Form, located in Appendix X of Standard 2 - Fiscal Policies and Procedures, to ensure consistent documentation of management review prior to submission. Since the personnel and fiscal management changes were implemented, SF-425 reports have been prepared and provided to the Executive Director in a timely manner prior to submission. The Executive Director reviews the reports, verifies the information as appropriate, and signs the reports to document management review and approval. This process provides clear evidence that financial reports are revi_ewed before submission and that appropriate oversight is occurring. The Alfred Saliba Family Services Center believes these corrective actions have addressed the condition noted in the finding. The organization will continue to monitor this process as part of its ongoing fiscal management framework to ensure sustained compliance, timely reporting, and proper documentation of management review. Anticipated Completion: Immediately Responsible Party: Jim Hartnett, Executive Director
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requ...
Finding Number: 2025-004 Condition: During the audit it was identified the Road Commission did not have formal written federal policies and procedures that document the processes and controls used to administer federal awards, including procedures for compliance \with applicable federal program requirements under Uniform Guidance (2 CFR, Part 200.303) Planned Corrective Action: Road Commission is in the process of developing and implementing a written federal policies and procedure addressing the administration of federal awards to ensure compliance with Uniform Guidance (2 CFR, Part 200). The policy will address the following key compliance areas: allowable costs, cash management, procurement, and conflict of interest. The policy shall be reviewed and modified to included all the necessary items outlined in the Uniform Guidance. Contact Person responsible for corrective action: Destain Gingell, Managing Director / CHE, Kathleen Cunningham, Finance Director Anticipated Completion Date: July 30, 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should...
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should be noted that we are in compliance with the requirements of Ramsey County, Minnesota (the administrator of the ARPA program) as to documentation, reporting and other requirements. Documentation of review of income eligibility is not required by Ramsey County. Action taken in response to finding: We will immediately implement a sign off procedure by staff when they review income eligibility. Name of the contact person responsible for corrective action: Chris Schmidt Planned completion date for corrective action plan: Immediate
Segregation of Duties Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the boa...
Segregation of Duties Auditor’s Recommendations: We recommend that the Authority assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Authority’s Response: The board reviews the reports monthly. A printed payroll report and checks written from meeting to meeting are provided and are approved and initialed. Also provided is a report of the bank statements for the board to review what has been received and what has been paid. Before any bills are paid they are approved at the meeting. If an error is made when inputting a deposit received into the software, the correction is printed and initialed approving the correction.
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant applica...
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant application process through closeout of a grant. This further ensures accurate and timely reporting going forward.
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. The new policy was approved by the board of Directors in December 2025. The new process is being implemented in 2026. Internal audit began monthly audits and corrective training in February 2026 with target goal by Q3 2026.
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced proc...
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced procedures designed to prevent similar issues in future reporting periods, including: (1) formalizing written policies requiring monthly accounts payable reconciliations; (2) adding a review control focused specifically on items outstanding more than 90 days, including documented investigation and resolution; and (3) training accounting personnel on these procedures and related documentation requirements. Management believes these corrective actions will improve the timely identification, review, and resolution of aged accounts payable balances in future reporting periods.
Views of Responsible Officials: Management respectfully acknowledges the auditors’ observation regarding the reconciliation of the fixed asset schedule to the BarCloud inventory management system. However, management disagrees with the classification of this matter as a Significant Deficiency and wi...
Views of Responsible Officials: Management respectfully acknowledges the auditors’ observation regarding the reconciliation of the fixed asset schedule to the BarCloud inventory management system. However, management disagrees with the classification of this matter as a Significant Deficiency and wishes to provide the following context for the record. Throughout the close of fiscal year 2025, management dedicated substantial time and resources to a comprehensive review and reconciliation of the Organization’s fixed asset records. This was a deliberate, proactive initiative undertaken by the finance and accounting team to identify and resolve historical discrepancies between the accounting system and BarCloud, enhance the quality and completeness of asset-level records, and establish a stronger foundation for ongoing compliance with 2 CFR 200.313(d). The discrepancies noted by the auditors were, in large part, the very items identified and addressed through this reconciliation effort—not indicators of a systemic or ongoing control failure.As part of this undertaking, management initiated a comprehensive effort to migrate all equipment records from legacy, manual binder-based files maintained at field offices to a centralized online BarCloud system. This effort is now substantially complete. Because a number of these binders were maintained at MBN’s overseas bureaus, obtaining timely access to the physical records presented logistical challenges that required additional coordination and time to resolve. To support this work, MBN engaged local vendors in each country where equipment records were maintained to perform additional inventory review and reconciliation, as well as independent professionals to assess the fair market value of equipment identified for disposition and to perform the required data sanitization of IT equipment in accordance with 2 CFR 200. As a result of this work, the Organization now maintains materially clean and reconciled fixed asset records. The condition observed during audit testing reflects the state of records prior to the completion of management’s remediation efforts, not the current state of the Organization’s controls. Management believes that the effort expended to bring the records into alignment, and the improved control environment that now exists as a result, should be considered in the assessment of severity. Accordingly, management does not believe that the remaining matters, in the context of the substantial remediation completed, rise to the level of a Significant Deficiency. Management agrees with the auditors’ recommendation to continue formalizing procedures for ongoing reconciliation between the accounting records and BarCloud. Management is committed to establishing a common asset identification methodology, implementing a periodic reconciliation schedule, and maintaining supporting documentation to evidence the process going forward. We appreciate the auditors’ recognition of the significant undertaking completed during fiscal year 2025 and remain committed to maintaining full compliance with Federal equipment management requirements under 2 CFR 200.313(d) and 2 CFR 200.303.
Finding Number: 2025-003 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. Anticipated Completion Date: On-going R...
Finding Number: 2025-003 Planned Corrective Action: We concur with the finding. We will continue with retaining documentation of sliding scale determination electronically. The CFO will continue to monitor whether the record retention policy is being followed. Anticipated Completion Date: On-going Responsible Contact Person: Cynthia Diaz, Finance Administrator
Finding 2025-001: Eligibility Recommendation: We recommend that management establish and implement formal policies and procedures for the administration of the FSEOG program, including clear guidance on the minimum and maximum award limits in accordance with federal regulations. Management should al...
Finding 2025-001: Eligibility Recommendation: We recommend that management establish and implement formal policies and procedures for the administration of the FSEOG program, including clear guidance on the minimum and maximum award limits in accordance with federal regulations. Management should also provide adequate training to Financial Aid Office personnel on applicable federal requirements, perform supervisory reviews of award calculations prior to disbursement, and conduct periodic monitoring to ensure ongoing compliance with established limits. Response: The College acknowledges the findings resulting from the initial year of the Federal Supplemental Educational Opportunity Grant (FSEOG) program's implementation. The College recognizes that the finding resulted from deficiencies in newly implemented award procedures during the first year of the FSEOG program. In light of this, we wish to provide context regarding the situation and the corrective actions undertaken to address the issue. The seven students identified in this finding were awarded FSEOG funds that reflected their significant financial need and the institution's commitment to enabling students to cover both direct and indirect enrollment costs. An internal review conducted by the Financial Aid Office revealed that these awards inadvertently exceeded the $4,000 annual maximum established by program regulations. Following this internal review, prompt corrective measures were enacted, culminating in the issuance of a formal memorandum to the Comptroller in October of FY26. This memorandum directed adjustments to the affected students’ FSEOG awards to ensure compliance with the prescribed annual maximum. This internal monitoring process underscores the College’s proactive commitment to program integrity and fiscal accountability. Furthermore, the unexpended funds were returned to the U.S. Department of Education during FY26. The College remains dedicated to the proper administration of the FSEOG program and has reinforced its internal review procedures. This includes conducting more frequent audits of award ceilings during active disbursement periods to prevent similar errors in future award years. To address the finding, the College will implement the following actions: 1. Establishment of Formal Policy and Standard Operating Procedures (SOPs): Within 30 days, the College will adopt and implement a dedicated section within the Financial Aid Policy and Procedures Manual specifically for the FSEOG program. This document will delineate federal award limitations, selection criteria based on exceptional financial need groupings, and compliance parameters in accordance with 34 CFR 676.20. 2. Staff Training and Competency Review: Prior to the next award cycle, the College will conduct a mandatory training workshop for all counselors and processing staff within the Financial Aid Office. This training will emphasize the identification of the FSEOG-eligible student population, the applicable selection criteria, and the importance of cross-referencing final award packages. 3. Monitoring and Long-Term Quality Control: The College will implement a mandatory two-tiered verification process. Prior to any FSEOG batch disbursement being sent to the Office of the Comptroller for final payment execution, a senior financial aid officer or director must review and authorize a compliance checklist. This checklist will confirm that there are no boundary violations, and any batch disbursement package containing an amount below $100 or exceeding $4,000 per academic year will be flagged for review. Quarterly compliance reviews will be documented and retained as part of the College's internal control records to verify continued compliance with FSEOG award requirements and to provide supporting documentation for future audits. Primary Responsible Office: Director, Financial Aid Office Oversight Office: Vice President for Enrollment Management and Student Services Overall CAP Completion Target: Addressed in Dec 2026
Finding 2025-002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal cont...
Finding 2025-002 Federal Agency Name: U.S. Department of the Treasury Program Name: COVID-19 Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Finding Summary: 2 CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and conditions of the federal award. Per 31 CFR 19.300, prior to enter in subawards and contracts with award funds, recipients must verify that such contractors and subrecipients are not suspended, debarred, or otherwise excluded pursuant to 31 CFR § 19.300. The County did not retain documentation of the verification that vendors were not suspended, debarred, or otherwise excluded prior to entering into a transaction with them. Responsible Individuals: Elijah Anderson, County Auditor Corrective Action Plan: Going forward, Taylor County will continue retaining documentation of the verification of vendors paid with federal funds against the sam.gov suspension and debarment review tool. Anticipated Completion Date: Completed
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