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Corrective Action Plans

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Finding 1160362 (2023-004)
Material Weakness 2023
Kansas Alliance for Wetlands and Streams INC
KS
Internal Control / Segregation of Duties
2023-004: Internal Control over Cash Management and Matching Responsible Party: Libby Albers, Executive Director Implementation Date: 1/21/2025 The KAWS Executive Director sends drafts of every affidavit to six of the staff funded by EPA 31 grants. As additional grant projects came onboard, this eff...
2023-004: Internal Control over Cash Management and Matching Responsible Party: Libby Albers, Executive Director Implementation Date: 1/21/2025 The KAWS Executive Director sends drafts of every affidavit to six of the staff funded by EPA 31 grants. As additional grant projects came onboard, this effective review approach was not carried over through the new grants. This oversight was discussed during the audit and the same affidavit review process was applied to the other EPA 319 grant.
View Audit 370743
Finding 1160361 (2023-003)
Material Weakness 2023
Kansas Alliance for Wetlands and Streams INC
KS
Questioned Costs Allowable Costs / Cost Principles Reporting
2023-003: Allowable Costs of Indirect Costs Responsible Party: Libby Albers, Executive Director Implementation Date: 11/1/2025 The KAWS Executive Director requested reimbursements of audit expenses that included contractual invoices and billing for direct hours spent on the effort. However, the Dire...
2023-003: Allowable Costs of Indirect Costs Responsible Party: Libby Albers, Executive Director Implementation Date: 11/1/2025 The KAWS Executive Director requested reimbursements of audit expenses that included contractual invoices and billing for direct hours spent on the effort. However, the Director neglected to follow up with the independent account to transfer reimbursement of the personnel hours out of the grant and into the administrative project code. The KAWS Executive Director will request a P&L by job report from the accountant on an annual basis and again when a grant is closing to ensure that any costs recorded as direct or indirect administrative expenses have been moved to the administrative project code and out of the grant.
View Audit 370743 Questioned Costs: $1
Finding 1160360 (2023-002)
Material Weakness 2023
Kansas Alliance for Wetlands and Streams INC
KS
Internal Control / Segregation of Duties
2023-002: Oversight over the Revenue Process Responsible Party: Libby Albers, Executive Director Implementation Date: Originally 2/15/2024, revised to retroactively begin with the 1/1/2025 statement 1. KAWS Executive Director will continue to log deposits and deposit documentation in an internal spr...
2023-002: Oversight over the Revenue Process Responsible Party: Libby Albers, Executive Director Implementation Date: Originally 2/15/2024, revised to retroactively begin with the 1/1/2025 statement 1. KAWS Executive Director will continue to log deposits and deposit documentation in an internal spreadsheet and reporting each deposit to the KAWS accountant via email. The Conservation Easement Specialists will check the deposit spreadsheet against the monthly bank statement to ensure that all deposits are present. This extra reviewer of bank statements is independent of any of the parties handling the deposits. 2. The Executive Director will request a monthly reconciliation report from the independent accountant and the Conservation Easement Specialist will compare the data against the expense reporting platforms, payment requests, and bank statements. The Conservation Easement Specialists will provide an email response upon completion of the review of the statements.
View Audit 370743
Finding 1160359 (2023-001)
Material Weakness 2023
Kansas Alliance for Wetlands and Streams INC
KS
Allowable Costs / Cost Principles Reporting Internal Control / Segregation of Duties
2023-001: Financial Reporting on Indirect Costs Responsible Party: Libby Albers, Executive Director Implementation Date: 1/29/2025 1. The KAWS WRAPS grants are multi-year grants. To date, KAWS has reported a flat indirect rate on each affidavit split evently across the reporting periods of the grant...
2023-001: Financial Reporting on Indirect Costs Responsible Party: Libby Albers, Executive Director Implementation Date: 1/29/2025 1. The KAWS WRAPS grants are multi-year grants. To date, KAWS has reported a flat indirect rate on each affidavit split evently across the reporting periods of the grant. With the additional reimbursement of the audit expenses in 2023, and loss of Assistant Director position, 2023 closed out with less administrative expenses than had been budgeted. 2. The Executive Director requested and received written acknowledgement from the Kansas Department of Health and Environment that the unexpected adminstrative income from 2023 could be applied to expenses incurred in 2024.
View Audit 370743
Finding 1160358 (2023-002)
Material Weakness 2023
Arizona's Children Association
AZ
Allowable Costs / Cost Principles Reporting
The unallowable expenses were "replaced" by unreimbursed lost revenue. All expenses that were submitted are being replaced by unreimbursed lost revenue.
The unallowable expenses were "replaced" by unreimbursed lost revenue. All expenses that were submitted are being replaced by unreimbursed lost revenue.
View Audit 370742
Finding 1160357 (2023-002)
Material Weakness 2023
City of Middlesboro, Kentucky
KY
Reporting
The City has submitted the report timely for the period of April 1, 2023-March 31, 2024. The missed reporting deadline was a one-off and all other reporting deadlines for the grant have been met.
The City has submitted the report timely for the period of April 1, 2023-March 31, 2024. The missed reporting deadline was a one-off and all other reporting deadlines for the grant have been met.
View Audit 370741
Finding 1160352 (2023-002)
Material Weakness 2023
Legal Aid of Northwest Texas
TX
Reporting
Finding 2023-002 Major Federal Program: 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Compliance Requirements: Reporting Response: LANWT acknowledges that the SEFA initially submitted to the auditors included a clerical error in the FALN classification for Contract #1696416. ...
Finding 2023-002 Major Federal Program: 21.027 - COVID-19 - Coronavirus State and Local Fiscal Recovery Funds Compliance Requirements: Reporting Response: LANWT acknowledges that the SEFA initially submitted to the auditors included a clerical error in the FALN classification for Contract #1696416. The $1,617,909 in expenditures was inadvertently reported under FALN 16.575 rather than the correct FALN 21.027 in the SEFA spreadsheet. However, the expenditures were allowable, properly documented, and fully supported by the grant agreement, which was provided to the auditors during fieldwork. LANWT respectfully disagrees with the classification of this matter as a compliance finding and significant deficiency. The misclassification did not involve any questioned costs, noncompliance with the grant terms, or omission of federal expenditures. The auditors had access to the source grant documentation, which clearly identified the correct FALN. In our view, this error was a joint oversight that resulted in a SEFA presentation correction, not a failure in internal control or compliance. Corrective Action: To prevent recurrence, LANWT has strengthened its SEFA preparation process by implementing the following procedures: All SEFA entries are now reviewed against source grant agreements by two independent finance staff members prior to submission. A checklist has been introduced to confirm correct ALNs and funding sources before SEFA finalization. Internal training has been conducted on SEFA requirements, including proper identification and reporting of federal assistance listing numbers. In future audits, LANWT will also request that the audit firm verify that the ALN and program name recorded on the SEFA are consistent with those identified in the source grant agreements, which are made available to the auditors during field work. The Chief Financial Officer (CFO) is responsible for ensuring the implementation and ongoing oversight of these corrective actions. LANWT remains committed to accurate and compliant reporting and appreciates the opportunity to clarify this matter. Date of Completion: June 20, 2025 Person Responsible to Ensure Completion: Bhuvana Kannan, CFO
View Audit 370737
Finding 1160351 (2023-001)
Material Weakness 2023
Legal Aid of Northwest Texas
TX
Questioned Costs Allowable Costs / Cost Principles Procurement, Suspension & Debarment
Finding 2023-001 Major Federal Program; 09.744050 – Legal Services Corporation – Basic Field Grant Compliance Requirements: Allowable Cost and Cost Principles Response and Corrective Action: The Chief Executive Officer (CEO) and LANWT accounting department will review and train on 45 CFR 1631 regard...
Finding 2023-001 Major Federal Program; 09.744050 – Legal Services Corporation – Basic Field Grant Compliance Requirements: Allowable Cost and Cost Principles Response and Corrective Action: The Chief Executive Officer (CEO) and LANWT accounting department will review and train on 45 CFR 1631 regarding the subject of Purchasing and Property Management. LANWT will review its policies and protocols to require prior purchase approval and exigent circumstances approval. Deadlines shall be calendared by the CEO and the accounting department whenever there is an exigent circumstance and approval will need to be requested within the 30-day notice period. The CEO will remain in periodic contact with LSC if any extenuating circumstances exist. The accounting manual will be updated with this protocol. Date of Completion: June 1, 2024 Person Responsible to Ensure Completion: Maria Thomas-Jones, CEO
View Audit 370737 Questioned Costs: $1
Finding 1160349 (2023-004)
Material Weakness 2023
Roanoke-Chowan Regional Housing Authority
NC
HUD Housing Programs Eligibility
1. Revisiting AMA Consulting Group Proposal:_x000B_RCRHA is in the process of revisiting a formal proposal previously received from AMA Consulting Group, LLC, which outlines a detailed "Agency Health Check" for our Public Housing program. This proposal includes: • An operational audit of tenant file...
1. Revisiting AMA Consulting Group Proposal:_x000B_RCRHA is in the process of revisiting a formal proposal previously received from AMA Consulting Group, LLC, which outlines a detailed "Agency Health Check" for our Public Housing program. This proposal includes: • An operational audit of tenant files and eligibility documentation • Process mapping to improve workflow and accountability • Quality control implementation • Recommendations for electronic file storage and ongoing compliance monitoring. 2. Recent Staff Training: Nan McKay Rent Calculation Course:_x000B_To immediately address gaps in eligibility documentation practices, RCRHA staff participated in the Nan McKay HCV and Public Housing Rent Calculations Course, held March 18-20, 2025, in Washington, NC._x000B_The three-day seminar provided comprehensive instruction in: • Income and asset verification under 24 CFR Part 5 • Adjusted income and allowable deductions • Total Tenant Payment (TTP) calculations for both HCV and Public Housing • Case study applications using HUD Form 50058. 3. Internal File Review and Compliance Checklist Implementation:_x000B_RCRHA has initiated a review of all active Public Housing tenant files to ensure that required eligibility documents are present, accurate, and properly stored. A standardized checklist is being introduced to guide staff and ensure uniform compliance across all tenant records. 4. Electronic File System Evaluation:_x000B_In alignment with HUD best practices and our consultant's recommendation, RCRHA is evaluating the feasibility of transitioning to an electronic document management system to ensure long-term retention, audit readiness, and streamlined access to eligibility documentation.
View Audit 370734
Finding 1160312 (2023-002)
Material Weakness 2023
Trailhead Institute
CO
Subrecipient Monitoring Procurement, Suspension & Debarment § 200.331 § 200.332 § 200.339 § 200.425 § 200.501
Trailhead is establishing a new Contract and Compliance Coordinator role to oversee contract compliance processes and to ensure that Trailhead’s policy on subrecipient monitoring is followed. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each...
Trailhead is establishing a new Contract and Compliance Coordinator role to oversee contract compliance processes and to ensure that Trailhead’s policy on subrecipient monitoring is followed. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant. This role will be responsible for internal monitoring and auditing. This role will ensure that all grant kick-off meetings follow a standard procedure and include: 1) A clear understanding of federal requirements for all involved fiscal, program, and compliance staff 2) Delegated assignments to program staff for implementing and documenting: a) Suspension and debarment prior to contracting with subrecipients b) Subrecipient vs contractor determinations c) Evaluation of each subrecipient’s risk of noncompliance i) Establish the appropriate subrecipient monitoring level based on risk. This compliance role will have the authority to ensure the procedures are completed by the assigned staff. Evidence of the completed procedure must be documented and saved in a newly created contracts database. This database will be a centralized storage that will be reviewed during internal compliance checks to ensure all required steps have been completed and documented. These documents and associated grant and contract documents will be part of an official repository.
View Audit 370698
Finding 1160310 (2023-001)
Material Weakness 2023
Trailhead Institute
CO
Subrecipient Monitoring Procurement, Suspension & Debarment Reporting
Trailhead is establishing a new Compliance Coordinator role to oversee contract compliance processes. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant and contract, that all necessary documents are properly filed, and that ongoing mon...
Trailhead is establishing a new Compliance Coordinator role to oversee contract compliance processes. This role will be responsible for ensuring that compliance requirements are integrated at the outset of each grant and contract, that all necessary documents are properly filed, and that ongoing monitoring is in place. This role will be responsible for internal monitoring and auditing. This role will ensure that all grant kick-off meeting follow a standard procedure, including a clear understanding of federal requirements. This position will either complete the FFATA themselves or delegate the responsibility to another. This role will have authority for ensuring the procedures are completed. Furthermore, evidence of the completed procedure will be documented and saved in a newly created contracts database. This database is a centralized storage that will be reviewed during internal compliance checks to ensure all required steps have been completed and documented.
View Audit 370698
Finding 1160271 (2023-002)
Material Weakness 2023
Heart of Georgia Regional Airport Authority
GA
Procurement, Suspension & Debarment Subrecipient Monitoring Matching / Level of Effort / Earmarking
THE BOARD WILL DOCUMENT THE PROCUREMENT PROCEDURES FOR FEDERAL AWARDS AND SUBAWARDS.
THE BOARD WILL DOCUMENT THE PROCUREMENT PROCEDURES FOR FEDERAL AWARDS AND SUBAWARDS.
View Audit 370658
Finding 1160233 (2023-002)
Material Weakness 2023
Blue Mountain Land Trust
WA
Procurement, Suspension & Debarment § 200.318 § 200.326
Action taken in response to finding: BMLT’s Board of Directors adopted a written procurement policy at its July 26, 2025, Board meeting.
Action taken in response to finding: BMLT’s Board of Directors adopted a written procurement policy at its July 26, 2025, Board meeting.
View Audit 370625
Finding 1160232 (2023-003)
Material Weakness 2023
Blue Mountain Land Trust
WA
Reporting
Action taken in response to finding: BMLT’s completed 2023 Single Audit and Data Collection form will be submitted with the completed Corrective Action Plan. BMLT’s Executive Director will ensure future timely compliance with any Single Audits.
Action taken in response to finding: BMLT’s completed 2023 Single Audit and Data Collection form will be submitted with the completed Corrective Action Plan. BMLT’s Executive Director will ensure future timely compliance with any Single Audits.
View Audit 370625
Finding 1160205 (2023-002)
Material Weakness 2023
Town of Coupeville
WA
Procurement, Suspension & Debarment § 200.318
The Town of Coupeville acknowledges SAO’s recommendation regarding the need to strengthen internal controls regarding federal procurement, as well as to update the procurement policy to ensure full compliance with the Uniform Guidance including conflict of interest and ethics sections. In response, ...
The Town of Coupeville acknowledges SAO’s recommendation regarding the need to strengthen internal controls regarding federal procurement, as well as to update the procurement policy to ensure full compliance with the Uniform Guidance including conflict of interest and ethics sections. In response, the Town is updating procurement contracts with suspension and debarment verbiage and aligning policy with the requirements outlined in the Uniform Guidance (2 CFR 200) ensuring that all procurement processes are conducted in accordance with federal regulations and standards of conduct. The Town further ensures all authorized purchasers within the Town of Coupeville will receive ongoing training in procurement policies particularly when engaging in grant activities.
View Audit 370581
Finding 1160204 (2023-001)
Material Weakness 2023
Franklin Home for the Aged D/b/a Peabody Place
NH
Questioned Costs Student Financial Aid Matching / Level of Effort / Earmarking
Condition Found: In accordance with the loan terms, Peabody Place is required to annually fund a capital asset replacement reserve of $100,000, debt payment reserve in the amount of $111,696, and a resident asset depletion reserve and facility fill reserve each for $50,000. The Organization did not ...
Condition Found: In accordance with the loan terms, Peabody Place is required to annually fund a capital asset replacement reserve of $100,000, debt payment reserve in the amount of $111,696, and a resident asset depletion reserve and facility fill reserve each for $50,000. The Organization did not make the required annual deposits into the debt payment reserve, capital asset replacement reserve, resident asset depletion reserve and the facility fill reserve. Individual(s) Responsible for Corrective Action: Lynda P. Goldthwaite, Executive Director and Stacey Matott, Director of Finance Planned Corrective Action: Peabody Place sought a debt work out in 2025 that would allow for deferral of required deposits for six months until January 1, 2026. Anticipated Completion Date: December 31, 2024
View Audit 370570 Questioned Costs: $1
Finding 1160182 (2023-010)
Material Weakness 2023
Grand Forks Housing Authority
ND
Internal Control / Segregation of Duties Material Weakness Reporting § 200.512
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review, implement, and document controls to ensure reporting is filed timely. Planned Completion Date for CAP Immediately
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review, implement, and document controls to ensure reporting is filed timely. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160178 (2023-009)
Material Weakness 2023
Grand Forks Housing Authority
ND
HUD Housing Programs Subrecipient Monitoring Material Weakness
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review responsibilities pertaining to VMS reporting and ensure timely, accurate, and appropriate VMS reporting. Planned Completion Date for CAP Immediately
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review responsibilities pertaining to VMS reporting and ensure timely, accurate, and appropriate VMS reporting. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160174 (2023-008)
Material Weakness 2023
Grand Forks Housing Authority
ND
HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its polies and procedures for ensuring inspections happen timely. Planned Completion Date for CAP Immediately
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its polies and procedures for ensuring inspections happen timely. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160170 (2023-007)
Material Weakness 2023
Grand Forks Housing Authority
ND
Eligibility HUD Housing Programs Material Weakness
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its policies and procedures for ensuring proper documentation on waiting list pulls. Planned Completion Date for CAP Immediately
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its policies and procedures for ensuring proper documentation on waiting list pulls. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160166 (2023-006)
Material Weakness 2023
Grand Forks Housing Authority
ND
Material Weakness Internal Control / Segregation of Duties
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its policies and procedures for ensuring rent reasonableness documentation is maintained within the files. Planned Completion Date for CAP Immediately
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority will review its policies and procedures for ensuring rent reasonableness documentation is maintained within the files. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160162 (2023-005)
Material Weakness 2023
Grand Forks Housing Authority
ND
HUD Housing Programs Internal Control / Segregation of Duties Subrecipient Monitoring
ontact Person Terry Hanson, Executive Director Corrective Action Plan The Authority has encountered turnover with their finance staff and will review, implement, and document controls to ensure that REAC filing is done on time. Planned Completion Date for CAP Immediately
ontact Person Terry Hanson, Executive Director Corrective Action Plan The Authority has encountered turnover with their finance staff and will review, implement, and document controls to ensure that REAC filing is done on time. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160158 (2023-004)
Material Weakness 2023
Grand Forks Housing Authority
ND
Eligibility Internal Control / Segregation of Duties Significant Deficiency
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority has encountered turnover with their tenant specialists and will review, implement, and document controls that will ensure file reviewed are performed in a timely manner. Planned Completion Date for CAP Immediately
Contact Person Terry Hanson, Executive Director Corrective Action Plan The Authority has encountered turnover with their tenant specialists and will review, implement, and document controls that will ensure file reviewed are performed in a timely manner. Planned Completion Date for CAP Immediately
View Audit 370549
Finding 1160154 (2023-003)
Material Weakness 2023
Holy Cross Head Start, INC
NY
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The Organization has implemented new controls and staffing recently that are intended to remediate this matter.
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The Organization has implemented new controls and staffing recently that are intended to remediate this matter.
View Audit 370540
Finding 1160153 (2023-002)
Material Weakness 2023
Holy Cross Head Start, INC
NY
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The Organization has implemented new controls and staffing recently that are intended to remediate this matter.
VIEWS OF RESPONSIBLE OFFICIALS AND PLANNED CORRECTIVE ACTIONS: The Organization has implemented new controls and staffing recently that are intended to remediate this matter.
View Audit 370540
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