Corrective Action Plans

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Finding 2025-001 - Procurement Policy Contact Person Responsible for Corrective Action: Gregory F. Sherman, General Manager Houlton Water Company Corrective Action To address Finding 2025-001 regardingthe absence of a formal Procurement Policy, the Houlton Water Company will implement the following ...
Finding 2025-001 - Procurement Policy Contact Person Responsible for Corrective Action: Gregory F. Sherman, General Manager Houlton Water Company Corrective Action To address Finding 2025-001 regardingthe absence of a formal Procurement Policy, the Houlton Water Company will implement the following corrective measures: Houlton Water Company is actively developing a comprehensive Procurement Policy to remedy the deficiency identified in the audit. Management is currently drafting the policy, ensuring it aligns with applicable regulatory requirements, industry standards, and internal operational needs. Upon completion of the internal draft, the policy will be presented to the HWC Board of Directors at the May 19, 2026 Board Meeting for review and preliminary approvaL. Should the Board request revisions, management will incorporate the necessary changes and resubmit the updated policy for final approval at the June 16, 2026 Board Meeting. Anticipated Completion Date: June 17, 2026
Effective immediately, the Executive Director will conduct a mid-year review each June to confirm that the first required subrecipient monitoring has been completed, and ensuring the second monitoring is scheduled and completed prior to fiscal year-end.
Effective immediately, the Executive Director will conduct a mid-year review each June to confirm that the first required subrecipient monitoring has been completed, and ensuring the second monitoring is scheduled and completed prior to fiscal year-end.
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and proce...
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and procedures in place for timely reimbursement requests will ensure that the County is receiving funds it is owed. In addition, this will ensure there are no cash flow shortages and increase opportunities for investment earnings. Cause: The County had one highway project for which costs were incurred in October and November 2024, and the related reimbursement was submitted and approved in June 2025. Possible Effect: By submitting untimely reimbursement requests, the County is not receiving funds it is owed in a timely manner, which has the potential to cause cash flow shortages. Repeat Finding: No. Recommendation: We recommend County management review internal controls currently in place and design and implement procedures to request reimbursements in a timelier fashion and to submit requests for reimbursements on at least a quarterly basis. Views of Responsible Officials: There is no disagreement with the audit finding. The County will implement procedures to ensure timely submission of reimbursement requests. Anticipated Completion Date: December 31, 2026.
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: ...
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: We intend to include a section in all future agreements with the town to confirm that contractors/vendors acknowledge their suspension and debarment status. These agreements and contracts will be signed and approved by multiple Town officials. Anticipated Completion Date: This adjustment to agreements and contracts will go into effect April 24, 2026.
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with ...
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: Prior to the submission of the P&E report, a copy will be printed and reviewed by another individual from our office (Town Manager or Utility Office Manager), or a member of our Town Council and that individual will initial or sign off on the document after their review. Anticipated Completion Date: This procedure will go into effect on June 1, 2026.
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: Testing of the federal program identified: • The Entity’s formally documented pro...
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: Testing of the federal program identified: • The Entity’s formally documented procurement policy was missing the required elements detailed under Uniform Guidance. • Four instances where the Entity did not follow the procurement process and did not have any formal documentation in place with vendors. • Four instances where the Entity entered into a contract with a vendor over $25,000 and there was no review performed to ensure the vendor was not suspended or debarred. Responsible Individuals: Sara Morris, Chief Financial Officer and Jay Watkins, Sr. Vice President of Broadband Services Corrective Action Plan: Management will update their procurement policy to ensure it includes all required elements in accordance with Uniform Guidance. In addition, management will implement procedures and control processes related to the review of procurement to ensure the procurement methods are being followed and documentation isretained to support compliance. Management will also ensure vendors are not suspended or debarred from doing business with the federal government prior to entering into a procurement transaction. Anticipated Completion Date: October 2026
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: The Entity does not have an internal control system designed to provide for a com...
Federal Agency Name: Department of Treasury Pass-through Agency: State of Indiana Office of Community and Rural Affairs Assistance Listing Number: 21.029 Program Name: Coronavirus Capital Projects Fund Finding Summary: The Entity does not have an internal control system designed to provide for a complete and accurate schedule of expenditures of federal awards (the schedule) being audited. We requested our auditors to assist with the preparation of the schedule and accompanying notes to the schedule . Responsible Individuals: Sara Morris, Chief Financial Officer and Jay Watkins, Sr. Vice President of Broadband Services Corrective Action Plan: It is not cost effective to have an internal control system designed to prepare the schedule of expenditures of federal awards. We requested that our auditors, Eide Bailly LLP, to assist with the preparation of the schedule of expenditures of federal awards. We have designated a member of management to review the drafted schedule of expenditures of federal awards, and we have reviewed with and agree with the final Schedule of Expenditures of Federal Awards. Anticipated Completion Date: Ongoing
Finding Reference Number: 2025-04 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Organization acknowledges the importance of preparing a complete and accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with Uniform Guidance requirements. ...
Finding Reference Number: 2025-04 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Organization acknowledges the importance of preparing a complete and accurate Schedule of Expenditures of Federal Awards (SEFA) in accordance with Uniform Guidance requirements. Management will strengthen internal controls over the identification, tracking, reconciliation, review, and reporting of federal awards to ensure all federal expenditures are properly captured and rep01ted in future periods. 1. Develop and implement a fom1al year-end SEFA preparation checklist that identifies all required information, including federal agency, pass-through entity, Assistance Listing Number, program name, award amount, expenditures, and any amounts passed through to subrecipients 2. Review all revenue sources, grant agreements, reimbursement activity, and general ledger accounts at least quarterly lo identify any federal awards that must be included on the SEFA. 3. Perform a documented reconciliation of SEFA expenditures to the general ledger and supporting grant records before the SEFA is submitted for audit. 4. The SEFA will be prepared by the third party outside accountant and reviewed by the Finance Director to ensure that all federal awards are accurately reported. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures for the specific grants will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. l. The Organization will update and maintain a fom1al policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. 1. The Organization will update and maintain a formal policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
WE WILL EVALUATE THIS AND ATTEMPT TO SEGRGATE DUTIES AS MUCH AS POSSIBLE.
WE WILL EVALUATE THIS AND ATTEMPT TO SEGRGATE DUTIES AS MUCH AS POSSIBLE.
Chillicothe Metropolitan Housing Authority discovered multiple errors in the work performed by the Public Housing Assistant during a quality control file review. As per policy, disciplinary actions were taken and subsequently the employee was terminated from CMHA. In addition, CMHA has had significa...
Chillicothe Metropolitan Housing Authority discovered multiple errors in the work performed by the Public Housing Assistant during a quality control file review. As per policy, disciplinary actions were taken and subsequently the employee was terminated from CMHA. In addition, CMHA has had significant staffing turnover in this position. The staff now performing the PH annual and interim recertifications have received/are currently receiving additional training, and more frequent quality control reviews are being completed to ensure accuracy and timely completion. All files for which the former PH Assistant was responsible for annual and interim calculations are being recertified and the calculations reviewed. Any errors found will be corrected going forward.
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2 4 Provide refresher training to all staff responsible for determining and entering participant eligibility classifications. Develop written procedures outlining eligibility determination requirements and reimbursement coding standards. Conduct periodic internal audits of participant eligibility classifications to identify and correct errors timely. Maintain documentation of training attendance and ongoing monitoring activities. Responsible Party Sonja Williams and Site Coordinators Expected Completion Date September 30, 2026
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective ac...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective actions: 1. Establish standardized procedures requiring all operating sites to submit enrollment forms and Income Eligibility Forms prior to reimbursement claims being submitted. 2. Develop a monitoring checklist to verify that all required participant documentation is collected, complete, and retained. 3. Require monthly compliance reviews of participant files for each operating site. 4. Provide additional training to site administrators regarding CACFP eligibility documentation and retention requirements. Responsible Party Jeff Reynolds and Sonja Williams Expected Completion Date September 30, 2026
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the procurement finding related to the lack of formal agreements aiid procurement documentation for certain food vendors. Management has implemented the f...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the procurement finding related to the lack of formal agreements aiid procurement documentation for certain food vendors. Management has implemented the following corrective actions: 1. Develop and implement a formal procurement policy consistent with federal procurement requirements under 2 CFR 200.3 18-200.326. 2. Require written agreements or contracts for all vendors where annual purchases are reasonably expected to exceed the federal small purchase threshold. 3. Maintain procurement documentation, including vendor quotes, contracts, and bid documentation, in a centralized electronic file. 4. Provide annual training to staff responsible for purchasing and program oversight on federal procurement standards and documentation requirements. Responsible Party Gina Franklin and Karrie Stanford Expected Completion Date September 30, 2026
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
The Homeland Security and Emergency Management Agency (HSEMA) agrees with the conditions and recommendations of this finding. From PSJC’s perspective, this finding includes prior year (FY2020) approved expenditures not reported in FY2025 SF-425. We believe there was a transparency gap, as the discre...
The Homeland Security and Emergency Management Agency (HSEMA) agrees with the conditions and recommendations of this finding. From PSJC’s perspective, this finding includes prior year (FY2020) approved expenditures not reported in FY2025 SF-425. We believe there was a transparency gap, as the discrepancies between the SF-425 reports and the SEFA expenditure totals should have been identified, disclosed and brought to our attention in prior audit engagements. Overall, we concur with the findings. The SEFA was adjusted in fiscal 2020 for expenditures that were not approved, however we did not capture the approved expenditures in the following years on SF425. Management will ensure that SEFA expenditure and SF 425 cash disbursements are aligned. We will perform first and second level review of the SF425 and SEFA. Management also concurs with the fact that the subrecipient passthrough on the SEFA should be non-district agencies. We will review the SEFA and report only non-district agencies as pass through to subrecipients.
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, t...
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, the procedure has been updated to report bi-weekly rather than monthly to ensure reporting under 30 days. The GMO Director will also provide continuous training to staff outside of the GMO to ensure staffing will not become a barrier, as experienced in early 2026. As of June 1, 2026, all FFATA entries as of the May 25th purchase order (R071) report have been reported. Additionally, as we plan for the forthcoming electronic grants management system (eGMS) we’re in discussion to add a report feature that will provide needed info for FFATA entry i.e., UEI, FAIN, award amount and purchase order # to automate the process. SEFA Reporting Compliance: Prior to the submission of the SEFA, the grant expenditures will be reviewed with the Accounting Officer, The AFO, and the Grants Program Manager for a detailed review of the SEFA to confirm expenditures are correctly categorized by fund and grants, reconciles to the DIFS R019 report and reflects the amount expended for sub-recipients. Effective FY26, subrecipient totals are uniquely identified with an account number that will reflect in the R019 report as a subset of total expenditures. This report will be used to complete the SEFA going forward.
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split betwee...
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split between grant and local projects can record their time to each funding source. This new process will be rolled out starting June 12, 2026.
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, t...
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, the procedure has been updated to report bi-weekly rather than monthly to ensure reporting under 30 days. The GMO Director will also provide continuous training to staff outside of the GMO to ensure staffing will not become a barrier, as experienced in early 2026. As of June 1, 2026, all FFATA entries as of the May 25th purchase order (R071) report have been reported. Additionally, as we plan for the forthcoming electronic grants management system (eGMS) we’re in discussion to add a report feature that will provide needed info for FFATA entry i.e., UEI, FAIN, award amount and purchase order # to automate the process. SEFA Reporting Compliance: Prior to the submission of the SEFA, the grant expenditures will be reviewed with the Accounting Officer, The AFO, and the Grants Program Manager for a detailed review of the SEFA to confirm expenditures are correctly categorized by fund and grants, reconciles to the DIFS R019 report and reflects the amount expended for sub-recipients. Effective FY26, subrecipient totals are uniquely identified with an account number that will reflect in the R019 report as a subset of total expenditures. This report will be used to complete the SEFA going forward.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with t...
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with their contract schedules and they self-report on a schedule-oriented tool. The CFSA team reviews, validates, and approves each and every invoice. The tool tracks invoiced cost for the entire fiscal year such that by year’s end there is a verified, validated catalogue of reported costs that are used to derive the family-based rate that drive the adjustment claims for these special tests and provisions.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
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