Corrective Action Plans

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View of Responsible Official: A written SOP was developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. Anticipated Completion Date: April 30, 2026 Responsible Con...
View of Responsible Official: A written SOP was developed for determining allowable costs and procurement requirements in accordance with the applicable CFR to guide key finance staff with responsibility for federally eligible expenditures. Anticipated Completion Date: April 30, 2026 Responsible Contact Person: Rhonda Williams, Financial Director
Finding Number: 2024-003 Planned Corrective Action: Management acknowledged the sliding fee adjustment errors resulted from incorrect calculation of sliding fee discount. Management will add an additional layer of review over the application of the sliding fee scale. Further, the Center will impleme...
Finding Number: 2024-003 Planned Corrective Action: Management acknowledged the sliding fee adjustment errors resulted from incorrect calculation of sliding fee discount. Management will add an additional layer of review over the application of the sliding fee scale. Further, the Center will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Andreea Mera, Chief Executive Officer
Finding Number: 2024-002 Planned Corrective Action: Management acknowledged the lack of data to support certain line items reported on the 2023 Uniform Data System (UDS) report filed. The Center will have processes and procedures in place to require proper retention of reconciliation and tie-out of ...
Finding Number: 2024-002 Planned Corrective Action: Management acknowledged the lack of data to support certain line items reported on the 2023 Uniform Data System (UDS) report filed. The Center will have processes and procedures in place to require proper retention of reconciliation and tie-out of supporting documentation to final filings which will alleviate this finding. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Andreea Mera, Chief Executive Officer
Root Cause Management concurs that federal expenditures totaling approximately $5,842,346 under ALN 21.029 were omitted from the initially prepared SEFA, along with an additional $206,139 of other federal programs, for a total of $6,048,485. Additionally, management discovered that $2,786,421 was om...
Root Cause Management concurs that federal expenditures totaling approximately $5,842,346 under ALN 21.029 were omitted from the initially prepared SEFA, along with an additional $206,139 of other federal programs, for a total of $6,048,485. Additionally, management discovered that $2,786,421 was omitted from the June 30, 2024 SEFA. The omission resulted from incomplete grant tracking reports not reconciled to the general ledger and grant agreements; absence of an independent secondary review; and procedures that did not fully capture pass-through and subrecipient activity. Objective Design and implement effective internal controls to ensure the SEFA is complete, accurate, and in compliance with 2 CFR §200.510(b) and §200.303; prevent recurrence of material omissions; and sustain readiness for Single Audit reporting. 1. Comprehensive Reconciliation Process Implement a standardized monthly and year-end reconciliation that ties federal award expenditures (including drawdowns and indirect costs) to the general ledger, award agreements/portals, and program manager reports. Create a SEFA Reconciliation Workbook with crosswalks by ALN, passthrough entity, award number, program, and period of performance. 2. Federal Awards Inventory & Certification Maintain a centralized Federal Awards Inventory listing all awards by ALN, award number, passthrough entity, and funding stream. Require annual certifications from responsible leadership team members confirming completeness and accuracy of reported expenditures and period-of-performance coverage. 3. Formal Review Workflow (Independent of Preparer) Establish a documented two-tier review: (1) VP of Finance prepares SEFA and reconciliation; (2) Leadership Team Members perform independent reviews using a SEFA Checklist covering ALNs, pass-throughs, subrecipient disclosures, notes (basis, indirect cost rate), and period-of-performance matching. Evidence the review via dated sign-offs. 4. Subrecipient & Pass-through Controls The VP of Finance create procedures to identify all pass-through and subrecipient transactions. Maintain subrecipient listings with amounts passed through and ensure required disclosures (ALN, pass-through numbers) are captured in SEFA. Reconcile subrecipient agreements and payment registers to SEFA. Leadership Team Members perform independent reviews for accuracy and completeness. 5. Close Calendar & Training Adopt an annual SEFA close calendar with milestones (pre-close, interim, final). Provide annual training for finance and program staff on Uniform Guidance reporting requirements and the SEFA Checklist; include updates to OMB Compliance Supplement as applicable. 6. Monitoring & Continuous Improvement Quarterly CAP monitoring by VP of Finance with status reports to the Finance Committee. Track metrics (e.g., % variance between GL and SEFA, number of checklist exceptions) and remediate promptly. Conduct a pre-audit SEFA "dry run" at least 60 days before year-end close. Roles & Responsibilities • VP of Finance: CAP owner; oversight, quarterly monitoring, reports to Finance Committee, designs reconciliation and review workflow; ensures adherence to checklist and certifications; prepares SEFA, reconciliation workbook, and supporting schedules. • Responsible Leadership Team Member/Program Managers: Certify award activity and completeness; provide supporting documentation. Timeline & Milestones Immediate (within 30 days): Approve CAP; establish Federal Awards Inventory template; draft SEFA Checklist; schedule training. Short term (within 60-90 days): Implement monthly reconciliation; obtain program certifications; pilot independent review on QI data. By next year-end close: Execute full close calendar; complete pre-audit SEFA dry run; document reviewer sign-offs; present monitoring results to Finance Committee. Compliance References • 2 CFR §200.510(h): SEFA preparation requirements (completeness, ALN, pass-through, etc.). • 2 CFR §200.303: Internal controls over federal awards. Management Statement (for 2 CFR §200.511(c) submission) Management agrees with the finding and has initiated the corrective actions described herein. The CAP will be monitored quarterly by the VP of Finance, with status updates provided to those charged with governance until all actions are fully implemented and operating effectively.
Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will develop and implement a subrecipient monitoring program. Proposed implementation date: The corrective action plan will be implemented as soon as possible.
Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will develop and implement a subrecipient monitoring program. Proposed implementation date: The corrective action plan will be implemented as soon as possible.
Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will work to ensure timely filing of required reports in the future. Proposed completion date: Management intends to have the policy in place immediately.
Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will work to ensure timely filing of required reports in the future. Proposed completion date: Management intends to have the policy in place immediately.
The District Office has established a separate bank account for its Cafeteria Fund in fiscal year 25. The District is also in the process of implementing procedures to ensure cafeteria funds are used exclusively for allowable food service purposes and are properly monitored and reconciled.
The District Office has established a separate bank account for its Cafeteria Fund in fiscal year 25. The District is also in the process of implementing procedures to ensure cafeteria funds are used exclusively for allowable food service purposes and are properly monitored and reconciled.
The District Office will work directly with the Federal Programs Coordinator to ensure more timely submissions of Reconciliation of Cash on Hand Quarterly Reports and Final Expenditure Reports are prepared accurately and submitted timely in accordance with grant requirements. The Business Manager wi...
The District Office will work directly with the Federal Programs Coordinator to ensure more timely submissions of Reconciliation of Cash on Hand Quarterly Reports and Final Expenditure Reports are prepared accurately and submitted timely in accordance with grant requirements. The Business Manager will do this by creating reminders on the Business Manager’s calendar that include due dates each quarter and reminding the Federal Programs Coordinator when their respective reports are due. The District will implement and form a review and monitoring process and provide any necessary training to staff responsible for grant reporting to ensure ongoing compliance.
The City will ensure that all future expenditures are tracked and reported to the proper periods and recorded appropriately.
The City will ensure that all future expenditures are tracked and reported to the proper periods and recorded appropriately.
The City will ensure that all future awards under this program are in compliance and separately report on the Schedule of Expenditures of Federal Awards. All pass-through expenditures will be reconciled to ensure accuracy going forward.
The City will ensure that all future awards under this program are in compliance and separately report on the Schedule of Expenditures of Federal Awards. All pass-through expenditures will be reconciled to ensure accuracy going forward.
The City will ensure that all future contracts awarded under this program are in compliance and will have contractors sign to verify that they are in compliance.
The City will ensure that all future contracts awarded under this program are in compliance and will have contractors sign to verify that they are in compliance.
Completion and Submission of Annual Single Audit – Significant Deficiency/Noncompliance · All Federal Programs Condition/Context: The County's Single Audit and reporting package was delayed for the year ended December 31, 2024, beyond the 9-month due date. As part of the County's year-end close, the...
Completion and Submission of Annual Single Audit – Significant Deficiency/Noncompliance · All Federal Programs Condition/Context: The County's Single Audit and reporting package was delayed for the year ended December 31, 2024, beyond the 9-month due date. As part of the County's year-end close, the Children and Youth federal revenues and expenditures were not timely reconciled between the programmatic reports and the general ledger leading to incomplete and inaccurate information being included in the County's general ledger system and incomplete information for the County’s Schedule of Expenditures of Federal Awards. The June 30, 2024 reconciliation was not completed until June 2025 and the December 31, 2024 reconciliation and necessary adjustments were not completed until October 2025. Cause: The Children and Youth fund reconciliations were not completed timely due to staffing limitations, which delayed the completion and filing of the County's December 31, 2024 Single audit and reporting package. Corrective Action Planned: In response to Finding 2024-002, the County is taking the following steps to ensure that these issues are rectified going forward. The issues regarding Children and Youth have been ongoing. The delay in the filing of the Single Audit was solely due to their lack of staffing and inability to complete their reconciliations and reporting timely. The Commissioners and Children & Youth Administration are well aware of the lack of staff and are working towards hiring individuals to complete the necessary tasks. The County continues to work with a sub-contractor in an effort to free up time of the full-time staff and assist with preparation and submission of monthly and quarterly reporting. Controller, Erik Diemer, Fiscal Director, Jennifer Barclay, County Commissioners and Director of C & Y are providing all available resources to assist the Fiscal Department of Children and Youth. Vacant positions in the Department have been filled, and future reconciliations will be timely.
2024-009–Special Tests and Provisions – Internal Control and Compliance over Housing Quality Standards City’s Corrective Action Plan: HOME on-site monitoring requires dedicated staffing capacity. The Housing Division has developed clear policies and procedures for HOME on-site monitoring; however, i...
2024-009–Special Tests and Provisions – Internal Control and Compliance over Housing Quality Standards City’s Corrective Action Plan: HOME on-site monitoring requires dedicated staffing capacity. The Housing Division has developed clear policies and procedures for HOME on-site monitoring; however, implementation has been constrained by limited staffing resources. The Department has requested additional staff in the most recent budget development cycles to support these requirements but has not been successful. The Department is evaluating alternative solutions, including the potential use of third-party consultants, to support implementation of HOME on-site monitoring requirements. Responsible Person: Director of Economic Development, and Housing Manager Expected Implementation FY 2026
2024-008 – Special Tests and Provisions – Internal Control and Compliance over Obligation, Expenditure, Payment Requirements City’s Corrective Action Plan: The Department concurs with this finding. The City has since implemented policies and procedures to ensure timely issuance of award letters to s...
2024-008 – Special Tests and Provisions – Internal Control and Compliance over Obligation, Expenditure, Payment Requirements City’s Corrective Action Plan: The Department concurs with this finding. The City has since implemented policies and procedures to ensure timely issuance of award letters to satisfy the 180-day obligation requirement, and processing of payments within 30 days of receipt of complete documentation, or to document the reason payment cannot be processed. Staff will continue to follow and improve compliance with these established processes and procedures to ensure timely contract execution and payment processing. While unforeseen circumstances may occasionally cause delays, such instances will be documented and addressed promptly. Responsible Person: Director of Economic Development, Housing Manager Expected Implementation Date: March 12, 2024
2024-007 – Special Tests and Provisions – Internal Control and Compliance over Environmental Reviews City’s Corrective Action Plan: Out of a sample size of twenty-one (21) files, one environmental review document was missing the required signatures. Current procedural documentation states that after...
2024-007 – Special Tests and Provisions – Internal Control and Compliance over Environmental Reviews City’s Corrective Action Plan: Out of a sample size of twenty-one (21) files, one environmental review document was missing the required signatures. Current procedural documentation states that after the environmental review document is completed by the project manager, it is to be routed to the First Level Reviewer (Division Manager), then to the Certifying Officer for signature. The Department will diligently ensure that the documentation is completed and routed through the approval process and will make this a priority Responsible Person: Director of Economic Development and Housing Manager Expected Implementation Date: FY 2025
2024-006 – Reporting – Internal Control and Compliance over Reporting City’s Corrective Action Plan: This finding is related to COVID-19 funding that was administered during the height of the pandemic, when multiple funding sources were required to be expended simultaneously. Section 15011 reporting...
2024-006 – Reporting – Internal Control and Compliance over Reporting City’s Corrective Action Plan: This finding is related to COVID-19 funding that was administered during the height of the pandemic, when multiple funding sources were required to be expended simultaneously. Section 15011 reporting was a new requirement within the CARES Act of 2020, to the Department and the City at that time. By the time this issue was identified as an area of deficiency in the prior audit period, it was no longer possible to retroactively correct or report for that respective audit year, nor for the current audit period. In response to the prior audit report, the City evaluated options to centralize Section 15011 reporting, given that it falls under the Federal Funding Accountability and Transparency Act (FFATA) of 2006 and is closely tied to procurement activities of over $150,000. The City explored whether this reporting could be managed through the City’s Grant Manager position under the Administrative Services Department (ASD) The City accepts the finding of noncompliance with WIFIA reporting requirements, as the Annual Comprehensive Financial Report (ACFR) for the year ended June 30, 2024 was dated September 17, 2025, which exceeded the required 180-day submission deadline of December 27, 2024. The delay was due to challenges in completing the City-wide ACFR resulting from ongoing staff turnover. As a corrective action, the City will strengthen internal processes and oversight to ensure the ACFR is completed and submitted in a timely manner in future reporting periods. The City will implement enhanced internal controls to ensure timely, accurate, and complete submission of Quarterly Project and Expenditure (P&E) Reports for both SLFRF and ARPA Revenue Loss. Corrective actions include establishing a formal internal reporting calendar with assigned responsibilities to meet Treasury deadlines, performing a documented quarterly reconciliation of general ledger obligations and expenditures to P&E report amounts, correcting prior reporting errors or duplications, and requiring supervisory review and approval of all reports before submission to the U.S. Department of the Treasury. Additionally, the City will develop standardized reporting templates, provide staff training on Treasury reporting requirements, and maintain oversight by the Finance Director to ensure ongoing compliance, accuracy, and timely reporting of all expenditures. Responsible Person: Grants Manager; Accounting Manager, CFO and Departments Administering Grants Expected Implementation Date: FY 2026
2024-005 – Procurement and Suspension, and Debarment – Internal Control over Procurement and Verification Against the System for Award Management (“SAM”) City’s Corrective Action Plan: The City acknowledges the finding and is in the process of implementing a formal procurement policy. This is curren...
2024-005 – Procurement and Suspension, and Debarment – Internal Control over Procurement and Verification Against the System for Award Management (“SAM”) City’s Corrective Action Plan: The City acknowledges the finding and is in the process of implementing a formal procurement policy. This is currently under development and is expected to be approved by FY-26. To address these issues, the City will implement standardized procurement procedures requiring the use of purchase orders and direct invoicing, documented approvals, and verification of vendors’ eligibility for all projects. Procurement policies will include suspension and debarment checking using SAM.gov, and all supporting documentation will be retained in procurement files. Staff involved in procurement and grant management will receive training to ensure consistent compliance with the updated procedures and federal regulations. Responsible Person: Procurement Manager, Grants Manager, and CFO Expected Implementation Date: FY- 2026.
2024-004 – Allowable Costs/Cost Principles – Internal Control over Payroll Expenditures City’s Corrective Action Plan: The City accepts the finding, which resulted from the implementation of a new ERP system for position control, benefits, and payroll that began in 2024 and was completed in 2025. To...
2024-004 – Allowable Costs/Cost Principles – Internal Control over Payroll Expenditures City’s Corrective Action Plan: The City accepts the finding, which resulted from the implementation of a new ERP system for position control, benefits, and payroll that began in 2024 and was completed in 2025. To address the identified conditions, the City will strengthen internal controls over federal payroll allocations by implementing documented reconciliation and review procedures, regularly validating system configuration and allocation files, and establishing processes to identify and correct duplicate or unusual benefit postings. The finding appears to be based on salary charges from two staff members whose time was charged to ESG-related accounts that were not part of their original salary allocation setup. Charging time to accounts outside of original salary allocations is not atypical across City departments and is a common practice when staff responsibilities or work assignments cross funding sources. Executive-time was designed to allow this flexibility so that time charged accurately reflects how staff time is spent. In this instance, the two staff members performed ESG-related activities, and time was charged accordingly to reflect actual work performed. Cross-department internal controls for federal payroll expenditure processing and reporting will be updated, with revisions expected to be completed and tested by 2027. Responsible Person: Payroll & Department(s) Administering Grants Expected Implementation Date: Fiscal Year 2026
2024-005: Segregation of Duties (Significant Deficiency) Views of Responsible Officials and Planned Corrective Actions: The Organization’s Executive Office Staff are responsible for the financial transactions and communicate frequently and dependably about transactions, receipts, and accounting issu...
2024-005: Segregation of Duties (Significant Deficiency) Views of Responsible Officials and Planned Corrective Actions: The Organization’s Executive Office Staff are responsible for the financial transactions and communicate frequently and dependably about transactions, receipts, and accounting issues. In this way, a segregation of duties is maximized given the small staff and limited ability of the Organization to expand staff. The Organization has two Office Assistant Managers. The first is the assistant to the CFO. This assistant is responsible for weekly payroll, reviewing client file completions after the first assistant reviews them, assisting with expense reports, and assisting with quarterly and yearly reports. She has Board of Directors approval to sign checks and approve bills on an as-needed basis in the event that other authorized signors are unavailable. This ensures that all checks and payments have dual signatures, as required. In the absence of the CFO or CEO, the checks and bills approved by the assistant are subsequently reviewed. She also is the supervisor of the second Office Assistant Manager. The second assistant is responsible for entering receipts/bills on a daily basis, printing, and balancing accounts payable and checks, and providing the first review of client file completions. This assistant has no check-signing or bill approval authority. She also has no access to payroll, journal entries, or bank information. The CEO also believes that distributing monthly financial reports to the Organization’s Board of Directors creates transparency that compensates for this deficiency in segregation of duties. Anticipated Completion Date - Ongoing, see corrective action plan above. Contact Person - Janelle Anderson, Chief Financial Officer
WMMHC will implement additional review procedures for grant expenditures to ensure timely filing and compliance with federal requirements.
WMMHC will implement additional review procedures for grant expenditures to ensure timely filing and compliance with federal requirements.
Now that Treasury Portal is updated with all obligations the County will utilize Oracle reporting to input all remaining expenditures in the applicable quarterly report.
Now that Treasury Portal is updated with all obligations the County will utilize Oracle reporting to input all remaining expenditures in the applicable quarterly report.
The Organization has developed and implemented written procedures to ensure timely submission of the data collection form and reporting package to the FAC. These procedures: (1) assign primary responsibility for the FAC submission to the Director; (2) require preparation of the FAC submission checkl...
The Organization has developed and implemented written procedures to ensure timely submission of the data collection form and reporting package to the FAC. These procedures: (1) assign primary responsibility for the FAC submission to the Director; (2) require preparation of the FAC submission checklist immediately upon receipt of the draft auditor’s reports; and (3) incorporate the FAC deadline into the Organization’s annual compliance calendar. Training on the new procedures was provided to key finance staff.
2024-003 Finding - In accordance with 2 CFR § 200.512(a), the audit must be completed and the reporting package, which includes the Data Collection Form (SF-SAC), must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of the auditor's report(s...
2024-003 Finding - In accordance with 2 CFR § 200.512(a), the audit must be completed and the reporting package, which includes the Data Collection Form (SF-SAC), must be submitted to the Federal Audit Clearinghouse (FAC) within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Recommendation - The Organization should review internal controls and implement necessary procedures to ensure that accounting processes are completed timely so the audit can be completed within the parameters of the due date. Action to be taken – Additional staffing has been added and long with ensuring that bank reconciliations are completed by the 10th day after the month ends in order to ensure audit field work is completed in a timely manner. Responsible person – Tony Postma, Interim Chief Financial Officer
Management will implement procedures to ensure payroll costs charged to federal awards are supported by after-the-fact documentation of actual time worked, in compliance with 2 CFR §200.430(i). Employees whose time is allocated to multiple programs will be required to complete time and effort report...
Management will implement procedures to ensure payroll costs charged to federal awards are supported by after-the-fact documentation of actual time worked, in compliance with 2 CFR §200.430(i). Employees whose time is allocated to multiple programs will be required to complete time and effort reporting. Payroll processing will include documented review and approval by separate individuals to strengthen internal controls and ensure accurate allocation of personnel costs.
Management will implement standardized cash drawdown procedures to ensure federal funds are requested only for immediate cash needs in accordance with Uniform Guidance. A consistent drawdown calculation template will be used, supported by incurred and allowable expenditures. Monthly reconciliations ...
Management will implement standardized cash drawdown procedures to ensure federal funds are requested only for immediate cash needs in accordance with Uniform Guidance. A consistent drawdown calculation template will be used, supported by incurred and allowable expenditures. Monthly reconciliations of drawdowns to actual expenses will be performed, and staff involved in federal fund management will receive training on federal cash management requirements.
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