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Corrective Action Plans

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Finding 1154893 (2024-005)
Material Weakness 2024
Southwest Health and Human Services
MN
Questioned Costs Allowable Costs / Cost Principles Reporting § 200.303
Finding Number: 2024-005 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer T...
Finding Number: 2024-005 Finding Title: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Reporting Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to review report instructions regularly, accurately identify appropriate eligible revenue and expenditures for each report and review for accuracy by implementing secondary review of the data that is being reported as well as resubmit any report corrections timely. An improved process has been implemented for verifying FTE payroll splits and verifying staff time is allocated to the appropriate program. Anticipated Completion Date: October 31, 2025
View Audit 367223 Questioned Costs: $1
Finding 1154892 (2024-006)
Material Weakness 2024
Southwest Health and Human Services
MN
Eligibility Material Weakness Internal Control / Segregation of Duties § 200.303
Finding Number: 2024-006 Finding Title: Eligibility – MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Actio...
Finding Number: 2024-006 Finding Title: Eligibility – MAXIS Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Kathryn Herding – Eligibility Supervisor Corey Remiger – Eligibility Supervisor Ashley VanOverbeke- Eligibility Supervisor Corrective Action Planned: The planned corrective action is to continue reminding and reviewing with staff on a regular basis and at unit meetings the need to utilize checklists with all applications and renewals so all required documentation is on file, verify income and asset requirements, and complete case transfers correctly. Supervisors and/or Lead Workers will also complete case reviews for accuracy. Anticipated Completion Date: November 30, 2025
View Audit 367223
Finding 1154890 (2024-004)
Material Weakness 2024
Southwest Health and Human Services
MN
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.303
Finding Number: 2024-004 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.563 Child Support Services Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – ...
Finding Number: 2024-004 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 93.563 Child Support Services Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to review report instructions regularly, accurately identify appropriate eligible revenue and expenditures for each report and review for accuracy by implementing secondary review of the data that is being reported as well as resubmit any report corrections timely. An improved process has been implemented for verifying FTE payroll splits and verifying staff time is allocated to the appropriate program. Anticipated Completion Date: October 31, 2025
View Audit 367223
Finding 1154888 (2024-003)
Material Weakness 2024
Southwest Health and Human Services
MN
Procurement, Suspension & Debarment § 200.303 § 200.318 § 200.319 § 200.324
Finding Number: 2024-003 Finding Title: Procurement, Suspension, and Debarment Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson...
Finding Number: 2024-003 Finding Title: Procurement, Suspension, and Debarment Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to improve and update the agency guidelines and policy for procurement and implement a process with supporting documentation that ensures federal requirements are met. Anticipated Completion Date: November 30, 2025
View Audit 367223
Finding 1154887 (2024-002)
Material Weakness 2024
Southwest Health and Human Services
MN
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties § 200.303
Finding Number: 2024-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Busin...
Finding Number: 2024-002 Finding Title: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Program: 10.561 State Administrative Matching Grants for the Supplemental Nutrition Assistance Program Name of Contact Person Responsible for Corrective Action: Lisa DeBoer – Director of Business Management Jenny Severson – Fiscal Officer Tiffany Bailey – Fiscal Officer Corrective Action Planned: The planned corrective action is to review report instructions regularly, accurately identify appropriate eligible revenue and expenditures for each report and review for accuracy by implementing secondary review of the data that is being reported as well as resubmit any report corrections timely. An improved process has been implemented for verifying FTE payroll splits and verifying staff time is allocated to the appropriate program. Anticipated Completion Date: October 31, 2025
View Audit 367223
Finding 1154886 (2024-003)
Material Weakness 2024
Silver Lake Regional School District
MA
Corrective Action Taken:The District is working to meet filing deadlines in the future.
Corrective Action Taken:The District is working to meet filing deadlines in the future.
View Audit 367221
Finding 1154885 (2024-002)
Material Weakness 2024
Silver Lake Regional School District
MA
Subrecipient Monitoring Internal Control / Segregation of Duties HUD Housing Programs
Corrective Action Taken:Although the Business Office has created a Federal Grants Compliance Manual, we are unable to follow the manual with fidelity due to the lack of adequate staffing. The District will continue to request additional staff during the next budget cycle.
Corrective Action Taken:Although the Business Office has created a Federal Grants Compliance Manual, we are unable to follow the manual with fidelity due to the lack of adequate staffing. The District will continue to request additional staff during the next budget cycle.
View Audit 367221
Finding 1154884 (2024-001)
Material Weakness 2024
Kaukauna Housing Authority
WI
Internal Control / Segregation of Duties Reporting
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size.
View Audit 367218
Finding 1154883 (2024-006)
Material Weakness 2024
Durham Public Schools
NC
Subrecipient Monitoring Cash Management Material Weakness
Contact Person: Jeremy Teetor, Chief Financial Officer Corrective Action Plan: The Board of Education will implement controls and procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to kee...
Contact Person: Jeremy Teetor, Chief Financial Officer Corrective Action Plan: The Board of Education will implement controls and procedures to ensure that all bank account and other required reconciliations are prepared on a timely basis going forward. The Finance department will also strive to keep key positions filled at all times and ensure that staff receives appropriate training regarding reconciliations. Proposed Completetion Date: Immediately
View Audit 367217
Finding 1154867 (2024-005)
Material Weakness 2024
Toledo Area Regional Transit Authority
OH
Procurement, Suspension & Debarment
Condition: There was no evidence to support that the Authority performed procedures to verify that the vendors were not suspended, debarred, or otherwise excluded prior to entering into contracts for 18 contracts within our testing population. Planned Corrective Action: Effective 6/1/2025, TARTA imp...
Condition: There was no evidence to support that the Authority performed procedures to verify that the vendors were not suspended, debarred, or otherwise excluded prior to entering into contracts for 18 contracts within our testing population. Planned Corrective Action: Effective 6/1/2025, TARTA implemented a new ERP system that will allow us to indicate and upload verification that a vendor was checked for suspension, debarment, or exclusions prior to entering into a contract in accordance with 2 CFR 180.300, going forward. Contact person responsible for corrective action: James Karasek Anticipated Completion Date: 6/1/2025
View Audit 367202
Finding 1154866 (2024-004)
Material Weakness 2024
Toledo Area Regional Transit Authority
OH
Questioned Costs Cash Management Material Weakness § 200.305
Condition: During our testing, we identified one reimbursement request that included a check that was not paid as it was voided and paid with a subsequent check, which was also requested for reimbursement. Planned Corrective Action: Effective 6/1/2025, TARTA implemented a new ERP system that will al...
Condition: During our testing, we identified one reimbursement request that included a check that was not paid as it was voided and paid with a subsequent check, which was also requested for reimbursement. Planned Corrective Action: Effective 6/1/2025, TARTA implemented a new ERP system that will allow us to electronically control, accumulated, and monitor all transaction related to our grant draws in accordance with 2 CFR 200.305 going forward. Contact person responsible for corrective action: James Karasek Anticipated Completion Date: 6/1/2025
View Audit 367202 Questioned Costs: $1
Finding 1154865 (2024-003)
Material Weakness 2024
Toledo Area Regional Transit Authority
OH
Questioned Costs Procurement, Suspension & Debarment § 200.32 § 200.320
Condition: During our testing, we identified two contracts that did not have adequate documentation to support the basis for the contract price. Planned Corrective Action: Effective 6/1/2025, TARTA implemented a new ERP system that will allow us to electronically control and verify all purchases in ...
Condition: During our testing, we identified two contracts that did not have adequate documentation to support the basis for the contract price. Planned Corrective Action: Effective 6/1/2025, TARTA implemented a new ERP system that will allow us to electronically control and verify all purchases in accordance with 2 CFR 200.32 standards for acceptable methods of procurement going forward. Contact person responsible for corrective action: James Karasek Anticipated Completion Date: 6/1/2025
View Audit 367202 Questioned Costs: $1
Finding 1154861 (2024-003)
Material Weakness 2024
Housing Authority of Trempealeau County
WI
Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking Eligibility § 200.303
Comments on findings and recommendations The organization concurs with the finding and the auditor’s recommendation. We agree that implementing an independent review process will strengthen accuracy and compliance with Rural Development requirements. Actions taken or planned The organization will as...
Comments on findings and recommendations The organization concurs with the finding and the auditor’s recommendation. We agree that implementing an independent review process will strengthen accuracy and compliance with Rural Development requirements. Actions taken or planned The organization will assign preparation and review of RD Form 3560-8 and HUD Form 50058 to different staff members. Anticipated completion date September 30, 2025
View Audit 367201
Finding 1154860 (2024-002)
Material Weakness 2024
Housing Authority of Trempealeau County
WI
Internal Control / Segregation of Duties
Comments on findings and recommendations The organization concurs with the finding and the auditor’s recommendation. Actions taken or planned The Board of Commissioners and management have reviewed the current duties of the Authority staff and segregated as much as possible with limited staff. Addit...
Comments on findings and recommendations The organization concurs with the finding and the auditor’s recommendation. Actions taken or planned The Board of Commissioners and management have reviewed the current duties of the Authority staff and segregated as much as possible with limited staff. Additionally, the Authority contracts with a 3rd party fee accountant to reconcile the bank statements monthly ( in addition to the Executive Director). The Board of Commissioners receives and reviews the monthly disbursement listing. The Board of Commissioners will continue to monitor rental and cash flow activities reported by accounting personnel monthly. Anticipated completion date September 30, 2025
View Audit 367201
Finding 1154851 (2024-001)
Material Weakness 2024
Hawaii Good Food Alliance
HI
Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.430
Effective January 1, 2025, employees are required to complete a monthly Personnel Activity Report (PAR) where the employees document the percentage of time they spent for each grant/program during the month with a brief description of the work performed for each project. The completed form is signed...
Effective January 1, 2025, employees are required to complete a monthly Personnel Activity Report (PAR) where the employees document the percentage of time they spent for each grant/program during the month with a brief description of the work performed for each project. The completed form is signed by the employee and their supervisor, then retained for our records. Effective September 1, 2025, monthly PARs will include contemporaneous certification by the employee that the distribution of hours worked is correct.
View Audit 367196
Finding 1154850 (2024-001)
Material Weakness 2024
City of Cheney
WA
Questioned Costs Reporting Matching / Level of Effort / Earmarking
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Cheney January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 20...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE City of Cheney January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the City for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2024-001 Finding caption: The City did not have adequate internal controls for ensuring compliance with federal allowable costs, matching and reporting requirements, and it did not comply with federal allowable costs and matching requirements. Name, address, and telephone of City contact person: Cindy Niemeier, Finance Director 609 2nd Street Cheney, WA 99004 509-498-9215 Corrective action the auditee plans to take in response to the finding: The City of Cheney recognizes the error in classifying a grant received from the Washington State Department of Commerce as a state grant rather than a federal pass­ through grant, which makes this funding source ineligible as matching funds in the funding awarded from the Department of Reclamation. The City has contacted the Department of Reclamation federal program to disclose the error and determine the required corrective action. The City of Cheney has proposed replacing the submitted reimbursement requests with City expenses as allowable matching expenses. The City is currently waiting on the Department of Reclamation for direction. The 2024 reporting error was corrected in 2025. Future projects with multiple funding sources will continue to be managed by the individual departments. The additional internal control will require the departments to meet quarterly with Finance to conduct internal audits of the reimbursement requests and completed reporting. Anticipated date to complete the corrective action: December 31, 2025
View Audit 367195 Questioned Costs: $1
Finding 1154849 (2024-003)
Material Weakness 2024
Isaac Elementary School District No. 5
AZ
Material Weakness Reporting Equipment & Real Property Management
Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: Since July 2025 the District has implemented processes to ensure accurate...
Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: Since July 2025 the District has implemented processes to ensure accurate and timely reporting. The District finds frequent journal adjustments to be problematic and an indication of inaccurate reporting. The District’s Completion Reports will be will be timely filed and supported by the accounting data.
View Audit 367184
Finding 1154848 (2024-002)
Material Weakness 2024
Isaac Elementary School District No. 5
AZ
Allowable Costs / Cost Principles Material Weakness Reporting
Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: Since July 2025 the District has implemented processes to ensure accurate...
Program Name/Assistance Listing Title: Education Stabilization Fund Assistance Listing Number: 84.425U Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: Since July 2025 the District has implemented processes to ensure accurate and timely reporting. The District finds frequent journal adjustments to be problematic and an indication of inaccurate reporting. The District’s Annual Financial Report (AFR) will be timely filed and supported by the accounting data.
View Audit 367184
Finding 1154847 (2024-001)
Material Weakness 2024
Isaac Elementary School District No. 5
AZ
Internal Control / Segregation of Duties Allowable Costs / Cost Principles Material Weakness § 200.303
Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants to Local Educational Agencies 84.010 Education Stabilization Fund 84.425C Education Stabilization Fund 84.425D Education Stabilization Fund 84.425U Education Stabilization Fund 84.425W Contact Person: James Serbin, C...
Program Names/Assistance Listing Titles: Assistance Listing Numbers: Title I Grants to Local Educational Agencies 84.010 Education Stabilization Fund 84.425C Education Stabilization Fund 84.425D Education Stabilization Fund 84.425U Education Stabilization Fund 84.425W Contact Person: James Serbin, Chief Financial Officer Anticipated Completion Date: June 30, 2026 Planned Corrective Action: Since April 2025, Federal & State grant expenditures are verified to conform to the grant applications. Budget revisions are requested and approved before expenditures are made. After reconciling expenditures to the ADE approved grant detail, timely reimbursement requests are made. Journal entries are expected to contain adequate detail and justification and Grant personnel now report to the Business Manager and Chief Financial Officer where they receive ongoing support, training and supervision. The District intends to be in compliance with 2 CFR Part 200.303 during the 2026 fiscal year.
View Audit 367184
Finding 1154833 (2024-008)
Material Weakness 2024
El Programa Hispano Catolico
OR
Internal Control / Segregation of Duties Reporting Significant Deficiency
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. EPHC has been behind on financial statements and previously were not able to submit the semi-annual financial statements. As of June 30, 2025, the first semi-annual financial statements was submitted.
View Audit 367181
Finding 1154832 (2024-007)
Material Weakness 2024
El Programa Hispano Catolico
OR
Internal Control / Segregation of Duties Reporting Significant Deficiency
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instr...
The Director of Finance and Accounting Manager began implementing process and procedures to ensure all invoices are filed in a timely manner to funders in July 2024. The importance of understanding the requirements of the agreements has been stressed to the finance team. The team has also been instructed to save on SharePoint all communication with funders regarding changes of when invoices are to be filed when the instructions differ from the agreement. To ensure timely submission of the performance reports, EPHC will use Sales Force software to track all due dates. This system will send reminders and will record submission dates. To ensure review of all performance reports, procedures will be put in place outlining roles and responsibilities of report preparation by managers and review by Program Directors.
View Audit 367181
Finding 1154831 (2024-006)
Material Weakness 2024
El Programa Hispano Catolico
OR
Special Tests & Provisions Eligibility Significant Deficiency
EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper ...
EPHC has long term employees that joined the organization when it was a program of Catholic Charities. EPHC does not maintain these records for employees that began with Catholic Charities. In early FY2026, EHPC will complete background checks on long term employees to ensure we maintain the proper documentation.
View Audit 367181
Finding 1154830 (2024-005)
Material Weakness 2024
El Programa Hispano Catolico
OR
Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do ...
The delegates from the board did receive the 40-hour training prior to entering the board but were unable to provide certification proof. Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, Board members will prepare a memo with self-attestation of completion for our records.
View Audit 367181
Finding 1154829 (2024-004)
Material Weakness 2024
El Programa Hispano Catolico
OR
Special Tests & Provisions Significant Deficiency Internal Control / Segregation of Duties
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
Moving forward a new process of policy with record keeping guidance will be implemented to ensure the documentation is kept on file. For training courses that do not provide a completion certificate, staff will prepare a memo with self-attestation of completion for our records.
View Audit 367181
Finding 1154828 (2024-003)
Material Weakness 2024
El Programa Hispano Catolico
OR
Questioned Costs Allowable Costs / Cost Principles § 200.430
EPHC uses a third-party vendor to process payroll. This system does not have the capability to allocate salaried employees based on time spent on the program recorded in the time keeping system. Because of this, the hours worked in each program need to be converted into percentages before payroll is...
EPHC uses a third-party vendor to process payroll. This system does not have the capability to allocate salaried employees based on time spent on the program recorded in the time keeping system. Because of this, the hours worked in each program need to be converted into percentages before payroll is submitted for processing. To ensure accuracy, EPHC will have a second reviewer confirm the manual entry conversion from hours worked to percentage of time worked for salaried employees for the remaining duration of time in a third-party payroll system. Effective January 2026, EPHC will implement a new payroll system that will be processed in-house. This system has improved functionality that will eliminate the need to make this conversion and the potential for errors.
View Audit 367181 Questioned Costs: $1
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