Corrective Action Plans

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Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will ...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will be in compliance with Uniform Guidance to ensure proper annual monitoring. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification for suspension and debarment prior to entering into a transaction/contract. With annual review of suspension and debarment throughout the program lifecycle. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested aft...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: The Grant and Accounting teams hold monthly in-person meetings to review grant-related expenditures. Going forward, email approval will be requested after each meeting and before the draw request is submitted to the governmental agency. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: CFO will be approving CEO timesheets Name(s) of the contact person(s) responsible for corrective action: Mary Lubben, CFO Planned completion date for co...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: CFO will be approving CEO timesheets Name(s) of the contact person(s) responsible for corrective action: Mary Lubben, CFO Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval operated effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at ...
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval operated effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training cont...
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training controls over the application of the sliding fee discount schedules. The Director of Patient Services (or designee) will perform monthly audits of 25 randomly selected patients accounts that received a sliding fee discount to verify that the correct discount schedule was applied and that the patient responsibility was calculated accurately. In addition, for any future changes to the sliding fee discount schedule, management will implement a transition review process that includes: • Verification that the updated fee schedule is accurately loaded into the billing system prior to the effective date and old fee schedules are inactivated. • Additional training for billing staff before implementation of any revised sliding fee schedule. • Continued monthly audits of sliding fee discounted patient accounts. • Quarterly reporting of audit results to Chief Financial Officer, to identify recurring issues and ensure corrective actions taken are effective. Anticipated completion date: July 31, 2026
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
The CFO corrected the Federal Draw schedule to identify the payroll used each pay period for the draw request. The schedule shows the replacement of termed staff and a countdown of available grant dollars per staff. This report balances the Federal Draw schedule every pay period.
Finding No. 2026-001: During testing of allowable costs for Major Program 93.912, one instance was identified in which payroll benefit costs charged to the federal award were overstated by $383 due to an error in the calculation of payroll-related benefits associated with an individual employee. As ...
Finding No. 2026-001: During testing of allowable costs for Major Program 93.912, one instance was identified in which payroll benefit costs charged to the federal award were overstated by $383 due to an error in the calculation of payroll-related benefits associated with an individual employee. As a result of the exception identified during audit testing, we performed additional procedures over the affected population and determined that an incorrect payroll base had been used in calculating benefit allocations charged to federal awards for certain employees for which payroll and benefits are allocated to federal programs. We identified unsupported payroll benefit costs and indirect costs charged to the following federal programs: Program 93.912-$15,046; Program 93.387-$1,901; and Program 93.889-$29,718, for total questioned costs of $46,665. We intend to return these funds to the grantor agencies. Accordingly, the $46,665 of unsupported costs was removed from expenditures reported on the Schedule of Expenditures of Federal Awards, and no known questioned costs are reported in the Schedule of Findings and Questioned Costs. Corrective Actions Planned: A simplified report has been identified that will reduce the risk of calculation errors. This report will be used for all future calculations related to payroll-related benefits for grants. Responsible Party: Karla Dillow, Assistant Director of Accounting Target Completion Date: March 31, 2027
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because...
This finding is due to the Village not having formal written policies in place required by Uniform Guidance. The Village is aware that these policies are required and will adopt all necessary policies. The Village does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Village will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Village President. The anticipated completion date of the corrective action plan is before the end of the 2027 fiscal year. The plan for adherence is the Council will review all proposed policies and adopt them, the Council will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Finding 2026-001 – Internal Control over Financial Reporting – Allowable Costs U.S. Department of Treasury Passed Through the County of Erie COVID-19: Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 Allowable Costs Contact Person Responsible for Corrective Action: Name: Tammi Michali T...
Finding 2026-001 – Internal Control over Financial Reporting – Allowable Costs U.S. Department of Treasury Passed Through the County of Erie COVID-19: Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 Allowable Costs Contact Person Responsible for Corrective Action: Name: Tammi Michali Title: Office Manager Phone/Email: 814-897-2690 / tmichali@ecgra.org Auditor’s Recommendation: The auditors recommend that management implement procedures to ensure all disbursements charged to federal programs are formally reviewed and approved by the Board, or by a properly designated approver, and that such approval is evidenced in writing and maintained with the supporting disbursement documentation. Management should also implement a monitoring procedure to identify any disbursements processed without timely approval and ensure corrective action is taken. Corrective Action Plan: A resolution was passed by the Erie County Gaming Revenue Authority’s Board of Directors affirming their consent to disburse funds for Round 2 of the Educator Retention Awards. The Board was informed by the executive director that this was a clerical oversight as the action to fund Round 2 had been discussed and was given verbal approval at previous Strategic Planning meetings. Anticipated Completion Date: Corrective Action Plan was completed on May 21, 2026
Recommendation: The Center should develop policies and procedures to help ensure pay rates are consistent with supporting employee agreements or other management-approved documentation. Corrective Action Taken: 1. Immediate Review and Correction Upon identification of the finding, the Center conduct...
Recommendation: The Center should develop policies and procedures to help ensure pay rates are consistent with supporting employee agreements or other management-approved documentation. Corrective Action Taken: 1. Immediate Review and Correction Upon identification of the finding, the Center conducted a comprehensive internal audit of pay rates for all employees hired from January 1, 2025, to the present. Any discrepancies identified during this review were promptly corrected to ensure alignment with approved documentation. 2. Staff Training Targeted training will be provided to all Human Resources and Payroll staff. This training will emphasize: The importance of accuracy in data entry and the use of self-review as a quality control tool; Accountability at both the individual and team levels for maintaining complete and accurate payroll data; and Proper preparation and retention of documentation supporting initial payroll entries and any subsequent changes. 3. Policy and Procedure Review The Center has performed a comprehensive review of its internal policies and procedures to: Ensure clear delineation of roles and responsibilities across hiring, onboarding, and payroll processes; and Provide detailed guidance on required documentation to support each step in these processes. 4. Double-Verification Process Management has reinforced a culture of shared accountability by implementing a doubleverification process. This includes: Requiring staff to review and confirm the accuracy of their own work prior to submission; and Requiring receiving staff to independently verify information and resolve any discrepancies before proceeding with further processing. 5. Continued Monitoring In addition to standard bi-weekly payroll reviews conducted by management, the Center will implement quarterly payroll system audits. These audits will verify that all payroll changes are accurate, properly documented, and supported by appropriate approvals.
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the gr...
Federal Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No. 10.557 Recommendation: Our auditors recommended the Organization update its grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has updated the grant allocation process and controls to ensure accurate documentation of expenditures allocated to the grant are retained and accurate fringe benefit costs incurred during the month are used to calculate the allocations. As part of this update management has reassigned responsibilities for various grants to ensure the process is followed.
Remaining balance was deposited on April 16, 2026. In the future management will ensure deposits are made timely or obtain HUD appproval permitting delay if there were cash flows issues.
Remaining balance was deposited on April 16, 2026. In the future management will ensure deposits are made timely or obtain HUD appproval permitting delay if there were cash flows issues.
Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction concurs with this finding. This issue was addressed in the prior audit. The grant ended shortly after completion of that audit, and there was no opportunity to change awarded amounts once the issue wa...
Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction concurs with this finding. This issue was addressed in the prior audit. The grant ended shortly after completion of that audit, and there was no opportunity to change awarded amounts once the issue was identified. The previous superintendent agreed not to pull funds back. The matter has been corrected in the new grant that began in October 2024, and the issue does not appear to affect the new grant. Mechanisms have been implemented to ensure that only schools meeting eligibility requirements receive funds. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Support for Federal Reimbursement - Literacy - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented mo...
Inadequate Support for Federal Reimbursement - Literacy - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented more stringent criteria for cash requests from schools in late 2024, and these requirements have been in place since that time. Although there has been considerable pushback from local education agencies due to the added burden, the Office has remained firm on the information required. Cash requests are audited quarterly by the Internal Control Auditor against submitted budget documents, and any issues identified are addressed. The more stringent criteria are fully implemented, and no further corrective actions are needed beyond continuing the current process. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Supporting Documentation for Local Agency Costs - WIC - DPHHS - The Montana Department of Public Health and Human Services does not concur because the recommendations would require receipt level documentation for every subrecipient transaction, which federal regulation does not require, a...
Inadequate Supporting Documentation for Local Agency Costs - WIC - DPHHS - The Montana Department of Public Health and Human Services does not concur because the recommendations would require receipt level documentation for every subrecipient transaction, which federal regulation does not require, and because the department’s existing monitoring framework meets the requirements of 2 CFR 200.332. Paragraph citations in this response refer to the Uniform Guidance as revised effective October 1, 2024; for awards issued before that date, the corresponding provisions are 2 CFR 200.332(b), (d), and (e). Under 2 CFR 200.332(c), a pass‑through entity must evaluate each subrecipient’s risk of noncompliance and risk of fraud to determine the appropriate level of subrecipient monitoring. Under 2 CFR 200.332(e), the required monitoring activities include reviewing financial and performance reports, following up on deficiencies and ensuring the subrecipient takes timely and appropriate action, and issuing management decisions on audit findings. Under 2 CFR 200.332(f), additional tools such as training and technical assistance, on‑site reviews, and agreed‑upon procedures engagements may be used depending on the risk assessment. The regulation does not require transaction level or receipt level documentation for all subrecipient expenditures as a condition of reimbursement. The department acknowledges that the auditors identified expenditures for which receipt‑level support was not on file at the time of review. The department’s position is that the controls described above, rather than universal receipt‑level retention, are the level of monitoring 2 CFR 200.332 requires given the risk profile of the Women, Infants, and Children (WIC) local agency network, and that the department retains the documentation it obtains when additional support is requested. Based on the department’s understanding of the audit results, the auditors did not report any unallowable costs during their review, and their finding focused solely on whether every cost was fully supported by receipt‑level documentation. Extending receipt‑level submission and retention to every expenditure would add substantial administrative work for the department and its local agencies without a corresponding improvement in the department’s ability to detect unallowable costs, which the existing expense report review and biennial on‑site review already address. For these reasons, the department does not concur with the recommendations. As provided in 2 CFR 200.511(c), the discussion above is the department’s detailed explanation of why it believes the recommended corrective action is not required. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - N/A
Noncompliant Rebate Calculation Review Controls - WIC - DPHHS - The Montana Department of Public Health and Human Services implemented a documentation tracking system and updated its procedures to require a documented review before invoicing. The department also retroactively reviewed and documented...
Noncompliant Rebate Calculation Review Controls - WIC - DPHHS - The Montana Department of Public Health and Human Services implemented a documentation tracking system and updated its procedures to require a documented review before invoicing. The department also retroactively reviewed and documented all rebate calculations for fiscal year 2026. The department completed this corrective action in May 2026. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 5/15/2026
Inadequate Supporting Documentation - Title 1 - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. More stringent criteria for cash re...
Inadequate Supporting Documentation - Title 1 - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. More stringent criteria for cash requests from schools were put in place in late 2024, and these requirements have been followed since that time. Although there was considerable pushback from local education agencies, the Office remained firm on the information required. The Office audits cash requests quarterly against submitted budget documents, and any issues identified are addressed. The more stringent criteria are fully implemented, and no further corrective actions are needed beyond continuing the current process. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Support for Federal Reimbursement - Title I - OPI - The Montana Office of Public Instruction partially concurs with this finding. Training and new process documentation were implemented in April 2025 to correct the issue. The previous audit was not completed until October 2024, with the f...
Inadequate Support for Federal Reimbursement - Title I - OPI - The Montana Office of Public Instruction partially concurs with this finding. Training and new process documentation were implemented in April 2025 to correct the issue. The previous audit was not completed until October 2024, with the final audit committee meeting held in December 2024, and the new process was put in place and communicated as quickly as possible. The process is now functioning correctly. The Office has implemented a tracking mechanism to ensure appropriate time reporting. For fiscal year 2027, the Office has added an additional monthly review of each federal budget to confirm that time reported aligns with expected and allocated time for each project. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and do...
Inadequate Access and Privilege Controls - TANF - LIHEAP - CHIP - Medicaid - DPHHS - The Montana Department of Public Health and Human Services completed the development of its accounts matrix for the CHIMES eligibility system in October 2025 and implemented an enhanced process for conducting and documenting access reviews, including verification of user permissions. These improvements have been fully incorporated into routine operations, and the department has implemented all aspects of the audit recommendations. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 10/24/2025
Inadequate Manual Override Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services implemented a business process in its eligibility system (CHIMES) on May 5, 2026, and revised it on August 25, 2026, to address common override reasons and to document the basis for each o...
Inadequate Manual Override Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services implemented a business process in its eligibility system (CHIMES) on May 5, 2026, and revised it on August 25, 2026, to address common override reasons and to document the basis for each override. Effective August 19, 2026, staff added a targeted question to the monitoring tool regarding manual overrides and issuances to ensure these items are consistently reviewed. The department considers this corrective action implemented and will evaluate its effectiveness during the upcoming monitoring cycle. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/25/2026
Inaccurate ACF‑204 Reporting Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services revised its instructions and implemented a mandatory review checklist on August 26, 2026. The updated process includes enhanced review steps and requires formal sign-off by both the prog...
Inaccurate ACF‑204 Reporting Controls - TANF - DPHHS - The Montana Department of Public Health and Human Services revised its instructions and implemented a mandatory review checklist on August 26, 2026. The updated process includes enhanced review steps and requires formal sign-off by both the program manager and the Temporary Assistance for Needy Families (TANF) unit designee prior to final report submission to ensure data accuracy. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/26/2026
Noncompliant Timely Reimbursement Controls - O&M - DMA - The Montana Department of Military Affairs partially concurs with the finding. The department recognizes the need to submit reimbursement requests timely and has implemented improved tracking procedures and a regular reimbursement‑request proc...
Noncompliant Timely Reimbursement Controls - O&M - DMA - The Montana Department of Military Affairs partially concurs with the finding. The department recognizes the need to submit reimbursement requests timely and has implemented improved tracking procedures and a regular reimbursement‑request process, generally on a bi‑weekly or monthly basis, to support timely submission of SF‑270s. However, the department cannot submit reimbursement requests until the applicable federal funding modification has been approved and funding has been allocated by the National Guard; therefore, delays attributable to pending federal funding availability are outside the department’s control. The department will continue to track expenditures and reimbursement due dates by award, monitor the status of funding modifications, submit reimbursement requests promptly when funding becomes available, and document the reason for any reimbursement request submitted outside the required timeframe. The department will also consult with the United States Property and Fiscal Office to identify whether alternative processes are available to allow reimbursement requests to be submitted without waiting for completion of a funding modification. Management will review outstanding reimbursement requests and documented exceptions regularly to ensure timely follow‑up. Responsible Party - Janae Brower, Chief Financial Officer, Montana Department of Military Affairs Target Implementation Date - 11/30/2026
Noncompliant Payroll Allocation Controls - O&M - DMA - The Montana Department of Military Affairs concurs with the finding and will strengthen controls to ensure payroll coding and allocations are updated timely. The department will create a process for all changes to task profile IDs to ensure accu...
Noncompliant Payroll Allocation Controls - O&M - DMA - The Montana Department of Military Affairs concurs with the finding and will strengthen controls to ensure payroll coding and allocations are updated timely. The department will create a process for all changes to task profile IDs to ensure accurate funding-split percentages and coding are in place before payroll processing. The department will perform reconciliations of payroll charges, document and promptly correct errors, and verify that corrections address all related coding elements and split percentages. Responsible Party - Janae Brower, Chief Financial Officer, Montana Department of Military Affairs Target Implementation Date - 11/30/2026
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