Corrective Action Plans

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Management will review its cash management procedures to ensure that federal drawdowns are supported by actual or immediate cash needs based on expenditures incurred. Management will also closely monitor subrecipient expenditure activity and reimbursement timing to ensure compliance with 2 CFR 200.3...
Management will review its cash management procedures to ensure that federal drawdowns are supported by actual or immediate cash needs based on expenditures incurred. Management will also closely monitor subrecipient expenditure activity and reimbursement timing to ensure compliance with 2 CFR 200.305(b) and minimize the time between receipt and disbursement of federal funds.
Management will coordinate with external auditors to ensure timely completion of the audit and to ensure compliance with 2 CFR 200.512 requirements.
Management will coordinate with external auditors to ensure timely completion of the audit and to ensure compliance with 2 CFR 200.512 requirements.
The City will implement additional control procedures to ensure all reports are filed in a timely manner.
The City will implement additional control procedures to ensure all reports are filed in a timely manner.
The Lorman Waterworks Association, Inc. acknowledges the late submission of the audit report and will make it a priority. The water association will implement accurate timelines for 2026 fiscal year audit.
The Lorman Waterworks Association, Inc. acknowledges the late submission of the audit report and will make it a priority. The water association will implement accurate timelines for 2026 fiscal year audit.
Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualify...
Procurement – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization consistently follow its established policies and procedures related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • Review Contract and procurement policies and procedures. • Compare current procurement process and training to the policies and identify areas for correction and improvement. • Update Policies and procedures as needed. • Implement procedures to review vendors on a periodic basis. • Implement procedures and assign responsibility for checking off that procurement documentation exists and is in the vendor folder or designated area. • Retrain staff involved in procurement on updated procedures. • Monitor process and adjust as needed. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: January 2027
Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Explanation of disagreement with audit finding: There is no disagreement with ...
Reporting – Assistance Listing No. 93.224/93.527 Recommendation: We recommend the Organization perform a final review of amounts entered within the UDS report, as compared to the supporting schedules, prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: • Update UDS procedure to pull detail reports on all numbers reported in the UDS. • Add to the UDS procedure a review of detail reports to tie them to UDS report • Add a sign off to UDS report as part of final review that detail reports were pulled and verified. Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: July 2026
View of Responsible Officials and Corrective Action Plan WESST acknowledges this finding, remains committed to continuous improvement, and has already taken proactive, substantive corrective action. During the fiscal year under review, the organization experienced a leadership transition when a new ...
View of Responsible Officials and Corrective Action Plan WESST acknowledges this finding, remains committed to continuous improvement, and has already taken proactive, substantive corrective action. During the fiscal year under review, the organization experienced a leadership transition when a new Chief Executive Officer assumed responsibility following the departure of a CEO who had served for 33 years. At the same time, WESST faced significant and sudden changes in long-term funding sources, requiring prompt financial and operational adjustments. A significant finance department change occurred in October 2025. As noted in the Statement of Condition above, no exceptions were identified after that point. In connection with this change, WESST implemented key control processes, including: o All expenses will be reviewed for allowability, allocability, and reasonableness before being charged to the grant. o Payroll charges recorded in the general ledger will be reconciled to employee time records or approved allocation schedules each month. Variances will be investigated and corrected in a timely manner. o All changes to payroll allocations require documented justification and formal review and approval. o Monthly expense reviews will be performed by the: • Staff Accountant • Program Director • Accounting Controller o These reviews will support proper classification of direct and indirect costs and help prevent inconsistent treatment Corrective Action Plan Timeline Completed implementation in March of 2026. Designation of Employee Position Responsible for Meeting Deadline Chief Executive Officer
We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31 federal requirement. Implementation Date: During the 2026-2027 fiscal year. Responsible Person: Mrs. Yadira Pereira Nieves Finance Director
We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31 federal requirement. Implementation Date: During the 2026-2027 fiscal year. Responsible Person: Mrs. Yadira Pereira Nieves Finance Director
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient t...
Finding 2025-002 Federal Agency Name: U.S. Department of Treasury Program Name: Coronavirus State and Local Fiscal Recovery Funds FFALN # 21.027 Finding Summary: Eide Bailly LLP prepared our single audit for Federal Coronavirus State and Local Fiscal Recovery Funds where the Town is a subrecipient to Douglas County who is the recipient of the funds. Eide Bailly LLP identified that the Town did not have documented or consistently applied internal controls to ensure compliance with the County’s subrecipient guidance requiring the submission of formal special reports for ALN 21.027. Responsible Individuals: Mark Henderson, Assistant Director of Castle Rock Water Corrective Action Plan: Staff will complete quarterly reports including project progress and estimated project infrastructure costs. The reports will be reviewed by management prior to submission to the recipient of the Federal Funds (Douglas County). Anticipated Completion Date: Ongoing during the period that the Town is a subrecipient of these funds for the project.
Finding 2025-002 Procurement and Suspension and Debarment (Compliance) – 2020 Criteria The City must comply with procurement standards set out at 2 CFR sections 200.318 through 200.326 within the Uniform Guidance. Condition The City’s procurement standards do not include all the essential elements a...
Finding 2025-002 Procurement and Suspension and Debarment (Compliance) – 2020 Criteria The City must comply with procurement standards set out at 2 CFR sections 200.318 through 200.326 within the Uniform Guidance. Condition The City’s procurement standards do not include all the essential elements as outlined in 2 CFR sections 200.318 through 200.326. In addition, the City did not retain adequate documentation for verification that vendors were not suspended or debarred parties. Corrective Action Plan Although the City was performing the review, the report from the SAM.gov website being maintained by the City to document said review did not provide evidence that there were no active exclusion records. Under the direction of the Finance Director working with the Senior Buyer / Analyst, this Procurement procedure and policy have been updated and distributed to the appropriate individuals. Adherence to this policy and procedure will be monitored by the Finance Director and the Internal Auditor.
Subject: 2025 Single Audit Finding 2025-004 2025-004 Management Response: Management acknowledges the finding. DEMRS did not submit the required quarterly financial and performance reports to the Illinois Emergency Management Agency (IEMA) for the Homeland Security Grant Program during the fiscal ye...
Subject: 2025 Single Audit Finding 2025-004 2025-004 Management Response: Management acknowledges the finding. DEMRS did not submit the required quarterly financial and performance reports to the Illinois Emergency Management Agency (IEMA) for the Homeland Security Grant Program during the fiscal year. Root Cause Analysis: Over multiple years, DEMRS experienced significant turnover in key finance and grant management positions, which created gaps in continuity and delayed the department's transition to IEMA's Amplifund reporting system. As prior management departed and new staff were onboarded, the department faced operational challenges that affected the consistency of its grant reporting processes. Due to Amplifund's requirement that reimbursement requests be submitted sequentially before performance reports can be filed, the delays in prior period submissions prevented DEMRS from accessing and submitting the quarterly reports. Statewide pauses in FEMA and IEMA grant processing further contributed to the backlog. Corrective Action: DEMRS will complete and submit all outstanding reimbursement requests and performance reports for UASI 2022, UASI 2023, and UASI 2024 to bring the County into full compliance with grantor requirements. Preventive Action: DEMRS will implement a grants compliance calendar that tracks all reporting deadlines. Future reports will be prepared by the Manager of Grants & Contracts and reviewed and approved by the Associate Director of Finance, with documented evidence of review. Responsible Party: Damian Albert, Associate Director of Finance, damian.albert@cookcountyil.gov. 312.603.8177 Tina Bhaga, Manager, Grants & Contracts, tina.bhaga@cookcountyil.gov, 312.603.8543 Planned Completion Date: January 1, 2027
Memo: Cause and Corrective Action Plan for Finding 2025-003 This correspondence serves as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to Finding 2025-003. During the FY2025 Single Audit, one audit finding was identified by Washington, Pittman & McKeever, LLC...
Memo: Cause and Corrective Action Plan for Finding 2025-003 This correspondence serves as Cook County Health (CCH) and Cook County Department of Public Health (CCDPH) response to Finding 2025-003. During the FY2025 Single Audit, one audit finding was identified by Washington, Pittman & McKeever, LLC. The root cause and corrective action plan is identified below. Condition During the current audit period, the Cook County Department of Public Health (DPH) did not comply with federal regulations regarding the use and reporting of program income as it relates to funds awarded through the RWHAP Root Cause Analysis The HIV grants transitioned to CCH from an external organization in July 2025. Award amounts were granted in multiple phases, requiring four budget revisions, with the final revision approved in December 2025. The contractual period covered March 2025 through December 2025. During the transition period, CCH lacked formal operational procedures to identify, record, and track program income. Several operational and administrative challenges contributed to this issue, including: • No written internal procedures were in place to define or track program income requirements. • No formal transition teams were established to identify core grant obligations, resulting in unclear interpretation of sponsor requirements. • CCH had not yet identified the appropriate internal systems or interdepartmental collaborations necessary to retrieve and reconcile program income data. • Organizational priorities during the transition focused on maintaining existing deliverables, including vouchering, budget compliance, hiring, and onboarding of direct and administrative staff. • Staffing Shortages, CCH onboarded personnel quickly as contractual employees, direct staff transitioned onboard as CCH employees in phases upon execution of grant contracts. Corrective Action Plan CCH Director of Grants Accounting is implementing formal written processes and procedures to ensure compliance with Federal Uniform Guidance requirements related to program income. The corrective action plan includes: • Developing standardized written procedures that clearly define program income requirements and tracking responsibilities. • Establishing shared roles and responsibilities across departments to support consistent data collection, reconciliation, and reporting. • Identifying the specific data elements required to accurately record and monitor program income. • Formalizing interdepartmental collaboration processes necessary to retrieve and validate program income information. • Defining the systems and reporting tools that will be used to track and maintain program income records. • Providing staff training on program income requirements, documentation standards, and compliance expectations. These actions will strengthen internal controls and ensure timely, accurate identification and tracking of program income moving forward, official approval/implementation is expected December 2026
Re: FY2025 Single Audit Finding 2025-002 In respect to 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Section 200.332, it was brought to my attention that the County performed inadequate monitoring of its subrecipients funded through ...
Re: FY2025 Single Audit Finding 2025-002 In respect to 2 CFR Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Section 200.332, it was brought to my attention that the County performed inadequate monitoring of its subrecipients funded through Coronavirus State and Local Fiscal Recovery Funds (SLFRF), as required by its internal policies. Below is the corrective action plan to address the finding. Each County department that issues sub-recipient agreements is responsible for the day-to-day monitoring of their respective SLFRF subrecipients, including reviewing financial and programmatic reports and ensuring compliance with the federal and County requirements. The Bureau of Finance (BOF) also been overseeing the monitoring of subrecipients in order to help identify potential compliance issues. Compliance Oversight and Technical Support (COTS) under the Bureau of Finance coordinates and conducts an annual review of each SLFRF programs and assesses all subrecipients or vendor relationships to ensure compliance across the County. The COTS process has helped the County address inadequate monitoring and compliance concerns. Most of the County s subrecipient activities are scheduled to conclude in September 2026 and the end of the SLFRF programmatic performance period is nearing. As such, the County has started the closeout preparation for both County departments and their subrecipients. The process includes: Communication of the closeout procedures including required documentation of monitoring activities Confirmation of receipts of financial reports and the supporting documents such as proof of payments Expenditure reconciliations between the County s financial system and ARPA grants management system Confirmation of all monitoring logs and programmatic reports submission It is expected the final COTS review to be completed by the end of the fiscal year and we believe these measures will mitigate and address any future instances of inadequate monitoring identified in the current finding 2025-002.
Re: Home Investment Partnerships Program (HOME), Federal Assistance Listing #14.239 County Department Department of Planning and Development (DPD) Finding 2025 001 Cause: Post Pandemic allocations to the County included several housing related fundings and initiatives, including Emergency Rental Ass...
Re: Home Investment Partnerships Program (HOME), Federal Assistance Listing #14.239 County Department Department of Planning and Development (DPD) Finding 2025 001 Cause: Post Pandemic allocations to the County included several housing related fundings and initiatives, including Emergency Rental Assistance I & II (ERA I& II), Homeless Sheltering, Homeless and Transitional Sheltering Physical Site Acquisition and Development, HOME ARPA (HUD Allocation), and HOME, CDBG CV development delays that challenged the Housing teams provision of services and compliance requirement. While HUD had extended post-pandemic compliance moratoriums into fiscal year 2024, Housing team hiring, training and implementation of compliance activities were unable to activate fully in the subject fiscal year to meet compliance. Team initial compliance training was implemented in FY 2025. DPD hired three additional staffers for a total of five to support compliance investigations moving forward. Corrective Action Plan: Special Test on Housing Quality Standards 1. Compliance training activities will continue to be coordinated by the Bureau's Compliance Management Team to strengthen program oversight and compliance efforts. As part of this initiative, 100% of Housing Team staff and management will receive compliance training, be qualified to perform compliance-related functions, and be assigned appropriate compliance responsibilities. a. All Housing Team staff and management will complete compliance training through HUD-sponsored virtual training or HUD-approved in-person training by November 30, 2026. b. Five of eight staffers will have hands-on site qualifications demonstrated by task and verified by management by November 30, 2026. 2. Required compliance planning for HOME programs will be completed by September 30, 2026. a. Plan will be reviewed and approved by Deputy Director and submitted to the Director by September 30, 2026. b. Initial site inspection appointments will be completed by October 31, 2026 c. Initial site physical inspections will commence by November 30, 2026. 3. Deputy Director will ensure that compliance site investigations and on-site file review will be completed by May 31, 2027. a. All reporting for respective site investigations shall be filed by above date b. All required communication to developer/owner teams shall be completed, mail and confirmation receipt by above date. Subrecipient Monitoring The department classified costs as subrecipient expenditures but should have classified as developer costs. Developer costs are not subject to subrecipient monitoring requirements under the Uniform Guidance. Therefore, the corrective action will be to assign a unique account code to address the finding where subrecipient monitoring will no longer apply. Grants Finance Manager will work with the Bureau of Finance to assign a unique account code by July 31, 2026. Endorsed By: Susan M. Campbell, Director
Material Weakness in Internal Control Over Financial Reporting The Agency’s year-end financial reporting controls did not detect and correct a material misstatement related to client assistance pass-through funding prior to the commencement of audit procedures. The misstatement related, in part, to ...
Material Weakness in Internal Control Over Financial Reporting The Agency’s year-end financial reporting controls did not detect and correct a material misstatement related to client assistance pass-through funding prior to the commencement of audit procedures. The misstatement related, in part, to the year-end confirmation and reconciliation process with State pass-through agencies. As a result, a material audit adjustment was required to properly state the financial statements in accordance with accounting principles generally accepted in the United States of America (GAAP). Management concurs with the finding. CAANH terminated its fiduciary services contract with NOI in 2025 and engaged CohnReznick with a start date of October 1, 2025, as its new fiduciary services provider. Management will continue to ensure that all year-end financial reporting, account reconciliations, and confirmation processes are completed in a timely manner. In addition, management will verify that all financial transactions are accurately recorded and reviewed prior to the commencement of the annual audit to support complete, accurate, and timely financial reporting. Amos Smith, President & CEO Will be in operation for all future audit periods.
Identify a new Auditing firm with proven experience working with FQHCs and their unique compliance requirements and revenue sources. Hire consultant to oversee the Audit process Engage Hough Consults to serve as the Interim CFO in response to the resignation of previous finance consultant. This cons...
Identify a new Auditing firm with proven experience working with FQHCs and their unique compliance requirements and revenue sources. Hire consultant to oversee the Audit process Engage Hough Consults to serve as the Interim CFO in response to the resignation of previous finance consultant. This consultant will review and address finance/Grants compliance gaps, review policies, create audit compliant month end workflows, oversee hiring of financial team. Hough Consults to train new finance team which includes the permanent CFO, accounts payable staff and NH executive team on new policies and procedures. Audit, Tax filing and Grant deadlines to be tracked by the VP/CFO
The Housing Authority has addressed the staffing levels for the program and is working with HUD to secure reimbursements for under funded HAP remittances. Additionally, the Authority is working with HUD to utilize reserve funds to alleviate the issue.
The Housing Authority has addressed the staffing levels for the program and is working with HUD to secure reimbursements for under funded HAP remittances. Additionally, the Authority is working with HUD to utilize reserve funds to alleviate the issue.
Finding 1222774 (2025-003)
Material Weakness 2025
Material Audit Adjustments
Material Audit Adjustments
Finding 1222774 (2025-003)
Material Weakness 2025
Recommendation: We recommend the City review its year-end close procedures to make sure that all balance sheet accounts are reviewed for the correct balance before final numbers are presented.
Recommendation: We recommend the City review its year-end close procedures to make sure that all balance sheet accounts are reviewed for the correct balance before final numbers are presented.
Finding 1222774 (2025-003)
Material Weakness 2025
Management’s Response and Actions Planned: The City will review its year-end close procedures to insure all balance sheet accounts have been reviewed and reconciled to the trial balance.
Management’s Response and Actions Planned: The City will review its year-end close procedures to insure all balance sheet accounts have been reviewed and reconciled to the trial balance.
Finding 1222773 (2025-002)
Material Weakness 2025
Preparation of Financial Statements and Related Footnotes
Preparation of Financial Statements and Related Footnotes
Finding 1222773 (2025-002)
Material Weakness 2025
Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.
Recommendation: This control deficiency is not unusual in a small city. However, it is the responsibility of management and the Council to decide whether to accept the degree of risk associated with this condition based on the cost of correction and other considerations.
Finding 1222773 (2025-002)
Material Weakness 2025
Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal e...
Management’s Response and Actions Planned: The City’s management is aware of this significant deficiency. Management reviews and approves the draft annual audited financial statements and distributes them to the users. For entities of this size, it generally is not practical to obtain the internal expertise needed to handle all aspects of the external financial reporting. Management recognizes this and feels it is effectively handling its reporting responsibilities with the procedures described above.
Finding 1222772 (2025-001)
Material Weakness 2025
Segregation of Duties
Segregation of Duties
Finding 1222772 (2025-001)
Material Weakness 2025
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties...
Recommendation: While we recognize the City’s office staff is not large enough to permit an adequate segregation of duties in all respects for an effective internal control structure, it is important that the City be aware of this condition and look for opportunities to improve segregation of duties or add mitigating controls to prevent material misstatement of the financial statements.
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