Corrective Action Plans

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September 15, 2025 Cognizant or Oversight Agency for Audit Combined Community Action, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent certified public accounting firm: Jarred, Gilmore & Phillips, PA, P.O. Box 779, 1...
September 15, 2025 Cognizant or Oversight Agency for Audit Combined Community Action, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2024. Name and address of independent certified public accounting firm: Jarred, Gilmore & Phillips, PA, P.O. Box 779, 1815 S Santa Fe, Chanute, Kansas 66720. Audit period: Year ended December 31, 2024. The findings from the September 15, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Finding: 2024-001: Noncompliance with Tri-Partite Board Composition Requirements Auditor’s Recommendation: The Organization should implement procedures to ensure that vacancies in the tri-partite board are filled in a timely manner so that compliance with board composition requirements is continuously maintained. Views of responsible officials and planned corrective action: In April 2025, the Organization appointed a new board member representing the low-income sector, restoring compliance with the tri-partite board composition requirement. The State of Texas, as the pass-through entity, accepted the Organization’s corrective action plan and deemed the matter resolved. If the Oversight Agency for Audit has questions regarding this plan, please call Kelly Franke, Executive Director, at (979) 540-2980. Sincerely, Combined Community Action, Inc. Combined Community Action, Inc.
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Angela Eck Contact Phone Number and Email Address: 260-868-5200, clerktreasurer@cityofbutler.in.gov Views of Responsible Officials: “We concur ...
FINDING 2024-002 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Reporting Contact Person Responsible for Corrective Action: Angela Eck Contact Phone Number and Email Address: 260-868-5200, clerktreasurer@cityofbutler.in.gov Views of Responsible Officials: “We concur with the finding” Mike Hartman, Mayor Angela M. Eck, Clerk-Treasurer Donald Stuckey, Attorney 215 S Broadway, Butler, IN 46721 260-868-5200 Main Line 260-868-5882 Fax www.butler.in.us INDIANA STATE BOARD OF ACCOUNTS 19 The City of Butler is an Equal Opportunity Provider. Explanation and Reasons for Disagreement: Not applicable Description of Corrective Action Plan: The Clerk-Treasurer will put the existing checklist for federal reporting in the year end binder and specifically mention it on the year end checklist so that it is not forgotten. Anticipated Completion Date: It has been completed as of August 18, 2025.
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Angela Eck Contact Phone Number and Email Address: 260-868-5200, clerktreasurer@cityofbutler.in.gov Views of Responsible Officia...
FINDING 2024-001 Finding Subject: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds – Suspension and Debarment Contact Person Responsible for Corrective Action: Angela Eck Contact Phone Number and Email Address: 260-868-5200, clerktreasurer@cityofbutler.in.gov Views of Responsible Officials: “We concur with the finding.” Explanation and Reasons for Disagreement: Not applicable Description of Corrective Action Plan: The Clerk-Treasurer will meet with the Mayor and Department Heads to ensure that they provide the Clerk- Treasurer’s Office time to verify that a potential vendor or contractor is not suspended, debarred or otherwise excluded from receiving federal funds. The Clerk-Treasurer will also create a form for this purpose and follow it for all contracts or purchases that are over $25,000. This will apply to all future federal projects. Anticipated Completion Date: The Clerk-Treasurer will meet with the Mayor and Department Heads before October 1, 2025. A form will be created by November 1, 2025.
Finding 2024-001 Department of Homeland Security and Emergency Management Federal Financial Assistance Listing 97.036 Disaster Grant Public Assistance Allowable Costs/ Activities Allowed or Unallowed Material Weakness in Internal Control over Compliance Finding Summary: In the testing of allowable c...
Finding 2024-001 Department of Homeland Security and Emergency Management Federal Financial Assistance Listing 97.036 Disaster Grant Public Assistance Allowable Costs/ Activities Allowed or Unallowed Material Weakness in Internal Control over Compliance Finding Summary: In the testing of allowable costs and activities, there were instances noted where payroll expenditures were paid by the Cooperative at the correct wage rates, but federal reimbursement for hours worked was calculated using the incorrect wage rates. Responsible Individuals: Jodi Bullinger, Troy Knutson, and Andy Weiss Corrective Action Plan: The Cooperative will perform a thorough review and reconciliation of supporting documentation for expenditures, including payroll transactions, before amounts are claimed for reimbursement. Anticipated Completion Date: December 31, 2025
Federal Agency: Department of Health and Human Services Federal Program Name: Healthy Start Communities Assistance Listing Number: 93.926 Federal Award Identification Number and Year: H4900052 Award Period: 4/1/2023-6/30/24 Type of Finding: • Significant Deficiency in Internal Control over Complianc...
Federal Agency: Department of Health and Human Services Federal Program Name: Healthy Start Communities Assistance Listing Number: 93.926 Federal Award Identification Number and Year: H4900052 Award Period: 4/1/2023-6/30/24 Type of Finding: • Significant Deficiency in Internal Control over Compliance Criteria or specific requirement: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Award requires compliance with the provisions of procurement, suspension, and debarment. EveryStep should have internal controls designed to ensure compliance with those provisions. Condition: During our testing, we noted EveryStep did not have adequate internal controls designed to ensure vendors were not suspended or debarred. Questioned costs: None Context: During our testing, it was noted that EveryStep was not reviewing vendors prior to entering into a contract with a vendor to ensure the vendor was not on the suspended or debarred vendor list maintained by the General Services Administration. Cause: EveryStep was unaware the contractors were not being reviewed to ensure they were not suspended or debarred. Effect: The auditor noted no instances of noncompliance with the provisions of procurement, suspension, and debarment; however, the lack of internal controls over these compliance requirements provides an opportunity for noncompliance. Repeat Finding: No. Recommendation: We recommend EveryStep design controls to ensure an adequate review process is in place to review potential contractors to determine they are not suspended or debarred. Views of responsible officials: There is no disagreement with the audit finding.
#2024-004 Written Uniform Guidance Policies Responsible Individual: Terry Wolterstorff, General Manager Corrective Action Plan: The District intends to develop written Uniform Guidance policies. Anticipated Completion Date: 2025
#2024-004 Written Uniform Guidance Policies Responsible Individual: Terry Wolterstorff, General Manager Corrective Action Plan: The District intends to develop written Uniform Guidance policies. Anticipated Completion Date: 2025
#2024-002 Finding: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individual: Terry Wolterstorff, General Manager Corrective Action Plan: At this time, the District will accept the degree of risk associated with this condition. For future audits, we...
#2024-002 Finding: Financial Statement and Schedule of Expenditures of Federal Awards (SEFA) Preparation Responsible Individual: Terry Wolterstorff, General Manager Corrective Action Plan: At this time, the District will accept the degree of risk associated with this condition. For future audits, we will continue to review the financial statements and SEFA in detail and agree to internal records and expectations. Anticipated Completion Date: Ongoing
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pacific Transit System January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the Transit for findings reported in this report in accordance with Title 2 U.S. Code of Federal Regulations (C...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Pacific Transit System January 1, 2024 through December 31, 2024 This schedule presents the corrective action planned by the Transit 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 Transit did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of Transit contact person: Mike Williams, Clerk of the Board PO Box 489, Raymond, WA 98577 (360) 875-9418 Corrective action the auditee plans to take in response to the finding: (If the auditee does not concur with the finding, the auditee must list the reasons for non-concurrence). Pacific Transit will confirm all vendors selected for purchases of $25,000 or more are registered with SAM.gov and are not suspended or debarred from doing business with the federal government. Anticipated date to complete the corrective action: September 17, 2025
Corrective action plan: The Finance Department will begin close out work on the year under audit as soon as the year ends, so that all accounts including expenditures will be accurately adjusted before the SEFA is prepared. Finance will verify all Assistance Listing Numbers on the SEFA. Once the SEF...
Corrective action plan: The Finance Department will begin close out work on the year under audit as soon as the year ends, so that all accounts including expenditures will be accurately adjusted before the SEFA is prepared. Finance will verify all Assistance Listing Numbers on the SEFA. Once the SEFA is prepared, it will be independently reviewed by a contracted CPA before submitting the SEFA to the auditor. Personnel responsible for corrective action: Lisa Donham (Finance Manager) and contracted CPA consultant. Estimated corrective action completion date: March 31, 2026
Corrective action plan: Management believes that the procurement process has improved considerably. Managers are following the procurement policy by making price comparisons and submitting quotes when required. Approvals for larger purchases are obtained by Resolution from Council. The Finance Manag...
Corrective action plan: Management believes that the procurement process has improved considerably. Managers are following the procurement policy by making price comparisons and submitting quotes when required. Approvals for larger purchases are obtained by Resolution from Council. The Finance Manager and the Accounts Payable Clerk monitor the documents submitted with purchase requests to ensure that the required documents have been submitted. Management believes that it is an isolated instance where a transaction lacked procurement documentation. Personnel responsible for corrective action: Lisa Donham (Finance Manager), Deidre Moyle (Accounts Payable), and Program Managers. Estimated corrective action completion date: December 31, 2025
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that organization improve grant tracking. Explanation of disagreement with audit finding: There is no disagreeme...
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that organization improve grant tracking. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In 2025, ACS is using a grant expenditure trackers for all grants to track spending. Name(s) of the contact person(s) responsible for corrective action: Nasreen Sajady Planned completion date for corrective action plan: This began in late 2024.
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends the Organization to review the various requirements involved with procurement requirements with the individuals ...
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends the Organization to review the various requirements involved with procurement requirements with the individuals involved in this process to ensure they understand the requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: ACS will follow the procurement policy and get a minimum of 3 quotes for purchases over ten thousand dollars when applicable. Name(s) of the contact person(s) responsible for corrective action: Nasreen Sajady Planned completion date for corrective action plan: September 2025
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that ACS review all participant files to ensure proper documentation is retained supporting the eligibility of a...
Rehabilitation for Survivors of Torture in Minnesota/Ethnic Community Self- Help Program; Refugee and Entrant Assistance – Assistance Listing No. 93.576 Recommendation: Auditor recommends that ACS review all participant files to ensure proper documentation is retained supporting the eligibility of applicants. We noted that there is currently a process in place to review files to ensure that only eligible participants are being served, but we recommend that a process is implemented and documented to ensure that there is proper review and approval of all applicants prior to the individual receiving services and that this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This will be grant dependent as many of the grant's ACS has the grantors retain the documentation and do a secondary review of eligibility. The Self-Help grant is a grant that is direct to the organization, and two people will review and document on the participation form they have reviewed the eligibility of the participants. Name(s) of the contact person(s) responsible for corrective action: Nasreen Sajady Planned completion date for corrective action plan: This will begin September 2025 and continue for the remainder of the programs needing a secondary review.
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Rome Mall Apartments agrees with the audi...
Finding #2024-001 Current Year Reporting Package and Data Collection Not Filed Timely: Recommendation: We recommend that management implement procedures to ensure that reporting packages and data collection forms are filed timely in the future. Action taken: Rome Mall Apartments agrees with the auditor’s recommendations and will implement procedures to ensure timely filing in the future. For questions regarding this corrective action plan, please contact Kyle Lyskawa, Chief Financial Officer, at (315) 424-1821.
Finding 2024-001 - Controls over submitted reimbursement invoices Recommendation: Tracking and cross-referencing payment reimbursement requests already submitted to the County and State would prevent re-submitting invoices. Action taken: The Authority will begin tracking reimbursement requests in gr...
Finding 2024-001 - Controls over submitted reimbursement invoices Recommendation: Tracking and cross-referencing payment reimbursement requests already submitted to the County and State would prevent re-submitting invoices. Action taken: The Authority will begin tracking reimbursement requests in greater detail
Management will review any future entries of this nature with care.
Management will review any future entries of this nature with care.
Finding Number: 2024-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Britt See-Benes, City Administrator and Sherry Erickson, Finance Director Corrective Action Planned The City Administrator and Finance Director will attempt to monitor transactions ...
Finding Number: 2024-001 Finding Title: SEGREGATION OF DUTIES Name of Contact Person Responsible for Corrective Action Britt See-Benes, City Administrator and Sherry Erickson, Finance Director Corrective Action Planned The City Administrator and Finance Director will attempt to monitor transactions and restructure the duties of office personnel to help ensure as much segregation of duties as possible within the City’s staffing limitations and funding constraints. Anticipated Completion Date Ongoing.
U.S. Department of Housing and Urban Development – CFDA 14.228 Condition: The County charged payroll costs using an internal allocation method that included salaries, benefits, and supplies, rather than actual expenditures. This method was not supported by an approved cost allocation plan. Additiona...
U.S. Department of Housing and Urban Development – CFDA 14.228 Condition: The County charged payroll costs using an internal allocation method that included salaries, benefits, and supplies, rather than actual expenditures. This method was not supported by an approved cost allocation plan. Additionally, the hours charged were based on total grant administration time, not specific to the CDBG program. Recommendation: The County should ensure that all costs charged to federal programs are based on actual expenditures or an approved cost allocation plan. Documentation should be maintained to support all reported costs, and internal controls should be strengthened to prevent reliance on unsupported methodologies. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will not be applying for any CDBG grants in the future unless there is adequate administrative cost allocation in the grant. The County will continue to make every effort to adequately close out CDBG grants and provide reports to the granting organization as staff and priorities allow. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for corrective action plan: Completed and on-going
View Audit 366553 Questioned Costs: $1
Federal program title: Community Development Block Grant – CFDA 14.228 Condition: During our test of the reporting requirements for Community Development Block Grant program, we determined that the County did not submit the required reports under Reporting of the Compliance Supplement. Recommendatio...
Federal program title: Community Development Block Grant – CFDA 14.228 Condition: During our test of the reporting requirements for Community Development Block Grant program, we determined that the County did not submit the required reports under Reporting of the Compliance Supplement. Recommendation: CLA recommends the County develop procedures, such as a reporting checklist to ensure that reporting requirements are tracked and met. Additionally, CLA recommends that the County perform cross training with employees to ensure that knowledge is shared among the team members. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The County will not be applying for any CDBG grants in the future unless there is adequate administrative cost allocation in the grant. The County will continue to make every effort to adequately close out CDBG grants and provide reports to the granting organization as staff and priorities allow. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins Planned completion date for corrective action plan: Completed and on-going
Federal program title - Highway Planning and Construction Program – CFDA 20.205 Recommendation: We recommend that management enhance the procurement controls to ensure that all required parties are reviewed for suspension and debarment prior to entering the transaction. Explanation of disagreement w...
Federal program title - Highway Planning and Construction Program – CFDA 20.205 Recommendation: We recommend that management enhance the procurement controls to ensure that all required parties are reviewed for suspension and debarment prior to entering the transaction. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Locally well-known and established area contractors had not always been checked for Debarment and Suspension verification. Contractors that the Department had not previously worked with were typically verified. All construction contracts entered into with the Trinity County Department of Transportation include a “Debarment and Suspension Certification” form (example attached), which requires signature of the contractor stating that they are not Debarred or Suspended. However, County staff will begin confirming agency eligibility through the System for Award Management (SAM) in future years. Name(s) of the contact person(s) responsible for corrective action: Lisa McNeely Department of Transportation Business Manager Planned completion date for correcting action plan: Completed
Local Assistance and Tribal Consistency Fund program (LATCF) - CFDA 21.032 Recommendation: We recommend the County refine its understanding and interpretation of the standards and ensure that the County policies and procedures are consistent with that understanding and interpretation. Explanation of...
Local Assistance and Tribal Consistency Fund program (LATCF) - CFDA 21.032 Recommendation: We recommend the County refine its understanding and interpretation of the standards and ensure that the County policies and procedures are consistent with that understanding and interpretation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We found this was due to timing of approvals that had to be taken to the board, and a misunderstanding/interpretation of the requirements. Noted for future reporting years. Name(s) of the contact person(s) responsible for corrective action: Christine Gaffney Auditor-Controller and Lisa McNeely Department of Transportation Business Manager. Planned completion date for correcting action plan: Completed
Federal program title - Local Assistance and Tribal Consistency Fund program (LATCF) CFDA 21.032 Recommendation: We recommend the County refine its understanding and interpretation of the standards and ensure that the County policies and procedures are consistent with that understanding and interpre...
Federal program title - Local Assistance and Tribal Consistency Fund program (LATCF) CFDA 21.032 Recommendation: We recommend the County refine its understanding and interpretation of the standards and ensure that the County policies and procedures are consistent with that understanding and interpretation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The LATCF funds were reported on the SEFA under CFDA 21.032 by the CAO’s department because the funds were transferred from the CAO’s fund to the DOT fund, with the understanding it would be expended. However, DOT did not spend the funds within the same fiscal year in which they received the transfer due to a misunderstanding that the funds could not be used for prior year expense. As a result, the funds were recorded as unearned revenue in fiscal year 2023/24, and the related expenditures will be reported in the following fiscal year. Name(s) of the contact person(s) responsible for corrective action: Lisa McNeely Department of Transportation Business Manager & Christine Gaffney Auditor-Controller. Planned completion date for correcting action plan: Completed
View Audit 366553 Questioned Costs: $1
Federal program title: Home Partnership Investment Program, and Local Assistance and Tribal Consistency Fund program CFDA 14.239, 21.032 Recommendation: We recommend that management establish and maintain a formal process for the retention and organization of all grant-related documentation. This pr...
Federal program title: Home Partnership Investment Program, and Local Assistance and Tribal Consistency Fund program CFDA 14.239, 21.032 Recommendation: We recommend that management establish and maintain a formal process for the retention and organization of all grant-related documentation. This process should ensure that key documents are securely stored, easily accessible, and periodically reviewed to support ongoing compliance with grant requirements. Additionally, the County should work with granting agencies to obtain copies of any missing agreements and perform a comprehensive review to identify and address any outstanding compliance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will not be applying for any CDBG grants in the future unless there is adequate administrative cost allocation in the grant. The County will continue to make every effort to adequately close out CDBG grants and provide reports to the granting organization as staff and priorities allow. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins. Planned completion date for correcting action plan: Completed and on-going.
Federal program title - Temporary Assistance for Needy Families (TANF) Program - CFDA 93.558 Recommendation: We recommend the County implement controls to ensure that all timesheets are properly approved by supervisor prior to submittal. Explanation of disagreement with audit finding: There is no di...
Federal program title - Temporary Assistance for Needy Families (TANF) Program - CFDA 93.558 Recommendation: We recommend the County implement controls to ensure that all timesheets are properly approved by supervisor prior to submittal. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Since FY 2015/2016, the Health and Human Services Agency has utilized the Cost Accounting Management System (CAMS), which includes an electronic time study and timecard tracking module. All HHSA staff are required to complete and submit their timecards through this system for supervisor approval prior to payroll submission. While the electronic system is the primary method of tracking and approval, paper timecards are also maintained as a secondary processing method within our agency. Our Timecard Policy and Procedures are reviewed with all new staff during onboarding and with all employees on an annual basis. This procedure outlines, in detail, the roles and responsibilities of both employees and supervisors in the submission and approval process—covering both the electronic and paper formats. Name(s) of the contact person(s) responsible for corrective action: Under direction of Elizabeth Hamilton Health and Human Services Director, the Staff Services Manager Jami Teal. Planned completion date for correcting action plan: Completed
Federal program title - U.S. Department of Housing and Urban Development – 14.239 Recommendation: CLA recommends the County develop procedures, such as including a compliance checklist in the receivables listing sent to the auditor’s office, to ensure that outstanding loan continuing compliance is p...
Federal program title - U.S. Department of Housing and Urban Development – 14.239 Recommendation: CLA recommends the County develop procedures, such as including a compliance checklist in the receivables listing sent to the auditor’s office, to ensure that outstanding loan continuing compliance is performed timely and documented in accordance with the HOME grant loan provision. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will not be applying for any CDBG grants in the future unless there is adequate administrative cost allocation in the grant. The County will continue to make every effort to adequately close out CDBG grants and provide reports to the granting organization as staff and priorities allow. Name(s) of the contact person(s) responsible for corrective action: Under direction of the County Administrative Officer, the Senior Financial Analyst Suzie Hawkins. Planned completion date for correcting action plan: Completed and on-going.
View Audit 366553 Questioned Costs: $1
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