Corrective Action Plans

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To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals w...
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals with adequate training and subject matter knowledge to perform assigned functions in accordance with appropriate standards and expectations. We are always receptive to positive constructive criticism in our effort to improve upon compliance and financial reporting. Sincerely yours, Rufus Wofford– Acting Chief Executive Officer
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals w...
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals with adequate training and subject matter knowledge to perform assigned functions in accordance with appropriate standards and expectations. We are always receptive to positive constructive criticism in our effort to improve upon compliance and financial reporting. Sincerely yours, Rufus Wofford– Acting Chief Executive Officer
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals w...
To whom it may concern: We have reviewed the comments provided herein and are in agreement with the comments and will remediate the findings as follows: We are reviewing the staffing of our finance department in an effort to ensure that on a go forward basis we reduce turnover and have individuals with adequate training and subject matter knowledge to perform assigned functions in accordance with appropriate standards and expectations. We are always receptive to positive constructive criticism in our effort to improve upon compliance and financial reporting. Sincerely yours, Rufus Wofford– Acting Chief Executive Officer
To improve the timeliness and accuracy of our quarterly and semi-annual reporting, Cayuga Centers has aligned reporting deadlines with internal reconciliation schedules. A reporting coordinator will be appointed to oversee submissions and ensure accuracy. Monthly reconciliations of qualifying costs ...
To improve the timeliness and accuracy of our quarterly and semi-annual reporting, Cayuga Centers has aligned reporting deadlines with internal reconciliation schedules. A reporting coordinator will be appointed to oversee submissions and ensure accuracy. Monthly reconciliations of qualifying costs and cash draws will support this process, and a reporting calendar with automated reminders will be implemented to keep all stakeholders on track.
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs ...
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs against program requirements and other relevant background documentation. For finding 2024-012, Cayuga will review relevant lease terms and program requirements. If, upon full evaluation, Cayuga Centers concurs that such costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. For steps to resolve the underlying control deficiency asserted or implied in this finding, please see Cayuga Centers’ response to Findings 2024-001 through 006 above.
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs ...
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs against program requirements and other relevant background documentation. For finding 2024-012, Cayuga will review relevant lease terms and program requirements. If, upon full evaluation, Cayuga Centers concurs that such costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. For steps to resolve the underlying control deficiency asserted or implied in this finding, please see Cayuga Centers’ response to Findings 2024-001 through 006 above.
As discussed above Cayuga Centers has engaged grants management advisors who will assist in evaluating this specific finding. To the extent that the finding merely asserts that indirect cost bases were improperly calculated in prior periods, please see Cayuga Centers’ response and actions steps with...
As discussed above Cayuga Centers has engaged grants management advisors who will assist in evaluating this specific finding. To the extent that the finding merely asserts that indirect cost bases were improperly calculated in prior periods, please see Cayuga Centers’ response and actions steps with respect to findings 2024-001 through 006. If, upon full evaluation, Cayuga Centers concurs that indirect costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs.
Cayuga Centers does not fully understand the scope of this asserted finding. It will, however, work with its auditors to fully assess this finding. As discussed above, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted findings. To the exte...
Cayuga Centers does not fully understand the scope of this asserted finding. It will, however, work with its auditors to fully assess this finding. As discussed above, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted findings. To the extent that the costs referenced in this finding are unallowable, Cayuga Centers will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. To the extent this finding asserts control failures, please see Cayuga Centers’ response to Findings 2024-005 and 006 above.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the drawdown process generally, Cayuga Centers has established a review protocol requiring that draws include only qualified expenditures incurred or expected within three business days. All draw requests require dual approval from both finance and program staff. A centralized draw request log is being maintained, including supporting documentation and reconciliation records. With respect to Finding 2024-008, Cayuga Centers does not entirely agree with the auditors’ assertion that accrued vacation expense was improperly included in draw requests. Under certain circumstances, costs of paid time off may be treated as incurred based on PTO earned, rather than PTO-paid. See 2 C.F.R. § 200.431(b). Cayuga Centers will further evaluate this asserted finding with the grants management advisors described above. To the extent there may be any compliance discrepancy, Cayuga Centers will take further appropriate action.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of these asserted findings in conjunction with Findings 2024-005 and 006 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. With respect to the drawdown process generally, Cayuga Centers has established a review protocol requiring that draws include only qualified expenditures incurred or expected within three business days. All draw requests require dual approval from both finance and program staff. A centralized draw request log is being maintained, including supporting documentation and reconciliation records. With respect to Finding 2024-008, Cayuga Centers does not entirely agree with the auditors’ assertion that accrued vacation expense was improperly included in draw requests. Under certain circumstances, costs of paid time off may be treated as incurred based on PTO earned, rather than PTO-paid. See 2 C.F.R. § 200.431(b). Cayuga Centers will further evaluate this asserted finding with the grants management advisors described above. To the extent there may be any compliance discrepancy, Cayuga Centers will take further appropriate action.
This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, ...
This finding is, in part, due to a gap in adequate personnel and oversight within the Finance Department for a brief period of time. As stated above, Cayuga Centers has contracted for Chief Financial Officer and Controller services as a near-term measure to fill gaps and improve processes. Further, Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding in conjunction with Finding 2024-005 to ensure any perceived deficiencies are addressed to the satisfaction of Cayuga Centers’ primary federal funder. The new Finance Team leadership have reinstated use of the class system in our general ledger to allocate direct costs to specific programs and clearly separate non-reimbursable expenses. Monthly reconciliations will be performed to ensure qualifying costs align with cash draw requests. Accounting staff have or will receive targeted training on cost allocation principles and documentation standards to support this effort.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Cayuga Centers has also begun the process of working with its main federal funder regarding this item and will coordinate closely with that funder in res...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Cayuga Centers has also begun the process of working with its main federal funder regarding this item and will coordinate closely with that funder in resolving it. As an immediate action step, Cayuga Centers is reinforcing training for all grant management personnel, emphasizing the distinction between allowable and unallowable costs. The Training Department is developing a virtual curriculum to issue to all required staff. A pre-approval process was introduced for all grant-funded expenditures, and program managers will be required to certify compliance before expenses are submitted for reimbursement.
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Evaluation of this finding and Cayuga Centers’ procurement policies will be completed no later than November 2025 and any improvements needed for complia...
Cayuga Centers has engaged grants management advisors who will assist in evaluating the scope of this asserted finding and address it accordingly. Evaluation of this finding and Cayuga Centers’ procurement policies will be completed no later than November 2025 and any improvements needed for compliance or recommended as best practice will be adopted. As an initial action step, Cayuga Centers has developed a compliance checklist for all significant and recurring purchases. This checklist requires evidence of competitive bidding, vendor selection, and justification for sole-source procurement. Staff involved in purchasing have received, or will receive, training on federal and organizational procurement policies. The Compliance Department will conduct quarterly reviews of procurement records to ensure adherence to established procedures.
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management overrid...
Cayuga Centers has changed key leadership positions and contracted in the near-term for Chief Financial Officer and Controller services. The new leadership team is working transparently to resolve internal control issues asserted in the audit report. To prevent future instances of management override, Cayuga Centers has implemented standardized procedures to ensure grant expenditures are properly classified in our financial system. Each transaction are supported by detailed documentation, including invoices, receipts, and grant-specific identifiers. Individuals responsible for grant oversight will undergo mandatory training to deepen their understanding of grant requirements, allowable costs, and reporting obligations. Additionally, Cayuga Centers is working to ensure open communication between staff and the Board. Under new leadership, the agency continues to enforce its Non-Retaliation Policy (Whistleblower). The Acting President’s office is establishing quarterly “Grant Compliance Forums” for employees to raise concerns related to grant administration.
Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts tha...
Department of Housing and Urban Development and Department of the Treasury 2024-002 Indian Housing Block Grant Program (IHBG) – Assistance Listing No. 14.867, Recommendation: We recommend that LHDME reviews all construction contracts to make sure they request certified payrolls for all contracts that exceed $2,000. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: In the future all construction contracts will be reviewed on an monthly basis to determine what contracts total $2,000.00 or over to make sure we have a certified payroll for these contracts. Name(s) of the contact person(s) responsible for corrective action: Jamie Navenma, Executive Director and Cheryl Mullins, Controller Planned completion date for corrective action plan: December 1, 2025
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-011: Reporting - Insufficient Policies to Ensure Completeness and Accuracy of Reports (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-011: Reporting - Insufficient Policies to Ensure Completeness and Accuracy of Reports (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will implement a standardized reporting checklist and will ensure that all reports undergo supervisory review and sign-off prior to submission Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct quarterly reviews of submitted reports and related documentation.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-010: Cash Management - Inadequate Policies for Drawdowns, Program Income, and Reconciliations (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: The...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-010: Cash Management - Inadequate Policies for Drawdowns, Program Income, and Reconciliations (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will draft and approve comprehensive written procedures, and will ensure that staff are trained on the standardized drawdown and reconciliation processes. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct annual reviews of drawdown and reconciliation policies with documented compliance checks.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There ...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-009: Eligibility - Lack of Segregation of Duties in Expenditure Determination and Approval (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will reassign roles to ensure clear separation between allowability determinations and expenditure approvals. If staffing constraints prevent full segregation, management will ensure that the Finance Manager performs secondary reviews. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: Management will conduct periodic internal monitoring with documented review of approvals.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-008: Cash Management - Inadequate Authorization and Supporting Documentation for Reimbursement Requests (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Fin...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-008: Cash Management - Inadequate Authorization and Supporting Documentation for Reimbursement Requests (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: A standardized reimbursement packet and formal approval workflow will be created. All reimbursement requests will be routed for required approvals. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The Finance Department will conduct monthly reconciliations and reviews of reimbursement submissions.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: Th...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-007: Activities Allowed or Unallowed / Allowable Costs - Insufficient Budget-to-Actual Reviews (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: A monthly review checklist and variance analysis template will be adopted. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The internal audit function will conduct semiannual reviews to confirm adherence to established review procedures.
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-006: Activities Allowed or Unallowed / Allowable Costs - Inadequate Chart of Accounts Segregation for Unallowable Costs (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreemen...
Section III – Major Federal Awards Programs – Findings and Questioned Costs (Cont.) Finding 2024-006: Activities Allowed or Unallowed / Allowable Costs - Inadequate Chart of Accounts Segregation for Unallowable Costs (Material Weakness) (Cont.) Corrective Action Plan (CAP) Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to Finding: Management will implement a comprehensive redesign of the chart of accounts, including the creation of new account codes and subaccounts to clearly identify unallowable costs. In addition, management will ensure that staff receive training on the revised coding structure. Official Responsible for Ensuring CAP: Finance Manager will be responsible for overseeing the implementation of corrective actions. Planned Completion Date for CAP: The planned completion date is December 31, 2025. Plan to Monitor Completion of CAP: The Finance Department will conduct quarterly internal reviews to ensure the proper use of the revised account codes and to verify the accuracy of cost classifications.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future timesheets and paystubs are reconciled and will ensure control policies are in place.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future timesheets and paystubs are reconciled and will ensure control policies are in place.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future payroll disbursements are supported by a timesheet and approved by a manager.
Procedures have been established and implemented to insist controls are in place and being followed to avoid risk of error and/ or fraud. Management will make sure all future payroll disbursements are supported by a timesheet and approved by a manager.
Management agrees controls over cash disbursements should be complied with and will be more meticulous in maintaining documentation that approval be granted before payment is made.
Management agrees controls over cash disbursements should be complied with and will be more meticulous in maintaining documentation that approval be granted before payment is made.
Finding 1166725 (2024-001)
Material Weakness 2024
Finding ref number: 2024-001 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of the County contact person: Leo Kim, CPA CFO, Mason County Auditor’s Office, Financial Service, PO Bo...
Finding ref number: 2024-001 Finding caption: The County did not have adequate internal controls and did not comply with federal suspension and debarment requirements. Name, address, and telephone of the County contact person: Leo Kim, CPA CFO, Mason County Auditor’s Office, Financial Service, PO Box 400, Shelton, WA 98584 360-429-9670 Ext 472 Corrective action the auditee plans to take in response to the finding: Mason County is committed to maintaining strong internal controls and ensuring compliance with all federal procurement requirements. While County policy already requires suspension and debarment checks, staff training and documentation practices need improvement. Corrective Action: • In 2025, the County revised its purchasing policy to include an attestation form allowing vendors to certify that they are not suspended or debarred. • Staff will be trained on how to perform and document suspension and debarment checks in SAM.gov. • The County is developing a process to conduct suspension and debarment checks when a vendor is first created and annually thereafter for all active vendors. • Compliance with these procedures will be a joint effort between the Budget Office, Auditor’s Financial Services Office, and responsible offices and departments. Mason County believes that enhanced training, consistent documentation, and proactive vendor verification will prevent recurrence of this issue and strengthen accountability across all departments. Anticipated date to complete the corrective action: December 31, 2025
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