Corrective Action Plans

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The County will implement a new policy to verify vendors are not suspended or debarred.
The County will implement a new policy to verify vendors are not suspended or debarred.
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These ex...
Current leadership and Management has implemented robust policies and procedures to ensure compliance with federal drawdown requirements. Currently, all drawdowns are based on 1/12th of the approved annual budget and are fully supported by actual expenditures recorded in the General Ledger. These expenditures exceed the amount of the monthly drawdown, ensuring we are not drawing funds in advance. Previous acceleration of drawdowns in prior years was not aligned with best practices and stemmed from poor cash flow management and inadequate internal controls. Our corrective action plan directly addresses these issues through strengthened oversight and improved fiscal discipline. Furthermore, in alignment with the Department of Health and Human Services’ “Defend the Spend” (DOGE) initiative, all drawdowns are now required to be substantiated by actual, documented expenses reflected in the General Ledger.
Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for ...
Management acknowledges the finding. We will conduct mandatory training sessions for all relevant personnel to ensure a clear understanding of the Sliding Fee Discount Program requirements and policy. Training will include proper documentation practices, eligibility verification, and procedures for applying discounts consistently. We will review and update our sliding fee discount policy to ensure clarity, consistency, and compliance with regulatory requirements. We will provide an annual review and obtain board approval of the Sliding Fee Discounting Program scheduled on an annual basis. Regular internal audits will be conducted to review the application of sliding fee discounts and identify any discrepancies before external audits. Results of internal audits will be shared with management, and corrective actions will be taken as necessary. We will assess the feasibility of implementing system controls or automated alerts within our electronic health record (EHR) and billing systems to reduce errors in discount applications. Additional oversight measures may be introduced to ensure all eligible patients receive the correct discount in accordance with policy guidelines. The above corrective actions are currently being implemented.
Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3%...
Going forward, we must be sure to follow the rules in OGAPP Manual 100.3, Personnel Costs, which states that even though cost of overtime/bonuses are chargeable to federal grants, they are only allowable to the extent that the costs comply with certain guidelines. For bonuses, they are limited to 3% of an employee's gross wages (not including fringes) or $1,500, whichever is less. The Ohio Department of Health (ODH) program administrator must approve all bonuses and enter a comment in GMIS in the project comments section.
Finding 1166097 (2023-006)
Material Weakness 2023
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address thi...
Audit Finding Reference: 2023-006 Improve Internal Controls Over Reporting (Significant Deficiency) Planned Corrective Action: The City strives to report accurate expenditures and regretfully an outside consultant was coordinating these tasks and working off site. Regretfully, I can only address this finding as learning experience. We cannot rely on a vendor to submit expenditure information without proper city sign off. This finding has been addressed moving forward. Our ARP A compliance office has been on board since this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T .. Spencer, City Comptroller December 31, 2025
Finding 1166095 (2023-005)
Material Weakness 2023
Audit Finding Reference: 2023-005 Improve Procurement Procedures (Significant Deficiency) Planned Corrective Action: The City strives to procure services per Federal Guidelines however, Lynn Public Schools provides millions of dollars for services however we need to do a better job to reach 100% com...
Audit Finding Reference: 2023-005 Improve Procurement Procedures (Significant Deficiency) Planned Corrective Action: The City strives to procure services per Federal Guidelines however, Lynn Public Schools provides millions of dollars for services however we need to do a better job to reach 100% compliance by the time our 2024 Singe Audit is completed. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025
Finding 1166088 (2023-004)
Material Weakness 2023
Audit Finding Reference: 2023-004 Update Federal Equipment/Real Property Listings (Material Weakness) Planned Corrective Action: The City strives to maintain accurate Fixed Assets, Lynn Public Schools purchase millions of dollars of Equipment using Federal Funds. I will work with the School Business...
Audit Finding Reference: 2023-004 Update Federal Equipment/Real Property Listings (Material Weakness) Planned Corrective Action: The City strives to maintain accurate Fixed Assets, Lynn Public Schools purchase millions of dollars of Equipment using Federal Funds. I will work with the School Business Administrator to track and include these assets annually. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025
Finding 1166078 (2023-003)
Material Weakness 2023
Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Depa...
Audit Finding Reference: 2023-003 Maintain Employee's Time and Effort Records (Material Weakness) Planned Corrective Action: The lack of record keeping in Community Development and our Special Education Department is a concern, CD has addressed this finding however still working with the School Department to address this finding. The context below is from CD: Corrective action implemented with City FY24 (07/01/23-06/30/24). Annually, a budget for staff salary and fringe is developed and approved by CD Director Marsh. The annual budget details staff hours and cost centers each will be charged during the year ( e.g. CDBG activity delivery, CDBG admin, Seaport Marina, Auditorium, ESG, etc.). Additionally, employees track time on individual time sheets weekly. This finding was also noted at the last HUD monitoring review, and marked as resolved and closed in June 2024 following HUD's post review. Name of Contact Person and Completion Date James Marsh, Executive Director of The Office of Community Development & Kevin McHugh, School Business Administrator December 31, 2025
Finding 1166069 (2023-002)
Material Weakness 2023
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site whi...
Audit Finding Reference: 2023-002 Improve Controls and Documentation Over Allowability of Costs (Significant Deficiency) Planned Corrective Action: We try our best to have proper paperwork in order prior to processing invoices. In the time of COVID, we had some issues with staff working off site which could of lead to this finding, I strongly feel that we are improving on this finding as we progress in stressing internal controls. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Stephen T. Spencer, City Comptroller December 31, 2025
Finding 1166049 (2023-001)
Material Weakness 2023
Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressin...
Audit Finding Reference: 2023-001 Improve Controls and Documentation Over Payroll Process (Material Weakness) Planned Corrective Action: The School Payroll Department is working to supply all applicable back up for staff being funded by Federal Funds. This has been an issue and we have been stressing that this is a finding and more diligence needs to occur in order to remove this finding. Management is striving to have this finding removed prior to the next review due to the protocols they have implemented. Name of Contact Person and Completion Date Kevin McHugh, School Business Administrator December 31, 2025
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionall...
Statement of Concurrence or Nonconcurrence: Family Wellness Outreach Center of Georgia agrees that the 2023 audit was not able to be completed within the 9 months after the end of the audit period due to our 2022 audit being significantly delayed. However, our agency acted responsibly, professionally, reasonably and in a timely manner to secure our 2022 audit within the required timeline. Despite our diligence, the previous auditing company and their representatives were grossly non-responsive and ultimately, we had to dispute our payment that was made in full for not receiving the 2022 audit services in a timely manner. This impacted our 2023 audit not being completed as indicated in the finding. Corrective Action: The Organization chose a new audit company that is responsive, professional and highly experienced in non-profit audits. The Organization continues to have a process in place to ensure that required audits are completed in accordance with established guidelines. In advance, we seek at least three bids from reputable audit companies; our finance team provides documentation in a timely manner; we utilize a designated person to ensure the audit process is not delayed including conducting routine follow-ups or check-ins and ensuring any issues are resolved quickly; and we pay our bills on time. Our corrective action plan is in place to ensure timely audits in the future as applicable.Name of Contact Person Sophia Nash – HR-Business Manager; 229-854-3660; hr.fwocga@gmail.com Projected Completion Date: December 31, 2025
Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training...
Planned Corrective: Management acknowledges the control deficiency and noncompliance related to submitting quarterly Project and Expenditure Reports to the Treasury and understands the importance of complying with these requirements for transparency and accountability. The City will provide training to staff on SLFRF reporting requirements and deadlines, implement written policies and procedures to ensure timely submission of all reports, including establishing a compliance calendar with automated reminders and maintaining a reporting log to track submission dates. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Katie Eviston, Finance Director, (937) 324-7700
Planned Corrective: Management acknowledges the deficiency related to Housing Quality Standards inspections and is committed to ensuring compliance with 24 CFR §92.504(d). The City will review and update its existing tracking systems to ensure inspection due dates for all HOME-assisted properties ar...
Planned Corrective: Management acknowledges the deficiency related to Housing Quality Standards inspections and is committed to ensuring compliance with 24 CFR §92.504(d). The City will review and update its existing tracking systems to ensure inspection due dates for all HOME-assisted properties are accurately monitored, and will confirm that responsibility for scheduling and completing inspections is clearly assigned to a designated staff member within the Community Development department. Overdue inspections will be completed promptly, with results documented in accordance with HUD requirements. In addition, the City will review and revise current policies and procedures to strengthen inspection scheduling, address staff turnover contingencies, and improve compliance monitoring. Staff will receive updated training on HUD property standards and inspection requirements to ensure ongoing compliance. Progress will be monitored quarterly, and updates will be provided to management and the governing body. Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Logan Cobbs, Community Development Director, (937) 324-7381
Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to sta...
Internal Control over Schedule of Expenditures of Federal Awards Year Ended December 31, 2023 Segregation of Duties Auditor’s Recommendations: We recommend that Eldred Borough assess the current structure and implement compensating controls where full segregation of duties is not feasible due to staffing limitations. These may include enhanced supervisory review, periodic oversight by the board or executive leadership, documentation of independent reviews, and rotation of duties when possible. Borough’s Response: Eldred Borough has board oversight and will continue to do so. The Borough employees do cover duties of the other employee when necessary and will continue to do so. Bank Reconciliations will be signed by Council. Pay Requisitions are signed by Council and will continue to do so.
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to e...
Compliance and Other Matters Year Ended December 31, 2023 Untimely Single Audit Filing Auditor’s Recommendations: The Borough should establish a system to closely monitor Single Audit deadlines, designate clear responsibilities for the audit process, and proactively communicate with the auditor to ensure timely completion and submission of the report. Borough’s Response: Eldred Borough was unable to contract a CPA to perform the single audit. This process included months of phone calls and emails to over 30 CPA and Accounting Forms across the State of Pennsylvania. The Borough has since contracted with a CPA firm to perform the 2024 single audit and do not anticipate it being delayed in submission.
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as iden...
Action Taken: The City has implemented new policies and procedures regarding grant reimbursements including, but not limited to, the creation of a grants unit. All activities regarding reimbursements are required to be reviewed and approved by a designee of the City’s CFO and other employees as identified. In addition, any project associated with outside funding has gone through or will go through a reconciliation process to evaluate its current standing, including all related receivables and payables, and will continue to do so monthly. The City is working to ensure all invoices are paid within a timely manner of the related award advances and according to application of Federal and State regulations.
Finding ref number: 2023-002 Finding caption: The Town did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of Town contact person: Randy Kilmer, Clerk/Treasurer PO Box 278 Twisp, WA 98856 Corrective action the auditee pl...
Finding ref number: 2023-002 Finding caption: The Town did not have adequate internal controls for ensuring compliance with federal procurement requirements. Name, address, and telephone of Town contact person: Randy Kilmer, Clerk/Treasurer PO Box 278 Twisp, WA 98856 Corrective action the auditee plans to take in response to the finding: Town of Twisp has since been working to draft updated federal award/purchasing/reporting policy, not only to address processes for procurement, but to establish federal purchasing policy in compliance with the recommendation of the recent audit findings including discipline for non-adherence to the policy. This Policy was adopted in October of 2024 and will alleviate any further issues with Federal procurement requirements. Anticipated date to complete the corrective action: Completed
Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor’s approval and audit trail to reflect the work performed. Budget and Grants in conjunction with the program and Human Resources will implement a hindsight r...
Corrective Action Planned: In July 2023, the Organization implemented ADP Work Force Now to systematically capture hours worked, the supervisor’s approval and audit trail to reflect the work performed. Budget and Grants in conjunction with the program and Human Resources will implement a hindsight review of employee working hours with a certification by the employee and supervisor. Name(s) of Contact Person(s) Responsible for Corrective Action: Betsey Knapp, Director of Budgets and Contracts; Alvin Sinckler, Chief Financial Officer Anticipated Completion Date: November 15, 2025.
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. A calendar of all federal reporting...
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. A calendar of all federal reporting requirements will be developed and maintained. This calendar will be reviewed monthly to ensure all federal compliance timelines are met. A federal program grant activity report will be shared monthly with the district leadership team. This report will keep financial monitoring to the forefront of the leadership team. All federal program reporting will be reviewed with the Business Office prior to submission. Business Office will complete federal program management and reporting training by December 31st by working with the federal program specialists at the State Department of Education and reading and retaining for future reference any grant specific guidance.
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. The Business Office will develop an...
There is no disagreement with the audit finding. All federal programs will have a federal programs director/coordinator and the Business Office will work closely with the federal programs director/coordinator to ensure that all federal compliance measures are met. The Business Office will develop and implement an accurate inventory tracking system for items purchased with federal funds. The board will review board policy to ensure it meets the uniform guidance as required for purchasing equipment with federal funds. Inventory records will be maintained by the federal program director and shared in entirety at the end of each fiscal year with the business manager. The business manager will review the inventory for accuracy and completeness. Inventory record management must track at a minimum the following: description of item, serial number or other identifying numbers, funding source, acquisition date, cost of the item, location of the item, disposal date and useful life. The tagging system will be developed to accurate track each inventory item within the district.
Condition: The Organization did not submit required program reports within the timeframes stipulated in the Community-Based Violence Intervention and Prevention Initiative grant agreement. Criteria: Per the grant agreement and financial reporting compliance requirements, recipients must submit perfo...
Condition: The Organization did not submit required program reports within the timeframes stipulated in the Community-Based Violence Intervention and Prevention Initiative grant agreement. Criteria: Per the grant agreement and financial reporting compliance requirements, recipients must submit performance and financial reports timely. Cause of condition: The delay was due to internal administrative challenges and competing priorities during the reporting period. Potential effect of condition: Late reporting may hinder the grantor’s ability to monitor program performance and compliance, potentially affecting future funding decisions. Recommendation: Implement stronger internal controls and calendar-based tracking to ensure timely submission of all required reports. Management response: The Organization is working to catch up on the outstanding invoices and have implemented adjustments to their process to help ensure timely submission going forward. Action Taken: The Organization has implemented process adjustments to its workflow to catch up on outstanding invoices and ensure timely submission of current invoices. As of November 14, 2025, all outstanding invoices have been submitted.
Corrective Action Plan: Accounts Payable Specialist will send a series of follow up emails to grant managers for, but not limited to IDEA, Title I, & 21 st Century Grants and will file in designated location for each respective grant. Business Administrator will follow up on a semi-annual basis. Nam...
Corrective Action Plan: Accounts Payable Specialist will send a series of follow up emails to grant managers for, but not limited to IDEA, Title I, & 21 st Century Grants and will file in designated location for each respective grant. Business Administrator will follow up on a semi-annual basis. Name of Responsible Person: Business Administrator - Evan Arsenault Anticipated Implementation Date of Corrective Action: July I, 2024
Description: Management should ensure that Uniform Guidance regarding time tracking related to federal grants is fully implemented. Auditors review of employee timesheets lacked evidence of review and approval, and certain employees did not prepare timesheets. Recommendation: Management should revie...
Description: Management should ensure that Uniform Guidance regarding time tracking related to federal grants is fully implemented. Auditors review of employee timesheets lacked evidence of review and approval, and certain employees did not prepare timesheets. Recommendation: Management should review the requirements of CFR 200.430 and ensure that current processes, whether digital or hard-copy driven, are consistent with the requirements of the Uniform Guidance. In addition, management should consider adding additional staff to its accounting and/or grants management team. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management will evaluate systems and processes to ensure time tracking procedures meet the standards outlined in the Uniform Guidance. Anticipated Completion Date: December 31, 2025
Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal proce...
Description: Management’s schedule of Expenditures of Federal Awards was incomplete, resulting in lack of identification of the need for a Single Audit and the delay in its completion. The State funder indicated that no Federal Single Audit was required. Management had not implemented a formal process for preparation of the SEFA. Recommendation: Management should prepare a master tracking schedule for government grants which includes the source of funding and audit and reporting requirements. The schedule should be prepared by someone with knowledge of the grant agreements and reviewed by a leader in the accounting department to ensure completeness. Responsible Contact: Laura McQuay, Vice President & Chief Financial Officer Corrective Action Planned: Management has implemented a master tracking schedule for government grants that includes the source of funding and audit and reporting requirements. This tracker is a joint effort between finance and grants management teams. Anticipated Completion Date: December 31, 2025
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