Corrective Action Plans

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In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action wi...
In response to the findings noted in the 2024 Single Audit for the Town of Pelham NH, we have developed the following corrective action plan to address the cited issue. Audit Finding 2024-001: The Town has not formalized written policies and procedures related to federal awards. Corrective Action with a Target Completion Date of December 31, 2025: The Town will draft and present a formal policy addressing this finding to the Board of Selectmen for review and approval prior to December 31, 2025. Responsible Party: Tammy Penny, Finance Director 6 Village Green Pelham, NH 03076 Phone: 603-508-3072 Email: TPenny@Pelhamweb.com Implementation of this policy will ensure that the Town is in compliance with applicable requirements and will prevent recurrence of the cited issue in future audits.
The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.
The Greening of Detroit has adjusted all indirect costs from being charged to the DNR grant for the current year 2025 and future years. The Greening of Detroit has also updated the grant budget to reflect the change to match the grant requirements.
The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the ...
The Greening of Detroit will ensure that we plan and complete our audits on time. Next year, we will schedule audits earlier in the year and set defined date range with our auditors to avoid late audit reports in the future. Our audits will be completed 15 days before the audit report is due to the clearing house.
Views of Responsible Officials and Planned Corrective Action: The Designees of the Grants Monitoring and Compliance team will oversee the completion of a physical inventory of all equipment that exceed $5,000 by October 31, 2026. The Grants team will also house documentation.
Views of Responsible Officials and Planned Corrective Action: The Designees of the Grants Monitoring and Compliance team will oversee the completion of a physical inventory of all equipment that exceed $5,000 by October 31, 2026. The Grants team will also house documentation.
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency...
Views of Responsible Officials and Planned Corrective Action: According to Appendix: American Rescue Plan CSLFRF HVAC Replacement and Improvement Grant Assurances of the 2021 CSLFRF HVAC Application it is stated the LEA/grantee assures: IX. It will submit such reports to the state educational agency as the state educational agency and Secretary may require to enable the state educational agency and the Secretary to perform their duties under the program; The LEA has also submitted an official correspondence to the Auditors from the Commonwealth of Virginia Department of Education’s Director of the Office of Federal Pandemic Relief Programs stating the following: On April 25, 2023, the Virginia Department of Education conducted monitoring to ensure that certain federally funded programs and activities supported with Elementary and Secondary School Emergency Relief (ESSER) formula grants; ESSER and Governor’s Emergency Education Relief (GEER) state setaside grants; and Coronavirus State and Local Fiscal Recovery Fund (CSLFRF) HVAC grants were implemented as stipulated by law. These federally funded programs were reviewed as operated by Richmond City Public Schools. Furthermore, RPS is a subrecipient. As such it is our stance that RPS was not required to create or submit quarterly financial activity reports to US Treasury. We were also not required to submit quarterly financial reports to the recipient (i.e. the Commonwealth of Virginia). Instead, RPS regularly submitted expenditures for reimbursement to VDOE on a nearly monthly basis via OMEGA. We also maintained financial records (invoices, GL transactions) via AS400 and LINQ and conducted annual single audits as required by the Single Audit Act & 2 CFR part 200, subpart F. We also complied with all monitoring activities conducted by VDOE. In turn, VDOE (the award recipient) used these artifacts to create and submit its quarterly financial reports to US Treasury, as required by statute. For more evidence of this "passthrough" structure of reporting, see the attached SLFRF Compliance and Reporting Guidance published by US Treasury and Updated October 2025 Part 2 Section B (p. 21-22) for a detail of which entities are required to submit quarterly reports. The following recipients are required to submit quarterly Project and Expenditure Reports: • States and U.S. territories • Tribal governments that are allocated more than $30 million in SLFRF funding • Metropolitan cities and counties with a population that exceeds 250,000 residents Coronavirus State and Local Fiscal Recovery Funds C • Metropolitan cities and counties with a population below 250,000 residents that are allocated more than $10 million in SLFRF funding • NEUs [Non-Entitlement Units of Government] that are allocated more than $10 million in SLFRF funding RPS does not fall into any of the aforementioned categories. We humble ask that you reconsider this finding.
November 4, 2025 Carver, Florek & James CPA’s Attn: Keegan Witt Audit Findings Corrective Action Plan Finding number: Section III: Federal Awards Findings and Questioned Costs Contact Person Responsible: Bonnie Buckingham Corrective Action Planned: Financial procedures that Community Food & Agricult...
November 4, 2025 Carver, Florek & James CPA’s Attn: Keegan Witt Audit Findings Corrective Action Plan Finding number: Section III: Federal Awards Findings and Questioned Costs Contact Person Responsible: Bonnie Buckingham Corrective Action Planned: Financial procedures that Community Food & Agriculture routinely follow are as follows: - Operations & Finance Manager will pull reports from QuickBooks accounting software for all federal grants for which a request for funds will be generated. - Executive Director reviews the draw down request, signs off on it, and the Executive Director or the Operations & Finance Manager files a request from the Federal portal, for funds expended for a specific program. All current and future expenditures and drawdown requests will be signed and dated with an electronic stamp certification prior to any drawdown request, as per the Financial Procedures stated above. All staff have been made aware of the strict adherence to this policy. Anticipated Completion Date will be immediate. Sincerely, Bonnie Buckingham Executive Director
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data...
Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Repeat Finding No Action Taken The health center will share one location to maintain all UDS files and ensure that the worksheet/and data that is prepared is locked so only the owner can make changes.
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does th...
Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that timesheets are reviewed and approved by the appropriate supervisor and ensure that they agree to the payroll register. Repeat Finding Yes Action Taken The staff accountant does the payroll. We save a backup timecard report each payroll that we are paying from the approved by the employee's supervisor. We also have an internal worksheet that we use to document any changes that are made. Once the accountant is done with her review the controller will do the second review before we finish processing the payroll enforcing internal controls that are in place and being followed.
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learnin...
Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Repeat Finding Yes Action Taken We will hold quarterly training on the Slide Fee process and share any relevant findings to support staff learning and development. The Slide Fee Coordinator will run a daily report to audit the slide fees entered the previous day to ensure accuracy.
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will implement a monitoring system to insure timely review and filing of quarterly reports. Pers...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will implement a monitoring system to insure timely review and filing of quarterly reports. Person Responsible: BCCD Manager Anticipated Completion Date: 11/12/2025
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will review federal suspended and debarred listings prior to awarding any projects. Person Respo...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: The District will review federal suspended and debarred listings prior to awarding any projects. Person Responsible: BCCD Manager Anticipated Completion Date: 11/12/2025
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: Bradford County will file reports on or before required due dates. Person Responsible: Michelle Shedden, chie...
U.S DEPARTMENT OF TREASURY COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing No. 21.027, Grant Period - Year Ended December 31, 2024. Planned corrective Action: Bradford County will file reports on or before required due dates. Person Responsible: Michelle Shedden, chief Clerk Anticipated Completion Date: 11/12/2025
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system...
Finding 2024.006 - Reporting Recommendation The Organization should establish a system of internal controls to ensure that all UDS related calculations are properly documented and maintained. Action Taken In response to the audit finding, I will develop and implement a formal internal control system to ensure that all Uniform Data System (UDS) related calculations are accurately documented and consistently maintained.
Finding 2024.005 - Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compli...
Finding 2024.005 - Procurement, Suspension and Debarment Recommendation The Center should develop a written procedure to review all vendors in accordance with the Uniform Guidance requirements for suspension and debarment. This procedure should be reviewed with the appropriate staff to ensure compliance with the requ irement. Action Taken In response to the audit finding, I wil l work with the Interim Chief Executive Officer, IT Director and Director of Operations to develop and implement a formal written procedure to ensure compliance with the Uniform Guidance requirements for suspension and debarment. This procedure will outline the steps for verifying vendor eligibility prior to procurement, including checking the System for Award Management (SAM.gov) to confirm that vendors are not suspended or debarred from receiving federal funds.
Finding 2024.004 -Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken In response to the audit finding, I will, in collaboration with the Chief Executive Off...
Finding 2024.004 -Allowable Costs/Activities Allowed or Unallowed Recommendation The Center should establish a system of internal controls to ensure that all cash disbursements are properly approved. Action Taken In response to the audit finding, I will, in collaboration with the Chief Executive Officer, develop and implement a comprehensive internal control system to ensure that all cash disbursements are properly reviewed and approved before processing. We will create a formal disbursement approval policy that outlines required documentation, approval thresholds, and designated approvers based on transaction type and amount. All disbursement requests must now be accompanied by supporting documentation (e.g., invoices and/or contracts) and routed through a multi-level approval workflow within our accounting system.
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a find...
Finding 2024.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken This was also a finding in the 2023 Audit. In response to the audit finding, I worked directly with the Director of Clinical Operations and the Patient Service Representative Manager to conduct a comprehensive review of the health center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and the definition of family size. We developed and implemented a step-by-step standard operating procedure (SOP) for Patient Service Representatives (PSR) staff to consistently assess and apply sliding fee discounts. The SOP included clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director's management team will conduct quarterly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to leadership and provide corrective follow-up and provide training for PSR personnel on the updated policy and procedures needed. I reported all identified and assessed changes to the health center's board of directors or its audit committee for review and oversight. The board verified that appropriate corrective action was being taken regarding internal controls.
The City of Royal City is committed to meeting all federal grant requirements and thanks SAO for providing guidance regarding this matter. We will proceed with developing written procurement procedures for purchases, services and public works contracts. It is our goal to ensure all stipulations are ...
The City of Royal City is committed to meeting all federal grant requirements and thanks SAO for providing guidance regarding this matter. We will proceed with developing written procurement procedures for purchases, services and public works contracts. It is our goal to ensure all stipulations are met for solicitation and award of Architectural and Engineering Services and Public Works contracts as required by state and federal granting agencies.
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- ...
Finding 2024-002 – Special Tests and Provisions The Organization did not properly determine the sliding fee discount given to patients selected for testing based on the sliding fee scale in effect for the year ended April 30, 2024. Since this occurrence, a new position has been created and staffed- Patient Service Representative Team Lead. This staff member oversees and trains the Patient Service Representatives in their responsibilities, including the sliding fee discount schedule application and compliance. A focus of this newly created position is training and compliance of the sliding fee schedule throughout all the clinics, which is ongoing from Oct. 15, 2024. The Patient Service Team Lead will be supervised by the Revenue Cycle Manager as part of the Finance Department reporting to the Interim CEO Bob Rodriguez, who will oversee this effort. The new position and implementation of training to correct the finding commenced Oct. 15, 2024.
Finding 1162268 (2024-013)
Material Weakness 2024
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
Finding 1162267 (2024-012)
Material Weakness 2024
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
Finding 1162266 (2024-007)
Material Weakness 2024
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
Finding 1162265 (2024-006)
Material Weakness 2024
We will work to implement a Risk Assessment plan. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to w...
We will work to implement a Risk Assessment plan. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
The District will ensure that there are at least 2 quotes obtained for any purchase over the $10,000 threshold using federal monies. The District will also verify that the vendor being used is not suspended or debarred by checking the SAM exclusions and requiring the vendor to provide a certificate ...
The District will ensure that there are at least 2 quotes obtained for any purchase over the $10,000 threshold using federal monies. The District will also verify that the vendor being used is not suspended or debarred by checking the SAM exclusions and requiring the vendor to provide a certificate of verification.
The District will ensure that any future contracts in excess of $2,000 using federal monies will contain provisions that require the contractor to comply with wage rate requirements and provide certified payroll reports on a weekly basis. This will allow the District to review these reports to ensur...
The District will ensure that any future contracts in excess of $2,000 using federal monies will contain provisions that require the contractor to comply with wage rate requirements and provide certified payroll reports on a weekly basis. This will allow the District to review these reports to ensure there are no violations.
Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025
Management concurs with the finding and has already implemented a compliance tracking system. A new policy was adopted during FY 2025 to ensure timely submissions moving forward. Contract Person: Brett Metzger, Outside Consultant Completion Date: November 11, 2025
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