Corrective Action Plans

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Finding 2024-001: Reporting – Recordkeeping Planned Corrective Action: The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP).  Review and analyze audit findings with staff, Area Managers, and Administration in order to ...
Finding 2024-001: Reporting – Recordkeeping Planned Corrective Action: The Chicago Park District will implement the following strategies to improve the management of the Summer Food Service Program (SFSP).  Review and analyze audit findings with staff, Area Managers, and Administration in order to prevent findings.  2025 DMC, has a new line at the bottom of the page, that will have staff print their name and then second line for signature and date. See attached for example.  Hold a citation meeting of sites that received ISBE citations in 2024, prior to the start of summer. In 2025, electronically send ISBE citations in real time, once wellness receives the citation is emailed to Park Supervisor and Area Manager.  Continue train monitors to review SFSP binders, check food temperature, date of service and signature recorded on all invoices and DMC, and attendance. Ensure seasonal monitors will be onsite for the duration of meal service.  Mandate that at least three of staff members per site are trained in SFSP (pending number of staff at park location).  Provide multiple in person trainings before start of the season to all field staff emphasize the importance of accuracy and details when following the Policy and Procedures of the Summer Food Service Program. Name of the Contact Person Responsible for Corrective Action: Farah Tunks, Director of Programming Meghan O’Boyle, Wellness Manager Anticipated Completion Date: September 30, 2025
The Fulton County District Attorney's Office has maintained compliance with their policy and procedure regarding time and effort management since August 2024. The SAKI grant employees per policy complete activity reports which document their activities on a biweekly basis, reflect time worked, and t...
The Fulton County District Attorney's Office has maintained compliance with their policy and procedure regarding time and effort management since August 2024. The SAKI grant employees per policy complete activity reports which document their activities on a biweekly basis, reflect time worked, and then sign those reports. Those reports are then reviewed and signed by a supervisor with a knowledge of their work. Those reports are maintained and kept in the Fulton County District Attorney's Office.
View Audit 369827 Questioned Costs: $1
The Fulton County Department of Behavioral Health and Developmental Disabilities (DBHDD) performs continuous monitoring activities with program subrecipients by conducting weekly meetings, reviewing monthly reports, invoices, and conducts quarterly performance reviews. DBHDD will strengthen its subr...
The Fulton County Department of Behavioral Health and Developmental Disabilities (DBHDD) performs continuous monitoring activities with program subrecipients by conducting weekly meetings, reviewing monthly reports, invoices, and conducts quarterly performance reviews. DBHDD will strengthen its subrecipient monitoring internal controls by properly documenting these reviews in order to be incompliance with 2 CFR 200.331, and the County’s Subrecipient Monitoring Policy.
The Department of Senior Services follows the monitoring standards established by the pass-through entity and has implemented process improvements to ensure that all Program Year 2024-2025 compliance processes were met. The current period monitoring plan, risk assessments and monitoring have been co...
The Department of Senior Services follows the monitoring standards established by the pass-through entity and has implemented process improvements to ensure that all Program Year 2024-2025 compliance processes were met. The current period monitoring plan, risk assessments and monitoring have been completed. The Department will maintain an annual monitoring plan to ensure that all subrecipients are monitored in compliance with 2 CFR 200 requirements.
Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsib...
Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsible Fatherhood Grants Award Period: September 30, 2023 – September 29, 2024 Award Period: September 30, 2024 – September 29, 2025 Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Teen Pregnancy Prevention Education Assistance Listing Number: 93.297 Assistance Listing Program Title: Adolescent Health Programs Award Period: July 1, 2023 – June 30, 2024 Award Period: July 1, 2024 – June 30, 2025 Management response to 2024-002: In response to the auditors’ recommendation, management has addressed this deficiency by assigning appropriate personnel to review and approve all Federal reporting before submission. Additionally, management has implemented specific procedures for review and approval of drawdown requests, which include reviewing the indirect cost rate applied in all drawdown requests.
Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsib...
Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Relationship, Education, Advancement, and Development for Youth for Life Project Assistance Listing Number: 93.086 Assistance Listing Program Title: Healthy Marriage Promotion and Responsible Fatherhood Grants Award Period: September 30, 2023 – September 29, 2024 Award Period: September 30, 2024 – September 29, 2025 Federal agency: U.S. Department of Health and Human Services Federal Award Project Title: Better Family Life’s Teen Pregnancy Prevention Education Assistance Listing Number: 93.297 Assistance Listing Program Title: Adolescent Health Programs Award Period: July 1, 2023 – June 30, 2024 Award Period: July 1, 2024 – June 30, 2025 Management response to 2024-001: In response to the auditors’ recommendation, management has addressed this deficiency by assigning appropriate personnel to properly track and monitor drawdown requests to ensure the costs requested for reimbursement have been incurred, are complete and accurate, and in line with Federal award requirements. Additionally, management has implemented specific procedures for review and approval of all drawdown requests.
The Council has implemented procedures to include documentation of approval for all grant-funded expenditures to strengthen internal controls and ensure compliance with federal standards.
The Council has implemented procedures to include documentation of approval for all grant-funded expenditures to strengthen internal controls and ensure compliance with federal standards.
Views of Responsible Officials and Planned Corrective Action: We agree with the recommendation and have implemented the recommendation as noted.
Views of Responsible Officials and Planned Corrective Action: We agree with the recommendation and have implemented the recommendation as noted.
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Ex...
U.S. Department of Justice 2024-005 Congressionally Mandated Awards – Assistance Listing No. 16.753 Recommendation: We recommend that the County develop internal controls and procedures to ensure drawdowns are performed in a manner to minimize the time between drawing and disbursing federal funds Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Fiscal Clerk has been trained on proper drawdown of grant funds and accurate recording of expenditures. Name of the contact person(s) responsible for corrective action: District Attorney Fiscal Clerk Planned completion date for corrective action plan: 12/31/25
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subaward...
U.S. Department of Housing and Urban Development 2024-004 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that the County develop internal controls and procedures to ensure that FFATA reporting requirements are met and ensure that all required subawards are reported accurately and timely to FSRS or SAM.gov. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All of our 2024 grants have been entered into FFATA and our 2025 grants and going forward will be entered when awarded. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 5/22/25
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accur...
U.S. Department of Housing and Urban Development 2024-003 Community Development Block Grants – Assistance Listing No. 14.218 Recommendation: We recommend that management identify its collections related to program income in a timely manner, modify its draw request appropriately, and report the accurate amounts to HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The county will continue to report the correct amount of program income to HUD. Receipts will be entered more timely to include as much December program income in the IDIS system prior to that system’s 12/31 close, as any entries made after 12/31 are considered for the future year. Name of the contact person(s) responsible for corrective action: Director of Community Development Planned completion date for corrective action plan: 12/31/25
Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal poli...
Finding Number: 2024-001 Finding Title: Cash Management - WIC Reimbursement to Member Counties Program: Special Supplemental Nutrition Program for Women, Infants, and Children Name of Contact Person Responsible for Corrective Action : Brandon Nelson Corrective Action Planned: Set up an internal policy where any payment remittance advices' must be responded to and completed within two weeks of receipt to ensure that payments are deposited, and member counties of the CHB are reimbursed for the expenses that were submitted for in a prompt manner. Anticipated Completion Date: August 15, 2025
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a man...
FISCAL YEAR OF FINDING: December 31, 2024 AUDITOR FINDING: 2024-001 The Authority is responsible for determining client eligibility and entering data into the State of Colorado’s WIC COMPASS system. Although the Medicaid ID number is required for individuals with adjunct eligibility, it is not a mandatory field in COMPASS. Therefore, eligibility can be processed without entering this number. Testing revealed that the Authority did not consistently follow established controls requiring documentation of the state case ID for individuals deemed eligible based on participation in other state programs. Since the Medicaid ID number is not a required field in the COMPASS system, eligibility determinations can be processed without it. The system lacks reporting capabilities to identify missing entries in this field. Additionally, due to a high caseload, the Authority does not have the capacity to conduct 100% case reviews for all clients served. It is recommended that the Authority expand existing case reviews to include five participant records per month per staff member. The results should be incorporated into annual performance evaluations. Additionally, we recommend enhanced training for all staff involved in eligibility determinations. CLIENT PLANNED ACTION: The Authority will implement the following corrective actions: • Denver Health WIC leadership will perform random record reviews of 5 participant records per month per staff member to ensure compliance with Colorado WIC Policies, including accurate income and eligibility documentation. • Include the results of the reviews, including adjunctive eligibility screen, from the 5 reviews per month in the annual employee performance evaluation and communicate the importance of documenting the Medicaid ID. • All Denver Health WIC staff will complete a new training on income determination and documentation. This training will be released by the state WIC office by the end of October 2025 and all staff should complete this training by the end of December 2025. Completion of this training will be documented with an acknowledgment signed by the WIC staff and maintained by the Denver Health WIC Program Manager. CLIENT RESPONSIBLE PARTY: Kate Bennett, WIC Program Manager COMPLETION DATE: 12/31/2025
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR...
US Department of Agriculture Federal Financial Assistance Listing #10.558 Child and Adult Food Care Program (CACFP) Applicable Federal Award Number and Year – 28-1183-000 7/1/2023 – 6/30/2024 and 7/1/2024 – 6/30/2025 Cash Management Material Weakness in Internal Control Over Compliance Criteria: CFR 200.303(a) establishes that the auditee must establish and maintain effective internal control over federal awards that provides reasonable assurance that the Organization is managing the federal awards in compliance with federal statutes, regulations and terms and conditions of the federal award. Condition: The Organization was unable to provide adequate documentation to support the number of meals claimed for reimbursement. Corrective Action Plan: Management is in the process of reviewing its existing controls over the tracking and submitting of its meal counts included in its attendance records for reimbursement. Individual Responsible For Corrective Action: Veronica Jones, Fiscal Services Director Anticipated Completion Date: December 31, 2025
Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Findi...
Finding 2024-002: Material weakness in internal controls over compliance – cash management Recommendation: Management should improve the monitoring of actual expenditures ot better algin cash needs and draw down requests with actual expenditures incurred. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action planned in response to the finding: In April of 2024, KRJC established a financial policy that ensures that funds are only drawn down for expenses incurred and/or accrued during the reporting period. All expenses are booked into KRJC’s accounting system. KRJC then calculates any funding due from BJA and then completes a draw down for any payments due. In an effort to ensure that funds are never overdrawn but that KRJC can pay sub-awardees and contracts in a timely manner, this process may occur multiple times in any given quarter. In addition, KRJC has worked to develop a pool of unrestricted funds and is working to develop an operating reserve, using private funds, that will allow the organization some additional flexibility in our financial operations and will ultimately allow KRJC to shift to quarterly drawdowns. Planned completion date for corrective action plan: July 2024
Finding 1157363 (2024-007)
Material Weakness 2024
Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exist...
Name of Contact Person Responsible for Corrective Action: Karen Warmack, Social Services Director Corrective Action Planned: The County will implement additional procedures, including reviews, to provide reasonable assurance that all necessary documentation to support eligibility determination exists and is properly input into MAXIS. County Comment: A Corrective Action Plan has been established with an anticipated completion date of December 31, 2025. Anticipated Completion Date: December 31, 2025.
Significant Deficiency in Internal Control over Compliance, Other Matters U.S. Department of the Treasury U.S. Department of Housing and Urban Development Coronavirus State and Local Fiscal Recovery Funds Community Development Block Grants/Entitlement Grants 21.027 14.218 Recommendation: We recommen...
Significant Deficiency in Internal Control over Compliance, Other Matters U.S. Department of the Treasury U.S. Department of Housing and Urban Development Coronavirus State and Local Fiscal Recovery Funds Community Development Block Grants/Entitlement Grants 21.027 14.218 Recommendation: We recommend that the Authority implements controls to ensure that the preliminary SEFA is mostly accurate so that the correct programs are tested. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Finance Department has implemented several processes and procedures to ensure pass-through funds or sub-awards are reported timely and accurately in the SEFA. The new processes include (1) review of grant award letters to determine reporting requirements, (2) comparing the award letter against the Minutes of the City Council or County Commissioners meetings to ensure grants accepted during the year are disclosed as such on both ends, (3) confirmed with source Agency Single Audit requirements, (4) and the implementation of revenue source checklist that will identify the source of the funds, type of grant, program name and cluster title, name of federal funding agency, federal assisting listing number (formerly known as CFDA number), etc. Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2025 Name(s) of the contact person(s) responsible for corrective action: Hector Ordonez, Vice President of Finance and Administration Planned completion date for corrective action plan: December 31, 2025
Corrective Action Plan: The ARC of Delaware will update monthly replacement reserve deposit amounts upon notification from HUD. The Arc will perform an analysis every 30 days to ensure deposits have been made for the appropriate amount. ARC completed this corrective action plan when it was notified ...
Corrective Action Plan: The ARC of Delaware will update monthly replacement reserve deposit amounts upon notification from HUD. The Arc will perform an analysis every 30 days to ensure deposits have been made for the appropriate amount. ARC completed this corrective action plan when it was notified during the prior period single audit. Contact Person Responsible for Correction Action: Stanley Kihara, Controller Completion Date: July 15, 2024
Corrective Action Plan: The County has agreed to strengthen internal controls through regular reconciliations between project managers and the Clerk’s office to ensure timely reporting, submission for reimbursement and inclusion on the financial statements. Responsible Party: Alpena County Treasurer...
Corrective Action Plan: The County has agreed to strengthen internal controls through regular reconciliations between project managers and the Clerk’s office to ensure timely reporting, submission for reimbursement and inclusion on the financial statements. Responsible Party: Alpena County Treasurer and Alpena County Administrator Date of Planned Corrective Action: July 1, 2025 Management Assessment: We concur with the audit assessment regarding this matter.
CONDITION: During my review of the Borough of Ellwood City’s internal controls over federal awards, I noted that the Borough does not have formal written policies and procedures surrounding the management of their federal award funds. Although not all-inclusive, an example of some of the required po...
CONDITION: During my review of the Borough of Ellwood City’s internal controls over federal awards, I noted that the Borough does not have formal written policies and procedures surrounding the management of their federal award funds. Although not all-inclusive, an example of some of the required polices would include written procedures for procurement, conflict of interest, and allowable costs. This is a repeat finding (2023-001) from the prior year.CRITERIA: Section 2 CFR 200.303 of the Uniform Guidance requires non-federal entities such as the Borough of Ellwood City to maintain effective internal controls over federal awards. In addition, the Uniform Guidance also recommends these internal controls follow guidance in Standards for Internal Control in the Federal Government (the Green Book), issued by the Comptroller General of the United States.RECOMMENDATION: I recommend that the Borough of Ellwood City adopt the required written policies and procedures surrounding the management of federal award funds as prescribed by Section 2 CFR 200.303 of the Uniform Guidance. The focus of these policies and procedures should be to ensure that the Borough officials who are responsible for carrying out the objectives of the federal financial award understand 1) the federal statutes, regulations, and terms and conditions of the award, 2) how to evaluate and properly monitor compliance, and 3) the steps to take if noncompliance is identified.MANAGEMENT’S PLANNED CORRECTIVE ACTION: Management of the Borough will begin the process of reviewing Section 2 CFR 200.303 of the Uniform Guidance with the objective of understanding what specific policies and procedures surrounding the management of their federal award funds are required. As recommended, the focus of these policies and procedures will be to ensure that the Borough officials who are responsible for carrying out the objectives of the federal financial award understand 1) the federal statutes, regulations, and terms and conditions of the award, 2) how to evaluate and properly monitor compliance, and 3) the steps to take if noncompliance is identified. The timeframe for researching the required written policies and procedures of the Uniform Guidance, and the development and implementation of these written policies and procedures will cover the period including the last quarter of calendar year 2025 through and including the 2nd quarter of calendar year 2026.Borough Officials responsible for the implementation of the Corrective Action Plan:Kevin Swogger, Borough Manager.
Finding Reference Number: 2024-001 – Internal Control over Special Tests and Provisions Description of Finding: Documentation of the rent reasonableness determination could not be located for one program participant. Statement of Concurrence or Nonconcurrence: There is no disagreement with this find...
Finding Reference Number: 2024-001 – Internal Control over Special Tests and Provisions Description of Finding: Documentation of the rent reasonableness determination could not be located for one program participant. Statement of Concurrence or Nonconcurrence: There is no disagreement with this finding. Corrective Action: Going forward, management will incorporate rent reasonableness determination procedures into the purchase request form checklist for all payments for rent assistance. Projected Completion Date: December 31, 2025
View Audit 369520 Questioned Costs: $1
To whom it may concern: The Carmelite System, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number as...
To whom it may concern: The Carmelite System, Inc. and Affiliates respectfully submits the following corrective action plan for the year ended December 31, 2024. The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING – FEDERAL AWARD PROGRAM AUDITS 2024-001 Federal Agency: U.S. Department of Homeland Security Federal Program Title: Federal Emergency Management Agency Disaster Grants Assistance Listing Number: 97.036 Federal Award Number and Year: 4496DR 2024 Pass-Through Agency: State of Massachusetts Pass-Through Number: CTFEMA4496STPAT00971 Criteria or Specific Requirement: In accordance with 2 CFR §200.403(g), to be allowable under federal awards, costs must be adequately documented. Additionally, 2 CFR §200.303 requires non-federal entities to establish and maintain effective internal control over the federal award that provides reasonable assurance that the entity is managing the award in compliance with federal statutes, regulations, and the terms and conditions of the award. Condition: During testing of expenditures under the FEMA grant, the System was unable to provide documentation showing approval of an invoice dated May 2020. This invoice was selected as part of the single audit sample. The lack of approval documentation represents a deficiency in internal controls over compliance with federal requirements. Questioned Costs: None. Context: The invoice in question was incurred in May 2020, prior to the implementation of the Acumatica AP approval workflow. In June 2020, the facility transitioned to Acumatica, which provides electronic tracking of invoice approvals. Cause: At the time of the expenditure, the facility did not have a centralized or electronic approval process in place. Approval documentation was maintained manually and was not retained or accessible during the audit. Effect: The absence of approval documentation for the invoice creates a risk that expenditures may not be properly reviewed or authorized, potentially leading to noncompliance with federal requirements. Although the cost was ultimately deemed allowable, the control deficiency could impact future compliance if not addressed. Recommendation: We recommend that the System ensure all expenditures under federal awards are supported by documented approvals. For legacy transactions, efforts should be made to retain or reconstruct approval documentation where feasible. Continued use and monitoring of the Acumatica system should be maintained to ensure compliance going forward. Planned Corrective Actions: Management agrees with the finding. The invoice in question was incurred during an emergency response period prior to the implementation of the Acumatica system. While approval was likely obtained at the time, documentation was not retained. With the implementation of the Acumatica AP approval process in June 2020, the System has taken appropriate steps to address the finding and enhance internal controls over invoice approvals. Name of contact person responsible for corrective action: Corrinne Schindler
Individual(s) Responsible: LaNita Perez, Controller and AP Specialist Action: Management will ensure that all procurement transactions comply with established policies and procedures. Competitive bidding, documentation of procurement methods, justification for sole-source contracts, and price/cost a...
Individual(s) Responsible: LaNita Perez, Controller and AP Specialist Action: Management will ensure that all procurement transactions comply with established policies and procedures. Competitive bidding, documentation of procurement methods, justification for sole-source contracts, and price/cost analyses will be required for all applicable purchases. Staff will receive training on procurement requirements under Uniform Guidance. Management will monitor procurement activities and verify that each purchase is supported by proper documentation. Compliance with policies and procedures will be checked regularly. Anticipated Completion Date: December 31, 2025
Individual(s) Responsible: Enrique Martinez, Grant Manager and Program Director Action: Management will implement a process to ensure all expenditures are properly documented and reviewed for allowability before being charged to the Program. Staff will be trained on documentation and compliance requ...
Individual(s) Responsible: Enrique Martinez, Grant Manager and Program Director Action: Management will implement a process to ensure all expenditures are properly documented and reviewed for allowability before being charged to the Program. Staff will be trained on documentation and compliance requirements. Internal controls will be strengthened to prevent unallowable costs. Anticipated Completion Date: December 31, 2025
View Audit 369484 Questioned Costs: $1
Finding Number: 2024-001 Finding Title: Suspension and Dearment Program: 21.027 COVID-19 – Coronavirus State and Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or debarred i...
Finding Number: 2024-001 Finding Title: Suspension and Dearment Program: 21.027 COVID-19 – Coronavirus State and Fiscal Recovery Funds Name of Contact Person Responsible for Corrective Action: Kristin Waddell Corrective Action Planned: Verifying that a new vendor has not been suspended or debarred is analyzed on a case-by-case basis depending on the Federal award. Doing this for each vendor for ARPA would significantly disrupt our A/P process with the limited number of staff we have. Anticipated Completion Date: Immediately
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