Corrective Action Plans

The grant administrator shall include notifications within their Outlook calendar two weeks prior to the due date for each progress report deadline. This will ensure progress reportes are completed and submitted on time.

Management will ensure Federal expenditures are obligated during proper period and reported appropriately.

We are fully committed to meet our reporting obligations for all of our donors. During 2024, the federal government had changed its login process to Payment Management System (PMS) and that resulted in access problems for our users at that time. Replacement account activation was gradual and took some time before we got the access to all the projects on PMS. We are already tracking both financial and narrative reports from the signing stage of projects, and most of the reports are prepared on time. Going forward, we will further strengthen our backup plans for submission of reports, both online and through email. We will develop a backup plan and strengthen delegation plans for each region during the times when the primary contact is not available

Finding 2024-005 – Reporting (repeat finding): Type: Material Weakness in Internal Control/Noncompliance. Condition: The CMHSP did not file the required annual Federal Financial Report as required for this grant. Corrective Action: Current Finance staff will review internal controls and make changes to ensure that reports are filed in accordance with the grant requirements. Contact Person: Kevin Hartley, CFO Completion date: October 1, 2024

Due to a vacant Finance Director position for a portion of fiscal year 2024, CTSA did not file the referenced report timely. However, CTSA has granted the appropriate access to our contracted accounting firm that will allow for timely reporting going forward.

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

The Department has ramped up recruiting efforts by advertising positions on external websites such as indeed. The accounting department has recently increased the wages of existing staff and the starting wages of all positions in an effort to attract and retain qualified staff.

Management acknowledges the need for compliance with reporting requirements for COVID-19 State and Local Fiscal Recovery Funds. We will follow the auditors’ recommendation to review our policies and procedures to ensure that internal controls are properly designed, implemented and maintained to ensure accurate and timely financial close and reporting.

Recommendation: We recommend that the District develop and implement formal policies and procedures to ensure that federal reports are reviewed for accuracy, completeness, and timeliness prior to submission. Management should assign responsibility for report preparation and review, implement checklists or reconciliation processes, and provide training to staff involved in federal reporting. Corrective Action: 1. Assign separate personnel for report drafting and supervisory review to ensure segregation of duties. 2. Create and require use of a Quarterly Report Review Checklist to confirm accuracy, completeness, and timeliness before submission. Person Responsible for Corrective Action: William Clayton, Finance Manager. Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

Recommendation: We recommend that the District strengthen its internal control system by implementing a formal tracking mechanism for federal reporting deadlines, assigning responsibility for report preparation and submission, and establishing a review process to ensure timely compliance with all grant reporting requirements. Corrective Action: 1. Designate a primary report preparer and assign a secondary reviewer to verify report accuracy, completeness, and timeliness prior to submission. 2. Implement a report review checklist to be completed and signed by both preparer and the reviewer, filed with each submission. Person Responsible for Corrective Action: William Clayton, Finance Manager Anticipated Completion Date for Corrective Action: Corrective Action is immediately implemented in response to the auditors’ recommendation.

Views of Responsible Official(s) and Planned Corrective Action: Management concurs with the finding. The report found lacking was reviewed by the Executive Director, and the error was based on a difference between cash and accrual accounting. Management will review federal financial reports with contracted accountants and retrieve source documents before submitting. Management will also review scope of contracted accounting services to ensure it includes review of all NEH reports.

The District acknowledges the continuing issue of receiving material vendor invoices many months after performance of contracted work. One set of late invoices entered into QuickBooks accounts payable with retroactive dates was not recognized as grant revenue earned. As recommended by the auditors, the District will begin tracking grant expenditures on an accrual basis beginning with the period ending July 31, 2025. In addition to the monthly recognition of cash accounts by the Finance Coordinator, all balance sheet accounts with material balances will be reconciled each month by the Treasurer with review by the Executive Director beginning with the period ending July 31, 2025. We anticipate both audit findings will be fully resolved by these actions. Responsible party: Patrick Moreland Date: Ongoing

FINDING 2024-004 Finding Subject: Water and Wast Disposal System for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Beth Jones Contact Phone Number and Email Address: 812 723-2739, clerk@paoli.in.gov Views of Responsible Officials: We concur with the findings Description of Corrective Action Plan: The town is contracted with Baker Tilly Financial Advisors and the Clerk Treasurer will provide all pertinent information to Baker Tilly in order for them to prepare the Statement of Budget, Income, and Equity- Form 442-2; and the Balance Sheet - Form 442-3) that is required by the USDA for the Sewer Bonds. Once the reports are completed by Baker Tilly, the Clerk Treasurer will review the reports and then submit them to the USDA. This will be done annually. Anticipated Completion Date: Effective immediately

Federal Agency Name: Department of Veterans Affairs Assistance Listing Number: 64.003 Program Name: VA Supportive Services for Veteran Families Program Compliance Requirement: Reporting Finding Summary: No review and approval processes are in place over quarterly progress reports. Corrective Action Plan: Management has implemented procedures and control processes to incorporate an independent review and approval over quarterly reporting and retain documentation to support the review was performed. Responsible Individuals: Teena Conrad, SSVF Program Manager, Lysa Allison, Executive Director and Sara VanVlack, Business Manager Anticipated Completion Date: June 2025

Finding Number: 2024-001 : Significant Deficiency and Noncompliance - Reporting Planned Corrective Action: As recommended, Management will implement controls and processes to ensure all required reports are submitted timely. Anticipated Completion Date : June 30, 2025 Responsible Contact Person: Randy Bartels, City Auditor

Audit Recommendation – We recommend that management and relevant staff participate in comprehensive training on federal grant compliance – emphasizing FFATA obligations and financial reporting deadlines – to ensure a clear understanding requirements. Management should then formalize and document procedures for FFATA reporting, including a calendar driven workflow with designated preparers and approvers, mandatory sign-off checklists, and automated reminders. Finally, the Organization should implement a centralized reporting tracking system that monitors all federal award deadlines and captures evidence of timely preparation, review, and submission for both financial and performance reports.   Management Response – We concur with the recommendation and in process of making changes the both the work flow and processes stated. Specifically, we have contracted with two outside consulting firms for both grant compliance and internal audit services from Certified Public Accountant licensed professionals. Finally, both independent consultants will report the compliance status to the CEO on a periodic basis. 

The Conservancy District has implmenented controls and processes to ensure that the required reports are prepared and submitted timely.

Management acknowledges the lapse in consistently meeting the grant requirement to submit financial reports within the specified 30-day period. To address this issue, the Organization has initiated a series of procedural improvements to ensure timely and accurate reporting moving forward. As a first step, the Organization has taken the crucial step of meeting with the grant manager to establish clear communication and alignment on reporting expectations. This direct dialogue has helped clarify requirements, strengthen mutual understanding, and lay the groundwork for a more seamless reporting process. To support ongoing compliance, the Organization has implemented a shared calendar for both program and fiscal management teams, providing a unified view of reporting deadlines and improving coordination and accountability across departments. Additionally, the Organization’s fiscal team has implemented a separate, dedicated calendar focused on financial reporting deadlines. This targeted approach allows the team to proactively track and meet reporting timelines with promptness and consistency.

Corrective Action Plan for Airport Improvement Program, Infrastructure Investment and Jobs Act Programs, and COVID-19 Airports Programs: Reporting – Finding 2024-002 We are in receipt of the Findings Required to be Reported by the Uniform Guidance, specifically finding 2024-002 regarding failure to complete and submit the required annual Federal Financial Reports (SF-425) for the two awards identified below for the year ended December 31, 2024. • Department of Transportation, Award Number 3-05-0047-031-2023, Award Year 2023 • Department of Transportation, Award Number 3-05-0047-032-2024, Award Year 2024 View of Responsible Officials and Planned Corrective Actions Management agrees with the finding. The City experienced turnover during the fiscal year leaving less time for preparation and review of required reporting. As a result, internal controls and review processes were not in place or were not followed to ensure all required reporting was completed accurately and timely. Overall, we will increase compensating controls by introducing additional management oversight and review for the processes in this area. We will develop a process for reviewing and tracking the submission of FFR reporting to the Federal Aviation Administration (FAA) to ensure that reporting is in compliance with FAA and CFR rules and regulations. Ember Strange, Chief Financial Officer, will be responsible to ensure this is accomplished. The corrective action plan will be implemented by December 31, 2025.

Finding Number: 2024-001 Planned Corrective Action: City of Norton will comply with all federal grant compliance requirements – including reporting requirements and deadlines. Anticipated Completion Date: June 2025 Responsible Contact Person: Pamela Keener, Finance Director

Create a detailed, step-by-step process for federal procurement to ensure compliance and awareness among all staff responsible for spending and reporting federal funds. Washington Local Schools - Federal Grants Management Process Require training for all staff involved in preparing, reviewing, or certifying federal grant reports, prior to beginning any work. Work with a Financial Program Manager at the Office of Budget and Management (Neal Bucklew was the district’s contact on this particular grant) to ensure that all activity reports are submitted correctly and received on time.

To address the finding, ARC will strengthen internal controls related to federal reporting by taking the following actions: 1. Enhance Reporting Oversight: The Finance Manager and Grants and Compliance Officer will assume primary responsibility for monitoring and verifying all federal reporting deadlines and submission requirements. 2. Document Retention Procedure: Additional double checks of record retention will take place in monthly reporting meetings, ensuring that centralized record keeping is complete. 3. Compliance Calendar Audit: A quarterly internal audit of the compliance calendar and reporting checklist will be conducted to verify deadlines are met.

2024-002 - Late submission of reports Auditor Description of Condition and Effect: The Agency failed to submit the required report for the federal grant within the stipulated deadlines as outlined in the grant agreement and Uniform Guidance. During reporting testing, it was noted that the Final FFR report was not submitted into the Payment Management Services (PMS) prior to the required due date. Late submission of reports results in noncompliance with federal regulations, potentially leading to administrative actions such as withholding of future grant funds, increased monitoring, or other penalties as deemed appropriate by the Federal awarding agency. The Agency did not comply with contractual reporting requirements. Auditor Recommendation: We recommend the Agency implement procedures to ensure timely submission of all required reports. Corrective Action: The Agency will implement a system of reviewing the semi-annual and annual federal financial reporting which would include the reports being prepared by the Financial Grants Manager, reviewed by the Chief Financial Officer and submitted by the Chief Executive Officer, all of whom will be aware of the reporting due dates as to ensure they are filed timely. Responsible Person: Anthony J Samon, CFO Anticipated Completion Date: Immediately, the Agency’s next FFR due date is September 30th.

Finding 2024-001: Preparation of Schedule of Expenditures of Federal Awards (SEFA) The single audit report included the following recommendation: We recommend Amtrak to strengthen the SEFA oversight process to ensure appropriate preparation and review of the SEFA to validate its accuracy, including reconciliation with prior year audited SEFA. This should include having one reviewer take overall responsibility for the completeness and accuracy of the final submitted SEFA. This robust review process should include appropriate procedures to confirm accuracy of the SEFA, which may include a protocol where representatives from various groups (both discretionary and non-discretionary federal programs) work collaboratively to review the SEFA and underlying details of expenditures, to ensure all the adjustments have been properly reflected as well as any projects that might have multiple fund sources are identified timely and reviewed for appropriate inclusion within the SEFA. Additionally, Amtrak should establish a process where any modifications of WBS funding assignments and allocations are updated in a timely manner Management Response/Status of Action Plans: Amtrak recognizes the need to improve the preparation and review of the SEFA. The company has documented the steps for preparing and reviewing the SEFA within its process narrative. The company will update the narrative to address the preparation and review issues that led to the multiple versions of the SEFA being provided during the audit. The company is in the process of updating the SEFA preparation documentation for FY2025, which will be used at the end of the year. The review procedures and controls are being enhanced to include a checklist to improve the review. The company will review and update the Grants Management Compliance Narrative and controls to improve timing of updates for modifications of WBS funding assignments. The contact for this item is Lucia Butts, AVP Funding and Grants. Amtrak anticipates fully remediating this finding by September 2025.

Action taken: Effective immediately, management has implemented a new federal grant reporting calendar to track the due dates for SF-425 and other federal reporting requirements. This adjustment ensures proper reporting and alignment with compliance requirements. Person responsible: ShaQuina Davis, Chief Operating Officer Date completed: March 12, 2025