Corrective Action Plans

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Finding 2025-001: Significant Deficiency and Noncompliance: Cut-off Errors in Preparing the SEFA Finding: The City’s reported expenditures on the fiscal year 2025 SEFA that were incurred in other fiscal years. For two grants that were closed out and finalized during fiscal year 2025, the City includ...
Finding 2025-001: Significant Deficiency and Noncompliance: Cut-off Errors in Preparing the SEFA Finding: The City’s reported expenditures on the fiscal year 2025 SEFA that were incurred in other fiscal years. For two grants that were closed out and finalized during fiscal year 2025, the City included certain expenditures incurred prior to January 1, 2025, on its 2025 SEFA, representing adjustment of amounts previously reported on the 2023 and 2024 SEFA to account for the finalized grant numbers. The adjustment amounts on the 2025 SEFA for these two grants do represent any actual expenditures incurred in 2025. Therefore, they were not reported on the SEFA in a manner consistent with the fiscal year in which they were recognized as expenditures in the financial statements. This resulted in a net effect of $32,815 of allowable costs reported on the fiscal year 2025 SEFA which were incurred in previous fiscal years. Corrective Actions Taken or Planned: The City has reviewed the circumstances noted in Finding 2025‑001 regarding the reporting of expenditures on the fiscal year 2025 SEFA for two federal airport grants that had already been closed and finalized. These grants required no additional programmatic or financial activity in fiscal year 2025, and the amounts appearing on the 2025 SEFA represented adjustments of expenditures originally recognized and reported in prior fiscal years. Because the grants are fully closed, no further corrective actions are required related to these specific awards beyond the correction already noted in the audit finding. To strengthen controls and ensure accurate reporting periods for all future federal airport grants, the City will implement a dual review process for annual grant expenditure reporting. Both the Airport Manager, MSO Management Analyst and the Finance Grant Accountant will independently review and validate the recording period for all federally funded airport grant expenditures prior to SEFA preparation. This additional verification step will help ensure proper cut off, alignment with the period of recognition in the financial statements, and continued compliance with federal reporting requirements. Contact Person: Shaun Cookson, Rachelle Mathews Anticipated Completion Date: To be completed by December 31st, 2026
ACDJFS will strengthen its internal controls and documentation practices related to the allocation of direct expenses and the completion of Random Moment Sampling (RMS) observations, particularly for programs serving both eligible and non eligible participants. 1. Strengthening Cost Allocation Contr...
ACDJFS will strengthen its internal controls and documentation practices related to the allocation of direct expenses and the completion of Random Moment Sampling (RMS) observations, particularly for programs serving both eligible and non eligible participants. 1. Strengthening Cost Allocation Controls ACDJFS will revise and reinforce its cost allocation procedures to ensure all direct expenses are properly assigned, consistently treated, and supported by clear documentation. Updated procedures will include supervisory review checkpoints and periodic reconciliation to ensure costs are charged in proportion to the benefit received by each program. 2. RMS Compliance and Documentation Standards ACDJFS provides a dedicated RMS Coordinator to maintain clear RMS compliance and documentation standards to ensure activities are coded accurately, consistently, and in accordance with state and federal requirements. Staff are expected to provide complete and accurate RMS responses that clearly describe the activity performed, its purpose, and the population served. Attention will be given to activities that support both eligible and non-eligible populations to ensure proper classification and allocation of costs. Allocation errors will be corrected promptly and documented. Incorrect RMS responses will be corrected and retrained immediately. All RMS responses are currently being reviewed. Supporting documentation must be maintained and readily available to substantiate RMS activities and demonstrate compliance during monitoring, audit, or review processes. Supervisors and management will routinely review RMS documentation and coding practices to ensure consistency, identify areas requiring clarification, and maintain the integrity of the agency's cost allocation methodology. The coding of direct expenses are reviewed prior to the processing month end to ensure that they are coded correctly. These standards help ensure RMS results accurately reflect agency operations and support the appropriate claiming of administrative costs. 3. Staff Training and Capacity Building ACDJFS will conduct targeted training for program and fiscal staff to ensure a consistent understanding of cost allocation principles, RMS documentation requirements, and compliance standards for programs serving mixed-eligibility populations. Annual refresher training will be incorporated into ongoing professional development efforts to reinforce expectations, maintain compliance, and support accurate coding practices. The RMS Coordinator will work closely with agency leadership and the Ohio Department of Job and Family Services (ODJFS) to monitor policy updates, guidance, and best practices related to Random Moment Sampling. The coordinator will obtain and disseminate updated information as quickly as possible to ensure staff receive timely communication, training, and technical assistance when changes occur. In addition, the RMS Coordinator will provide weekly reviews and updates to agency management, creating multiple levels of oversight and accountability. This ongoing review process allows leadership to identify trends, address potential concerns early, verify compliance, and ensure consistent application of RMS requirements across all programs. Through training, communication, and regular management review, ACDJFS strengthens internal controls and promotes the accuracy and integrity of its RMS activities. 4. Monitoring and Continuous Improvement ACDJFS leadership will conduct quarterly monitoring of allocation patterns, RMS samples, and documentation quality. Findings will be used to make timely corrections and guide additional staff training. Monitoring results will be retained and used to support continuous improvement. 5. Implementation Timeline All corrective actions, including updated procedures, training, and monitoring mechanisms—will be implemented within 90 days and maintained on an ongoing basis. Annual RMS training was completed in July 2025. ODJFS provided RMS training to all staff in December of 2025. ODJFS will provide annual RMS training scheduled for September 2, 2026. ODJFS will provide RMS Coordinator training on August 6, 2026. RMS training for Management/Fiscal is scheduled for July 7, 2026. Written documentation of fiscal procedures and policies is being reviewed and will be implemented by September 1, 2026.
Management’s Response/Corrective Action Plan: MSAD 15 will update its federal procurement checklist to ensure that all future federally funded construction, alteration, or repair contracts in excess of $2,000 explicitly incorporate Davis-Bacon Act wage rate requirement clauses.
Management’s Response/Corrective Action Plan: MSAD 15 will update its federal procurement checklist to ensure that all future federally funded construction, alteration, or repair contracts in excess of $2,000 explicitly incorporate Davis-Bacon Act wage rate requirement clauses.
Finding No. 2025-001 – Suspension and Debarment In April 2024, GMHA began requiring the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants for Invitation for Bids and Request for Proposals. To ensure the suspension and debarment verif...
Finding No. 2025-001 – Suspension and Debarment In April 2024, GMHA began requiring the Certificate Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion for Covered Contracts and Grants for Invitation for Bids and Request for Proposals. To ensure the suspension and debarment verifications are performed for all federal expenditures, the Accounting Department and Materials Management Department will ensure invoices that are later converted to federal funding contain the certificate. Name of Contact Person(s) Responsible for Corrective Action: Amacris Legaspi, General Accounting Supervisor Audrey Paulino, Hospital Materials Management Assistant Administrator, Acting Anticipated Completion Date: Completed.
Condition: the District did not provide an updated capital asset report including additions, deletions, and depreciation expense which is to be reported as a direct expense. Recommendation: The District's capital asset accounting and reporting system be updated to reflect additions, deletions and de...
Condition: the District did not provide an updated capital asset report including additions, deletions, and depreciation expense which is to be reported as a direct expense. Recommendation: The District's capital asset accounting and reporting system be updated to reflect additions, deletions and depreciation expense on an annual basis Method of Implementaton: Capital asset records will be reviewed annually and updated to reflect all additions, deletions, and depreciation. The inventory will be reconciled to the general ledger before year-end financial reporting.
Telluride Regional Airport Authority (“TRAA”) respectfully submits the following corrective action plan for the year ended December 31, 2025. Reference Number: 2025-001 Finding: TRAA’s 2025 Single Audit brought forth finding(s) which required a corrective action letter or Plan. The following item re...
Telluride Regional Airport Authority (“TRAA”) respectfully submits the following corrective action plan for the year ended December 31, 2025. Reference Number: 2025-001 Finding: TRAA’s 2025 Single Audit brought forth finding(s) which required a corrective action letter or Plan. The following item related to the Airport’s federal grant reimbursements: - Program 20.106 revenues were underreported by $1,092,801 in 2025. This underreporting stems from expenditures being incurred in 2025 but the corresponding reimbursement request, and revenue recognition, was not recorded until 2026, partially attributed to delays in submitting reimbursement requests. Corrective Action: TRAA agrees that the finding is correct. Moving forward, management will review grant expenditures at year-end to verify that the related revenues have been accrued, and management will work to file reimbursement requests for outstanding grants on a more timely basis. Personnel Responsible for Corrective Action: Linda Soucie, Business Manager Anticipated Completion Date: December 31, 2026 for fiscal year 2026
Recommendation: We recommend that the Foundation get caught up and hold meetings with each Principal Investigator to answer any questions they have. The goal would be to make sure they are comfortable with the reporting that is being done timely going forward. We also recommend that policies and pro...
Recommendation: We recommend that the Foundation get caught up and hold meetings with each Principal Investigator to answer any questions they have. The goal would be to make sure they are comfortable with the reporting that is being done timely going forward. We also recommend that policies and procedures in place be reviewed and updated to ensure that this issue doesn’t recur in the future. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: 1. The ongoing comprehensive financial review of Principal Investigator (PI) projects will be completed to ensure all project accounts are current and accurate. As PI account reconciliation is completed, PIs will be offered the opportunity to meet with members of the accounting team to review their project financial statements. 2. A Project Financial Reporting policy will be developed for Board approval which will dictate the required frequency and format of financial reports, and which will comply with applicable policies. Templates for PI financial reporting will be improved to provide accurate, easily comprehensible and actionable information to enable PIs to make informed financial management decisions. The Finance Committee will monitor the timeliness of statement delivery. Name(s) of the contact person(s) for corrective action: Alicia Swan, Board Chair Completion date for corrective action plan: 12/31/26
2025-002 Procurement Suspension and Debarment Name of Contact Person: Chief Financial Officer: Ahmed Zibare Corrective Action: Community Medical Wellness Centers USA will develop a system that maintains the required documentation for procurements in a centralized location. Proposed Completion Date: ...
2025-002 Procurement Suspension and Debarment Name of Contact Person: Chief Financial Officer: Ahmed Zibare Corrective Action: Community Medical Wellness Centers USA will develop a system that maintains the required documentation for procurements in a centralized location. Proposed Completion Date: September 30, 2026
2025-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Ahmed Zibare Corrective Action: Community Medical Wellness Centers USA: • Is providing immediate re-training to staff on issues identified. • Continues to provide ongoing training to current and new staff in...
2025-001 Sliding Fee Discount Determination Name of Contact Person: Chief Financial Officer: Ahmed Zibare Corrective Action: Community Medical Wellness Centers USA: • Is providing immediate re-training to staff on issues identified. • Continues to provide ongoing training to current and new staff involved in Sliding Fee Discount Program (SFDP) on program requirements and proper implementation of sliding fee determination and billing. • Will continue ongoing Sliding Fee Audits to assess staff knowledge, provide feedback, and offer guidance, as needed. Proposed Completion Date: September 30, 2026
Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will...
Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will prepare the monthly SNP Claim for Reimbursement Summary report and compile all supporting meal count documentation. 2. Prior to submission, the Administrative Assistant to the Director of Food Services or another designated individual independent of the preparation process will: a. Review the claim for mathematical accuracy; b. Verify meal counts against supporting documentation; c. Confirm claims are submitted within required timelines; and 3. Evidence of the review and approval will be documented through: a. Signature or electronic approval on the reimbursement summary report; and b. Retention of supporting documentation in accordance with federal and state record retention requirements. 4. A written standard operating procedure (SOP) outlining these review and approval responsibilities will be developed and communicated to applicable personnel. The Business Manager will periodically monitor compliance with the procedure to ensure controls remain effective.
City of Maumelle, Arkansas Corrective Action Plan Contact Name: Brad Ashford Contact Phone Number: 501-851-2500 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2025 Finding #2025-002 – Statement of Condition: The City's policies and procedures did not include requirements related to suspen...
City of Maumelle, Arkansas Corrective Action Plan Contact Name: Brad Ashford Contact Phone Number: 501-851-2500 Audit Firm: Forvis Mazars, LLP Audit Period: December 31, 2025 Finding #2025-002 – Statement of Condition: The City's policies and procedures did not include requirements related to suspension and deparment. Additionally, the City did not perform procedures to ensure vendors used in covered transactions were not suspended, debarred, or otherwise excluded. Response: The City concurs with the finding. Management will implement additional controls related to suspension and deparment. The completion date for the above-mentioned corrective action was December 2026.
Corrective Action: The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Ro...
Corrective Action: The City will implement formal review and approval process for reimbursement requests within grant management policy; and require documentation (signatures/dates) to evidence compliance. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will integrate suspension and debarment verification into purchasing workflow; require verification prior to purchase order approval; and update procurement policy to clearly define compliance requirements and documentation standards. Responsible Individual(s): Michael El...
Corrective Action: The City will integrate suspension and debarment verification into purchasing workflow; require verification prior to purchase order approval; and update procurement policy to clearly define compliance requirements and documentation standards. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Crissy Cantu, Purchasing Manager. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will implement standardized inventory management procedures for federally funded assets; maintain detailed item-by-item inventory records; conduct periodic management reviews of inventory listings; and ensure all required equipment is properly tracked and reported. Respon...
Corrective Action: The City will implement standardized inventory management procedures for federally funded assets; maintain detailed item-by-item inventory records; conduct periodic management reviews of inventory listings; and ensure all required equipment is properly tracked and reported. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael El...
Corrective Action: The City will establish centralized grant deadline calendar and grant compliance checklist for all programs; assign all grant monitoring responsibility to Grants Department; and incorporate compliance requirements into departmental procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City will implement and enforce procedures requiring purchase orders or equivalent authorization documentation to be prepared, approved, and retained prior to incurring federally funded expenditures. The City will also implement review procedures to ensure supporting documenta...
Corrective Action: The City will implement and enforce procedures requiring purchase orders or equivalent authorization documentation to be prepared, approved, and retained prior to incurring federally funded expenditures. The City will also implement review procedures to ensure supporting documentation is complete and maintained in grant expenditure files. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Crissy Cantu, Purchasing Manager. Timeline: In Progress. Estimated October 2026.
Corrective Action: The City will implement formal Section 3 policies and procedures for applicable CDBG projects. The policies will identify applicable projects, assign responsibility for compliance monitoring, establish worker certification and documentation requirements, and provide for documentat...
Corrective Action: The City will implement formal Section 3 policies and procedures for applicable CDBG projects. The policies will identify applicable projects, assign responsibility for compliance monitoring, establish worker certification and documentation requirements, and provide for documentation retention and periodic review procedures. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated October 2026.
Corrective Action: The City will implement formal procedures to ensure pre-rehabilitation inspection documentation is reviewed and approved by the designated approving authority. Procedures will clearly assign preparer and reviewer responsibilities, maintain appropriate segregation of duties, and re...
Corrective Action: The City will implement formal procedures to ensure pre-rehabilitation inspection documentation is reviewed and approved by the designated approving authority. Procedures will clearly assign preparer and reviewer responsibilities, maintain appropriate segregation of duties, and require supporting documentation to be retained in project files. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated October 2026.
Corrective Action: The City will establish a centralized grant reporting calendar to monitor federal reporting deadlines; assign responsibility for the timely preparation and submission of required reports; and implement review procedures to ensure compliance with federal reporting requirements. Res...
Corrective Action: The City will establish a centralized grant reporting calendar to monitor federal reporting deadlines; assign responsibility for the timely preparation and submission of required reports; and implement review procedures to ensure compliance with federal reporting requirements. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director. Timeline: In Progress. Estimated September 2026.
Corrective Action: The City has begun implementing formal equipment management procedures for federally funded assets, including the green tagging of grant-funded assets utilizing the RCI asset management system. The City will conduct and document a physical inventory of federally funded equipment a...
Corrective Action: The City has begun implementing formal equipment management procedures for federally funded assets, including the green tagging of grant-funded assets utilizing the RCI asset management system. The City will conduct and document a physical inventory of federally funded equipment at least once every two years; reconcile inventory results to property records; investigate discrepancies timely; and retain supporting documentation to demonstrate compliance with federal equipment management requirements. Responsible Individual(s): Michael Elizalde, Grants & Strategic Initiatives Director; Vidal Roman, Finance Director. Timeline: In Progress. Estimated September 2026.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: Controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Management’s response/corrective action plan: The School Business Manager and the Assistant Superintendent/Special Education Director will ensure all contracts going forward will have the contract language necessary to prevent using any parties who have been suspended or debarred.
Management’s response/corrective action plan: The School Business Manager and the Assistant Superintendent/Special Education Director will ensure all contracts going forward will have the contract language necessary to prevent using any parties who have been suspended or debarred.
2025-001 Internal Controls over Allowable Cost – Disaster Assistance Grants Point of Contact: Rachael Wilkinson, Director, APOHSEP Management’s response and corrective action plans are as follows: 1. Management acknowledges the recommendation and has taken steps to enhance oversight of the Federal E...
2025-001 Internal Controls over Allowable Cost – Disaster Assistance Grants Point of Contact: Rachael Wilkinson, Director, APOHSEP Management’s response and corrective action plans are as follows: 1. Management acknowledges the recommendation and has taken steps to enhance oversight of the Federal Emergency Management Agency (FEMA) reimbursement requests, including those prepared by third-party consultants. Ascension Parish Government is implementing a formalized review process by the Ascension Parish Office of Homeland Security and Emergency Preparedness (APOHSEP) prior to submission to ensure that all expenditures are accurate, properly supported, and classified in accordance with FEMA requirements. 2. This process will include reconciling reimbursement requests with underlying payroll records, equipment logs, and other supporting documentation, as applicable. Management will continue to monitor FEMA submissions to ensure compliance with applicable federal guidelines and strengthen documentation of review procedures. 3. Additionally, Ascension Parish Government will amend the project worksheet to address the identified errors
Finding 2025-002: Community Development Block/Grants/ State's Program and Non-Entitlement Grants in Hawaii Assistance Listing No. 14.228 Compliance Requirement: Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Compliance (material nonco...
Finding 2025-002: Community Development Block/Grants/ State's Program and Non-Entitlement Grants in Hawaii Assistance Listing No. 14.228 Compliance Requirement: Special Tests and Provisions Grant No.: Not applicable Type of finding: Internal Control (material weakness) and Compliance (material noncompliance) Recommendation: The City should establish and implement formal policies and procedures requiring weekly certified payrolls be obtained and reviewed against the applicable Davis-Bacon wage requirment before contractor payment. The review should be documented and include evidence of comparison of labor classifications, wage rates, fringe benefits, and reviewer approval. Action Taken: Management will establish comprehensive, formal policies and procedures to ensure strict compliance with Davis-Bacon regulations alongside all applicable federal and state grant requirments. If there are questions regarding this plan, pleasecall the responsible parties listed below. Sincerely yours, Heather Sanchez City Manager City of Alamosa, Colorado Emily Martinez Finance Director City of Alamosa, Colorado
The City will establish and document formal subrecipient-monitoring procedures consistent with 2 CFR §200.332. The audit found that the City did not document its review of the subrecipient's Single Audit report, evaluate whether the subrecipient's audit finding related to City-provided funds, or fol...
The City will establish and document formal subrecipient-monitoring procedures consistent with 2 CFR §200.332. The audit found that the City did not document its review of the subrecipient's Single Audit report, evaluate whether the subrecipient's audit finding related to City-provided funds, or follow up on discrepancies in the subrecipient's Schedule of Expenditures of Federal Awards. 1. Maintain a complete inventory of all federal subawards, including the subrecipient, federal program, Assistance Listing Number, award amount, period of performance, and applicable compliance requirements. 2. Require each subrecipient to submit its annual Single Audit report or written confirmation that it was not subject to the Single Audit requirement. 3. Review each applicable Single Audit report and the Federal Audit Clearinghouse for findings that could relate to City-funded subawards. 4. Compare subaward information reported by the subrecipient on its Schedule of Expenditures of Federal Awards to the City's accounting and grant records. 5. Investigate and resolve any reporting discrepancies, including missing pass-through entity information, incorrect Assistance Listing Numbers, or omitted federal expenditures. 6.. Use a standardized monitoring checklist and retain all supporting documentation in the applicable grant file. Responsible Officials Anticipated Completion Date The revised monitoring checklist will be completed by September 30, 2026. Review and follow-up concerning the identified subrecipient will be completed by December 31 , 2026. Monitoring will continue throughout the duration of each subaward. Contact Person Responsible for the Corrective Action Plan Cynthia Smith, Finance Director City of Chicago Heights 1601 Chicago Road Chicago Heights, Illinois 60411
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