Corrective Action Plans

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Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient ...
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient to support compensation costs charged to the Community Development Financial Institutions Program in accordance with 2 CFR § 200.430. The Organization's methodology relied on management-established allocation percentages based on employee responsibilities and anticipated level of effort supporting CDFI Fund activities. While management believes the costs charged to the award were incurred in support of eligible program activities, the Organization recognizes that documentation supporting the allocation methodology did not meet the standards required under Uniform Guidance. Planned Corrective Action: Beginning July 1, 2026, the Organization will implement formal time and effort reporting procedures for all personnel whose compensation is charged, in whole or in part, to federal awards. Specifically, the Organization will: 1.The CFO will establish a cost allocation plan which includes a methodology to support salary, wage, and fringe benefit charges, and other applicable costs, to the federal award and to support allocation among cost objectives. 2. The CFO will implement a documented process for personnel activity reporting and/or periodic certifications (or other equivalent documentation) that reasonably reflects actual work performed and supports the allocation of compensation costs to eligible activities. 3. CFO will reconfigure the current workforce management system to ensure projects, departments, and contextual details are logged at the source. 4. The COO will review existing timesheet submission and review policy to ensure compliance with federal requirements. The policy will require supervisory review and approval of personnel activity documentation/ certifications consistent with the payroll cadence and retain documentation in the grant file and/or payroll file. The CFO will review and enforce compliance with timesheet submission requirements. 5. The CFO will implement a dynamic allocations module within Sage Intacct to facilitate automated allocation of time and fringe benefits to federal and other programs. 6. The CFO will ensure that the systems established perform periodic reconciliation and after-thefact review of payroll and fringe benefit allocations. The CFO will make timely adjustments when actual activity differs from budget estimates or planned allocations. 7. The CFO, COO, and other personnel working on federal programs will receive training on the documentation standards in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 8. The CFO and COO will provide training to program and finance personnel on the documentation standards. in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 9. The CFO will, as part of the monthly close process, review compensation charged to federal awards to ensure all costs are appropriate and supported prior to requesting reimbursement. Management believes these actions will strengthen internal controls over compensation costs charged to federal awards and ensure compliance with Uniform Guidance requirements going forward. Responsible Official: Julia Gazizova, Chief Financial Officer Anticipated Completion Date: September 30, 2026.
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Finding #2025-004: Written Uniform Guidance Policies Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: The System is working on developing written Uniform Guidance policies. Anticipated Completion Date: Ongoing
Finding #2025-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: Management of the System has reviewed the financial statements and schedule of expenditures of federal awards (SEFA) ...
Finding #2025-001: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individuals: Don Peterson, System Manager Corrective Action Plan: Management of the System has reviewed the financial statements and schedule of expenditures of federal awards (SEFA) prepared by Ketel Thorstenson, LLP. The financial statements and SEFA have been compared and reconciled to the internal records maintained by the System. Management and the Board of Directors has been given adequate opportunity to ask questions regarding the financials statements and note disclosures and have received sufficient responses from the auditors prior to final publication of the audited financial statements and SEFA. Management is satisfied that appropriate actions have been taken to allow them to take responsibility for the financial statements. Anticipated Completion Date: Ongoing
Finding 1224786 (2025-002)
Material Weakness 2025
Ecotrust is implementing a formal, documented, risk based approach to subrecipient monitoring consistent with 2 CFR 200.332. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub grantee management from a centralized model to a distributed model in which program manager...
Ecotrust is implementing a formal, documented, risk based approach to subrecipient monitoring consistent with 2 CFR 200.332. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub grantee management from a centralized model to a distributed model in which program managers assumed responsibilities for which tools and training were insufficient. To correct the underlying deficiency, Ecotrust is taking the following specific actions: • Adopting formal, written policies and procedures that require a documented risk assessment for each subrecipient and require that assessed risk drive the level of monitoring. • Performing and documenting a risk assessment for every subrecipient, including documented consideration of each subrecipient’s audit results and prior year findings. • Using the assessed risk to determine and document the nature, timing, and extent of monitoring, applying enhanced monitoring procedures to higher risk subrecipients and retaining documentation supporting the performance and results of those procedures. • Engaging an outside consultant, Jennifer Hutton, who has grantee management experience gained at Mercy Corps and other non profits, to work with the finance team and program managers to develop the supporting processes, tools, and accountability measures, supported by training for all participants.
Finding 1224785 (2025-001)
Material Weakness 2025
Ecotrust is strengthening its controls over federal financial reporting to ensure required SF‑425 Federal Financial Reports are submitted (in a timely manner) in accordance with 2 CFR 200.328 and applicable award terms. Approximately three years ago, following turnover, Ecotrust shifted grantee and ...
Ecotrust is strengthening its controls over federal financial reporting to ensure required SF‑425 Federal Financial Reports are submitted (in a timely manner) in accordance with 2 CFR 200.328 and applicable award terms. Approximately three years ago, following turnover, Ecotrust shifted grantee and sub‑grantee management from a centralized model to a distributed model in which program managers assumed responsibilities for which tools and training were insufficient. To correct the underlying deficiency, Ecotrust is taking the following specific actions: • Assigning clear, documented responsibility for the preparation and timely submission of all federal financial reports (including the SF‑425), with a designated primary preparer and a backup to ensure continuity of reporting during staff absences or turnover. • Establishing a federal reporting calendar that tracks all federal financial report due dates, with proactive advance reminders shared across the finance and program teams. • Providing periodic training to finance and program staff to reinforce awareness of federal financial reporting requirements and deadlines. • Engaging an outside consultant, Jennifer Hutton, who has grantee‑management experience gained at Mercy Corps and other non‑profits, to work with the finance team and program managers to develop the supporting processes, tools, and accountability measures.
Finding #2025-002 – Material Weakness and Material Noncompliance. U. S. Department of Housing and Urban Development, Community Development Block Grants/Entitlement Grants, Assistance Listing #14.218, Passed through the City of Houston, Contract year: 11/07/23 – 10/31/26. Condition and context: Manag...
Finding #2025-002 – Material Weakness and Material Noncompliance. U. S. Department of Housing and Urban Development, Community Development Block Grants/Entitlement Grants, Assistance Listing #14.218, Passed through the City of Houston, Contract year: 11/07/23 – 10/31/26. Condition and context: Management failed to include a federally funded contract on the SEFA for the last two years totaling $522,014. Omitting these expenditures from the SEFA resulted in incorrectly reported federal expenditures. Recommendation: Develop policies and procedures to identify and reflect all federal programs on the SEFA and reconcile the federal expenditures to the federal program revenue on a routine basis. Planned corrective action: The Vice President of Finance and Administration will be provided with all funding agreements to identify any new federal grants. Additionally, the project management team and the Vice President of Finance and Administration will now meet bi-weekly to discuss new funding agreements in order to identify any new funding that is federally sourced and would require inclusion on the SEFA. Responsible officer: Michele Nezi Marvin, Vice President of Finance and Administration. Estimated completion date: July 1, 2026.
Managements Corrective Action Plan Year Ending – December 31, 2025 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2025. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2025-001 – Allowable Cost Principles – Payro...
Managements Corrective Action Plan Year Ending – December 31, 2025 In response to the Single Audit performed by Baker Tilly US, LLP for calendar year ending December 31, 2025. Schedule of finding and Questioned Costs: Section III – Federal Award Findings: 2025-001 – Allowable Cost Principles – Payroll Evidence of Review Contact: Jennifer Moore Title: Controller Phone number: 310-795-0257 Federal Assistance # 93.217 Estimated Completion Date – September 2026 Corrective Action - Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky will implement a process improvement plan in 2026 that addresses the finding: • For our 2025 Single Audit, we discovered a system limitation in Dayforce preventing approval of timecards beyond the automatic cut-off time. • In partnership with the Human Resources department, staff will establish an “after the fact” approval process to ensure that all timecards are reviewed and approved by management. o The current system will continue to push through timecards to make the defined payroll cut-off time. o A manual process will be established to review and approve missed timecards after payroll is processed. ▪ Managers are to review and approve timecards, even though the timecards have been processed. ▪ A log will be maintained acknowledging missed approvals, logging hours, areas of work, and manager approval o If any errors or changes need to be made, those will be reflected within the next payroll cycle.
The Shaquille O'Neal Foundation acknowledges the observation regarding the documentation requirements under 2 CFR §200.318(a). While the Foundation did not have a formal written procurement policy in place during the audit period, it did implement procurement practices designed to comply with the Un...
The Shaquille O'Neal Foundation acknowledges the observation regarding the documentation requirements under 2 CFR §200.318(a). While the Foundation did not have a formal written procurement policy in place during the audit period, it did implement procurement practices designed to comply with the Uniform Guidance requirements. Specifically, the Foundation maintained oversight of contractor performance in accordance with 2 CFR §200.318(b) by ensuring that all contractor agreements and applicable purchase orders incorporated the required federal contract provisions and procurement language. The Foundation monitored contractor performance to verify that work was completed in accordance with the terms, conditions, and specifications of each agreement. The Foundation recognizes that documenting these procurement procedures in a formal written policy is a separate requirement under 2 CFR §200.318(a). To address this deficiency, management has developed and adopted a written Procurement Policy that aligns with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (2 CFR Part 200). The policy formalizes the Foundation's procurement procedures, internal controls, competition requirements, contract oversight responsibilities, and documentation standards to ensure ongoing compliance with federal regulations. Management believes this corrective action fully addresses the audit finding and strengthens the Foundation's procurement governance for future federal awards.
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environm...
The Foundation, through its outsourced bookkeeping firm, acknowledges the audit observation regarding the duplicate reimbursement of lender expenditures. Management believes this was an isolated administrative error rather than the result of a deficiency in the Foundation's internal control environment. The Foundation maintains controls designed to ensure that expenditures charged to federal awards are reviewed for allowability, properly supported, and approved before submission for reimbursement. In this instance, a subsequent reimbursement from the lender was not identified through the Foundation's normal monitoring process. Management contacted the grantor and resolved the matter by applying other allowable expenditures to the federal award, thereby eliminating any duplicate recovery of federal funds. To further strengthen existing controls, the Foundation has enhanced its procedures to specifically track expenditures submitted for reimbursement under federal programs and monitor any subsequent refunds, credits, rebates, or reimbursements received from vendors or other third parties related to those expenditures. In addition, management will document a post-submission review process to identify vendor credits or recoveries received after reimbursement requests have been submitted and determine whether any adjustment to future reimbursement requests or repayment to the granting agency is required.
Contact Person Mark Kinzler, General Manager Corrective Action Plan All mileage charged to federal awards will be capped at the allowable federal rate to ensure any internal mileage rates exceeding this cap will be covered by non-federal or unrestricted funds. Completion Date Immediate
Contact Person Mark Kinzler, General Manager Corrective Action Plan All mileage charged to federal awards will be capped at the allowable federal rate to ensure any internal mileage rates exceeding this cap will be covered by non-federal or unrestricted funds. Completion Date Immediate
The Airport has incorporated the addition of electronic approvals for Airport Improvement Plan invoices within its existing procurement policy.
The Airport has incorporated the addition of electronic approvals for Airport Improvement Plan invoices within its existing procurement policy.
The Airport plans to complete a credit memo for all the amounts drawn down on the 2025 grants and reissue a pay request for the remaining federal share on the eligible expenses to be in accordance with the match in the grant agreements.
The Airport plans to complete a credit memo for all the amounts drawn down on the 2025 grants and reissue a pay request for the remaining federal share on the eligible expenses to be in accordance with the match in the grant agreements.
Segregation of Duties
Segregation of Duties
Name of Contact Person: Lisa Steffl, City Clerk
Name of Contact Person: Lisa Steffl, City Clerk
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Correction Action: The finance related tasks will be separated as much as possible and alternative controls will be used to compensate for the lack of separation. The City Council will become more involved in providing some of these controls.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Auditor Prepared Financial Statements
Auditor Prepared Financial Statements
Name of Contact Person: Lisa Steffl, City Clerk
Name of Contact Person: Lisa Steffl, City Clerk
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
Correction Action: The City Clerk will continue to review GASB pronouncements and GASB disclosure checklists to ensure she is aware of financial statement requirements and new pronouncements.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Proposed Completion Date: The City Council will implement the above procedures immediately.
Corrective Action Plan Finding No.: 2025 - 002 Condition: The District procured $885,950 of services from a food service vendor and did not follow the formal methods of procurement outlined in 2 CFR 200.320(b)(2), 105 ILCS 5/10-20.21, and their established procurement policy as they did not procure ...
Corrective Action Plan Finding No.: 2025 - 002 Condition: The District procured $885,950 of services from a food service vendor and did not follow the formal methods of procurement outlined in 2 CFR 200.320(b)(2), 105 ILCS 5/10-20.21, and their established procurement policy as they did not procure the services through a competitive request for proposal process. Plan: While the district did obtain a two-year waiver from the Illinois State Board of Education regarding Food Service procurement regulations, management concurs with the finding. The District will strengthen its procurement procedures to ensure purchases subject to the Uniform Guidance procurement requirements are conducted using the appropriate procurement method and adequately documented. Management will provide additional training to personnel responsible for federal procurements and implement a review process to verify compliance with federal procurement requirements prior to contract award. These procedures will be implemented for all applicable procurements beginning in fiscal year 2027. Anticipated Date of Completion: August 30, 2026 Name of Contact Person: Mr. Harrison Neal, Assistant Superintendent of Business and Finance
FINDING 2025-002 This is Department of Family and Support Services’ first Single Audit where FFATA reporting was reviewed under Sam.gov rather than FSRS.gov. The Sam.gov system does not keep records of historical changes/ updates to published reports. Every time a report is modified, the date of sub...
FINDING 2025-002 This is Department of Family and Support Services’ first Single Audit where FFATA reporting was reviewed under Sam.gov rather than FSRS.gov. The Sam.gov system does not keep records of historical changes/ updates to published reports. Every time a report is modified, the date of submission is updated to reflect the current date. Effective August 1, 2026, DFSS will track and document changes or updates made to a FFATA report by using screenshots. Additionally, DFSS will update FFATA reports when the original contract and budget allocation is modified. DFSS will submit separate FFATA reports for each program funded by contract number. The FFATA reports will be delineated in Sam.gov by the purchase order number and the release number using the new Subaward ID format “PO#_Release#.” Chief Research Analyst Kaur from DFSS’ Grants unit will be responsible for ensuring the changes are implemented for FFATA reporting. Deputy Commissioner of Contracts, IT, and Programmatic Monitoring Givens will be responsible for providing oversight and monitoring the process with the Department of Family and Support Services (DFSS) Contracts staff to add the sub awardee’s UEI to the contract for all future amendments and new contracts is implemented by August 1, 2026.
The Center for Advanced Defense Studies (C4ADS) acknowledges the finding related to disbursement approvals and the instance where required pre-disbursement authorization was not documented in the system. Existing C4ADS policy requires the approval of the budget manager before finance team approval o...
The Center for Advanced Defense Studies (C4ADS) acknowledges the finding related to disbursement approvals and the instance where required pre-disbursement authorization was not documented in the system. Existing C4ADS policy requires the approval of the budget manager before finance team approval on all credit card transactions — this sequence ensures that someone with operational authority verifies necessity and project relevance before charges are recorded. The accounting manager, as the administrator of the credit card online portal, has the ability to override/approve out of sequence with approval from the Senior Director of Operations. Due to staff turnover, the accounting manager inadvertently approved a charge out of cycle. Divvy does not permit retroactive correction of approval order and the accounting manager failed to appropriately document the event. As a result of this finding, C4ADS has implemented the following corrective actions: ● Strengthen Approval Controls: C4ADS added an additional review step where the Director of Finance and the Senior Director of Operations review all credit card charges to ensure all charges have two approvers. In cases where the charge has one approver, the Director of Finance confirms with the Senior Director of Operations that the final coding is appropriate prior month ending billing and month end reporting. ● Enhance Documentation and Monitoring: To demonstrate review, the Director of Finance communicates any anomalies to the Senior Director of Operations via Monday.com, C4ADS’ online ticket and tracking system. The Senior Director of Operations approval, or rejection, is logged in that system. ● Staff Training and Reinforcement: Additional training has been provided to the accounting department related to the approval override system and the appropriate documentation. These measures have been implemented and incorporated into ongoing financial processes to ensure all disbursements are properly authorized and documented.
2025-004 Uniform Guidance Audit Submission CONTACT PERSON: Cing Huai, Treasurer ANTICIPATED COMPLETION DATE: June 30, 2027 VIEW OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a...
2025-004 Uniform Guidance Audit Submission CONTACT PERSON: Cing Huai, Treasurer ANTICIPATED COMPLETION DATE: June 30, 2027 VIEW OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The City will work to develop and adopt controls to ensure that the year-end financial statements are prepared in a timely manner so as to facilitate a timely audit submission as set forth in the Uniform Guidance.
Finding No.: 2025-003 Condition: During our testing of expenditures submitted for reimbursement under the Special Education Grant, we noted that expenditures included in reimbursement requests were difficult to reconcile to supporting documentation and the District's accounting records. Specifically...
Finding No.: 2025-003 Condition: During our testing of expenditures submitted for reimbursement under the Special Education Grant, we noted that expenditures included in reimbursement requests were difficult to reconcile to supporting documentation and the District's accounting records. Specifically, amounts recorded within the general ledger for certain purchased services and supplies and materials expenditures were incomplete and could not independently support the amounts claimed for reimbursement. District personnel were required to provide additional grant tracking schedules and other supporting records to reconcile the expenditures reported for reimbursement. Plan: Management agrees with the finding and will strengthen grant tracking and reconciliation procedures to ensure expenditures submitted for reimbursement are fully supported, accurately recorded in the general ledger, and readily traceable to the underlying documentation. Anticipated Date of Completion: 6/30/2027 Name of Contact Person: Scott, Assistant Superintendent for Business Services/CSBO Management Response: N/A
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