Corrective Action Plans

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Finding Reference Number: 2025-001 Federal Agency: U.S. Department of Health and Human Services Program Name: Aging Cluster Assistance Listing Number: 93.044/93.045/93.053 Responsible Official: Penny Crawford, Chief Executive Officer; Kelsey Swinderman, Financial Manager Views of Responsible Individ...
Finding Reference Number: 2025-001 Federal Agency: U.S. Department of Health and Human Services Program Name: Aging Cluster Assistance Listing Number: 93.044/93.045/93.053 Responsible Official: Penny Crawford, Chief Executive Officer; Kelsey Swinderman, Financial Manager Views of Responsible Individuals: The Agency acknowledges the documentation deficiencies identified related to payroll and contract management. These issues were largely due to leadership transitions and changes in operational processes. The Agency has evaluated these gaps and is actively implementing corrective actions to strengthen internal controls and ensure compliance with Uniform Guidance requirements. Corrective Action Plan: Corrective actions currently in progress include: • Standardizing documentation requirements for all employee pay rates, including maintaining supporting documentation within personnel files • Implementing internal review procedures to ensure payroll changes align with Board-approved actions • Centralizing contract management and maintaining all executed service provider agreements in a secure, accessible location • Establishing documentation retention procedures to ensure all supporting records for federal award expenditures are complete and readily available for audit review The Agency is committed to fully resolving these issues and strengthening internal processes to ensure ongoing compliance and accountability. The Agency is implementing enhanced internal control procedures to ensure that all costs charged to federal awards are properly authorized, documented, and maintained in accordance with federal requirements. These improvements include the development of standardized processes for payroll documentation, contract management, and documentation retention. Internal review procedures are also being strengthened to ensure alignment between Board approvals and financial records. Anticipated Completion Date: June 30, 2026
The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare the schedule of expenditures of federal awards that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Autho...
The Authority’s Board of Commissioners and management will continue to rely on the use of their outside auditors to prepare the schedule of expenditures of federal awards that were presented in accordance with generally accepted accounting principles. Management will assign a person within the Authority with the skills, knowledge and expertise to review and approve the schedule of expenditures of federal awards.
COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF CAYEY Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Auditor Report: Report on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2024 – ...
COMMONWEALTH OF PUERTO RICO AUTONOMOUS MUNICIPALITY OF CAYEY Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Auditor Report: Report on Compliance and Internal Control in Accordance with Government Auditing Standards and OMB Super Circular Uniform Guidance Audit Period: July 1, 2024 – June 30, 2025 Fiscal Year: 2024-2025 Principal Executive: Hon. Ronaldo Ortiz Velázquez, Mayor Contact Person: Mrs. Eunice Díaz, Finance and Budget Director Phone: (787)738-3211 Original Finding Number: 2025-003 Statement of Concurrence or Non concurrence: We concur with the finding. Corrective Action: As an internal control and prevention measure, the budget sent by the Agency will be verified with the percentages (%) established in the contract. If they do not match, ACUDEN will be asked to amend the budget. Also, as part of the corrective action plan, the municipality will be moving the location of its centers in search of better accessibility for participants and to be more aggressive in providing services and spending the allocations in full. Implementation Date: During fiscal year 2025-2026. Responsible Person: Mrs. Natasha Vázquez Federal Programs Director
Student Financial Assistance Cluster – Assistance Listing No. 84.033 Recommendation: We recommend the University review current processes for calculating and tracking the students employed in community service activities for its Federal Work Study funds to meet the minimum 7% requirement. Explanatio...
Student Financial Assistance Cluster – Assistance Listing No. 84.033 Recommendation: We recommend the University review current processes for calculating and tracking the students employed in community service activities for its Federal Work Study funds to meet the minimum 7% requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is prepared to return the FY25 FWS Unspent portion of the 7% Community Service required spending (7% of Final FWS Funding of $742,211 = $51,954.77 (rounded to $51,955) [Community Service spending requirement] minus $25,061 (FWS funds spent in community service as reported on FISAP) = $26,894 (Unspent portion of 7% to be returned to ED). Since the pandemic year, ISU’s off-campus (community service) participation has been dwindling and overall FWS participation has suffered since many students and employers are opting to be involved in the University’s Career Path Internship (CPI) program over FWS. Due to the struggles in recent years to meet the 7% Community Service requirement, ISU has been applying for a waiver of the Community Service requirement but thus far our waiver requests have been denied. The Financial Aid Office is reviewing current processes related to tracking FWS Community Service spending and partnering with the Career Center to proactively identify off-campus participants and looking at ways to cooperate with the University’s CPI program participants who are FWS-eligible and who are working in Community Service activities and plan to expand on-campus FWS Community Service opportunities to meet the minimum 7% community service requirement. Name(s) of the contact person(s) responsible for corrective action: James Martin, Director of Financial Aid and Katheryn Wareing, Senior Accountant for Financial Aid/FWS Administrator Planned completion date for corrective action plan: 08/24/2026
Finding 2025-003 Name of Responsible Individual: Angelo Chrisomalis, Sr. Director Grants and Contracts Corrective Action: Due to a change that occurred after the reporting period appropriately reallocating one employee’s effort to the federal funding source, the certification was not displayed on th...
Finding 2025-003 Name of Responsible Individual: Angelo Chrisomalis, Sr. Director Grants and Contracts Corrective Action: Due to a change that occurred after the reporting period appropriately reallocating one employee’s effort to the federal funding source, the certification was not displayed on the effort report. The employee has certified that this effort was charged appropriately to this award. We are reviewing our policies and procedures to ensure redistribution of labor is performed within a timely manner. We have moved to an annual effort reporting process aligned to the federal regulations and are implementing the Cayuse Effort Reporting module that will more effectively track and report effort. The system will be implemented during our next effort reporting cycle. Anticipated Completion Date: March 1, 2026
2025-004 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Take...
2025-004 Activities Allowed or Unallowed U.S. Department of Labor Assistance Listing Number 17.258/17.259/17.278 Recommendation: We recommend that the Board design and implement controls to ensure that all charges to federal programs are adequately reviewed and approved prior to payment. Action Taken: The Board will evaluate existing review and approval processes for federal program charges and implement appropriate controls to ensure all expenditures are thoroughly reviewed, properly authorized, and fully supported before payment is made. As part of the review of charges, a daily review of invoices will be implemented to ensure that all invoices coded to WIOA are allowable costs. The Board’s allowable costs are reviewed by three members: Fiscal Coordinator, Fiscal Manager and Executive Director. These are reviewed and approved by each before the costs are paid. Evidence of these allowable costs will have reviewer’s initials and date reviewed on the bills/invoices themselves and a checklist with signatures that they have reviewed these.
Management will review grant reporting procedures and evaluate potential process refinements related to the calculation and inclusion of indirect costs with reimbursement requests, consistent with the approved indirect cost rate where applicable. The previous approach reflected a conservative decisi...
Management will review grant reporting procedures and evaluate potential process refinements related to the calculation and inclusion of indirect costs with reimbursement requests, consistent with the approved indirect cost rate where applicable. The previous approach reflected a conservative decision with respect to indirect cost recovery.
Management will review current grant tracking and reimbursement procedures and pursue improvements, as appropriate, to strengthen coordination across grant programs. Opportunities to enhance review processes prior to submission will also be considered to help minimize duplicate charges and support c...
Management will review current grant tracking and reimbursement procedures and pursue improvements, as appropriate, to strengthen coordination across grant programs. Opportunities to enhance review processes prior to submission will also be considered to help minimize duplicate charges and support compliance with federal requirements.
Finding: #2025-002- Time and Effort Reporting Assistance Listing/Program Title: #84.027 A/IDEA Flow Through and #84.173A/Preschool Entitlement (Special Education Cluster) Federal Agency/Pass-Through Entity: U.S Department of Education/Wisconsin Department of lnstruction Award Numbers/Year: 2025-1333...
Finding: #2025-002- Time and Effort Reporting Assistance Listing/Program Title: #84.027 A/IDEA Flow Through and #84.173A/Preschool Entitlement (Special Education Cluster) Federal Agency/Pass-Through Entity: U.S Department of Education/Wisconsin Department of lnstruction Award Numbers/Year: 2025-133332-DPI-FLOW-341 and 2025-133332-DPI-PRESCH-347/2024-2025 Criteria: In accordance with the federal Uniform Guidance, charges to federal awards for salaries and benefits must be based on records that accurately reflect the work performed. Such records must be supported by time and effort documentation. Condition: During the auditors' testing of payroll charges, it was noted that the District did not maintain adequate time and effmi documentation to support the allocation of salaries and benefits to the Special Education Cluster. Specifically, one employee's time was coded to the Special Education Cluster at a fixed 10% allocation. Cause: The District did not have adequate internal controls to ensure required time and effort documentation was consistently obtained and maintained for all employees whose salaries and benefits were charged to the Special Education Cluster. Staff turnover and lack of training contributed to inconsistent application of federal requirements. Effect: Because required time and effort documentation was not properly maintained, salaries and benefits charged to the Special Education Cluster may not accurately reflect actual time spent working on the program. As a result, these costs are unallowable under the Uniform Guidance. Questioned Costs: The absence of proper documentation results in questioned costs of $7,037, representing the salary and benefit amounts charged to the program for the one employee without adequate support. Recommendation: The auditor recommends that the District strengthen internal controls over time and effort reporting to ensure all employees funded in whole or in part by federal programs complete required documentation in accordance with Uniform Guidance. Additionally, a monitoring process should be implemented to ensure time distribution report is are completed accurately and retained in accordance with record-keeping requirements. Response: Management concurs with the finding and will implement internal control improvements to ensure full compliance with federal time and effort documentation requirements.
Corrective Action Plan: The University accepts this finding and has removed the questioned costs from the award. Management will reinforce and reiterate the internal controls process to the staff responsible for the review of the grant expenditures during the financial reporting process. Management ...
Corrective Action Plan: The University accepts this finding and has removed the questioned costs from the award. Management will reinforce and reiterate the internal controls process to the staff responsible for the review of the grant expenditures during the financial reporting process. Management will also communicate via our Financial Administrative Bulletin to the grants administration community our internal controls around 2 CFR 200. Management will conduct 2 CFR 200 training with the impacted departmental grant administration by March 5, 2026 Completion Date: March 31, 2026 Contact Person: Paul Gasior 443-997-8141
Management will prepare the schedule of expenditures of federal awards as part of the year end closing process to determine our audit requirements under the Uniform Guidance and provide the schedule to the audit firm during the financial audit process.
Management will prepare the schedule of expenditures of federal awards as part of the year end closing process to determine our audit requirements under the Uniform Guidance and provide the schedule to the audit firm during the financial audit process.
FINDING 2025-003 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Beth Quinn Contact Phone Number and Email Address: 260-728-3306 quinnb@nadams.k12.in.us Contact Person Responsible for Corrective Action: Abi West, Director of Special Ed...
FINDING 2025-003 Finding Subject: Special Education Cluster (IDEA) - Earmarking Contact Person Responsible for Corrective Action: Beth Quinn Contact Phone Number and Email Address: 260-728-3306 quinnb@nadams.k12.in.us Contact Person Responsible for Corrective Action: Abi West, Director of Special Education Contact Phone Number and Email Address: 260-824-5880 awest@awssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Cooperative maintains a tracking spreadsheet to monitor hours worked by staff providing services to non-public students. Staff member will record K-12 and preschool hours separately on their Time and Effort Log. The Cooperative will then document these hours, distinguishing between Part B funds and Preschool funds. For kindergarten-aged students, the Speech-Language Pathologist will collaborate with the Student Record Administrative Assistant to identify students eligible under Section 5a (619 funding). Specifically, these are kindergarten students who are not yet six years old as of December 1. Such students are funded through both the 611 and 619 grants. Time and effort for preschool students, including 5a students, will be prioritized to the 619 grant until its allocated funds are fully expended. Once the 619 funds are exhausted, effort will be shifted to the 611 grant accordingly. Proportionate share reports will be based on actual expenditures within the six-month period, as reflected in our tracking spreadsheet. This process will be corrected for FY 2023 (611 and 610) and FY 2024 (611 and 910) to ensure compliance and prevent recurrence of similar findings in the next audit cycle. Anticipated Completion Date: September 1, 2025
Information on the federal program : Subject: Child Nutrition Cluster (CNC) Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (Or Other Identifying Numbers): FY2...
Information on the federal program : Subject: Child Nutrition Cluster (CNC) Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (Or Other Identifying Numbers): FY23-FY24, FY24-FY25 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed and Unallowed, Allowable Costs Audit Findings: Material Weakness, Other Matters Condition : The School Corporation did not have adequate internal controls in place to ensure that the School Corporation complied with the allowable cost requirements. Context : During our testing of the School Corporation’s compliance with the allowable cost requirements for the Child Nutrition Cluster (CNC), we tested 40 vendor disbursement transactions and 40 payroll disbursement transactions and identified the following exceptions: 1. For one vendor disbursement, the School Corporation incorrectly recorded the disbursement for $820 to Fund 800 (School Lunch Fund) that should have been recorded to Fund 300 (Operations Fund), resulting in an unallowable cost being charged to the food service fund. 2. For one payroll disbursement, the School Corporation inaccurately entered the number of hours worked by a cafeteria employee for one pay period, resulting in an overpayment to the employee by $5,568. The employee notified the School Corporation of the overpayment and remitted the overpayment back to the School Corporation. These errors were attributable to deficiencies in the internal controls over the review and approval of vendor and payroll expenditures. Views of Responsible Official : We concur with the finding. Description of Corrective Action Plan : Management will enhance controls and review processes surrounding vendor and payroll expenditures charged to the Child Nutrition. The Food Service Director will be receiving periodic reports to review expenditures charged to the CNC to monitor charged costs. The payroll exceptions report is now checked by the Executive Assistant and Payroll. Responsible Party and Timeline for Completion : Immediately corrected
Information on the federal program: Subject: COVID-19 - Education Stabilization Fund, Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Programs: Elementary and Secondary School Emergency Relief Fund (ESSER III) Assistance Listings Nu...
Information on the federal program: Subject: COVID-19 - Education Stabilization Fund, Activities Allowed or Unallowed and Allowable Costs/Cost Principles Federal Agency: Department of Education Federal Programs: Elementary and Secondary School Emergency Relief Fund (ESSER III) Assistance Listings Number: 84.425U Federal Award Numbers and Years (or Other Identifying Numbers): S425U210013 Pass-Through Entity: Indiana Department of Education Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Audit Finding: Material Weakness, Internal Control Condition: The School Corporation did not have internal controls in place to ensure compliance with the activities allowed or unallowed and allowable cost/cost principles requirements. The School Corporation had not designed or implemented adequate policies or procedures to ensure that stipend and wage rates were properly reviewed and approved. Context: For the testing of activities allowed and unallowed costs-cost principles, 12 vendor disbursements and 40 payroll disbursements were selected for testing. The following deficiencies were noted related to controls over pay rate approvals: • For 10 of 10 stipends sampled, the School Corporation could not provide proper approval of the stipend amount. The total of amount of stipends sampled was $5,056. The total amount of stipends charged to the grant for the audit period was $57,558. • One employee was underpaid by $9, and the error was not caught during the review process. • For two of seven hourly employees sampled, the School Corporation provided a pay chart. However, approval of the rates was not available. • One teacher received twice their regular paycheck amount due to a contract pay off. The School Corporation could not provide approval or additional support related to the contract payoff amount of $1,528. Views of Responsible Officials: Management agrees with the finding and has prepared a corrective action plan. Description of Corrective Action Plan: Management will retain documentation and approval for stipend and hourly pay rates. Management will review all pay runs and ensure the accurate amount of pay is disbursed and retain documentation for any changes in pay amounts. Responsible Party and Timeline for Completion: The Treasurer will be responsible for implementing the corrective action plan, which will go into effect immediately.
Provider/Employee will submit payroll records/invoices by student services monthly/bi-monthly to the bookkeeper. Once payroll records or invoices are received, the CFO will prepare a spreadsheet that calculates the time/amounts serviced by the non-public school and member school. Once the total hour...
Provider/Employee will submit payroll records/invoices by student services monthly/bi-monthly to the bookkeeper. Once payroll records or invoices are received, the CFO will prepare a spreadsheet that calculates the time/amounts serviced by the non-public school and member school. Once the total hours are calculated, a percentage based on total hours worked for each member school will be used to allocate the provider/employee time for each member school. This documentation will be attached to each reimbursement request.
2025-001 Eligibility Over Title I Program: Title I - Grants to Local Educational Agencies Federal Assistance Listing Number: 84.010 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 25FT1TTI-511375-01A Questioned Costs: $-0- Type of Fin...
2025-001 Eligibility Over Title I Program: Title I - Grants to Local Educational Agencies Federal Assistance Listing Number: 84.010 Federal Agency: U.S. Department of Education Pass-Through Agency: Arizona Department of Education Grantor Number: 25FT1TTI-511375-01A Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition/Context: During our testing of school eligibility and funding, we discovered the District did not maintain records that agreed to the low-income student counts as reported to the Arizona Department of Education to properly allocate Title I funding by poverty level. Corrective Action: The District will ensure in future periods that records are maintained to support lowincome students and the allocation of Title I funding as reported to the Arizona Department of Education. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Jenette King, Business Manager
Recovery Services of Northwest Ohio, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024-June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently w...
Recovery Services of Northwest Ohio, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024-June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. 2025-001 Type of Finding: Significant deficiency identified: The organization is charging payroll costs to grants based on budgeted amounts rather than costs supported by time and effort documentation. Recommendation: Implementation of either a timekeeping system where timecards include documentation of time allocated to each grant or the implementation of a time study process with the lookback procedures to meet the time and effort documentation requirements in accordance with the Uniform Guidance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The organization will implement time and effort documentation/time study for federal awards and charge grant staff costs based on such documentation. Name(s) of the contact person(s) responsible for corrective action: Jean Groves, CFO, Recovery Services of Northwest Ohio, Inc. 419-782-9920. Planned completion date for corrective action plan: March 15, 2026.
The District, under new office management will review contracts against the board approved salary schedules before the employees are paid. Also, when an employ-ee separates from the District, earned pay will be recalculated and reviewed to deter-mine if there is a difference in pay.
The District, under new office management will review contracts against the board approved salary schedules before the employees are paid. Also, when an employ-ee separates from the District, earned pay will be recalculated and reviewed to deter-mine if there is a difference in pay.
CORRECTIVE ACTION PLAN June 30, 2025 Women for a Healthy Environment submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Herbein + Company, Foster Plaza 10, 680 Andersen Drive, Suite 205, Pittsburgh, PA 15220 Audit pe...
CORRECTIVE ACTION PLAN June 30, 2025 Women for a Healthy Environment submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Herbein + Company, Foster Plaza 10, 680 Andersen Drive, Suite 205, Pittsburgh, PA 15220 Audit period: Year ended June 30, 2025 Contact: Michelle Naccarati-Chapkis, Executive Director The finding from the June 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Section III - Federal Award Findings and Questioned Costs 2025-001 ALLOWABLE COSTS, CASH MANAGEMENT, AND REPORTING – SIGNIFICANT DEFICIENCY Federal Program U.S. Department of Housing and Urban Development - Healthy Homes Production Program - ALN 14.913 Criteria Under OMB guidance, Public Law (Pub. L) No. 116-117, Payments Integrity Information Act of 2019, and Executive Order 13520 on reducing improper payments, federal agencies are required to take actions to prevent improper payments, review federal awards for such payments, and as applicable, recover improper payments, including any duplicate payment. Condition While working to provide a population of invoices for audit testing, management identified five invoices that were submitted for reimbursement twice, resulting in an overdraw of federal money. Additionally, while performing audit procedures over cash management and reporting, we noted that there was no review and approval of reports submitted for reimbursement. The Organization is required to submit quarterly reports for reimbursement. Neither of the two reports selected for testing contained evidence regarding review or approval prior to submission. Cause Duplicate invoices were submitted due to a temporary process change at the Organization when there were federal governmental department changes occurring related to federal programs. The Organization’s process change resulted in multiple people submitting reimbursement for the same expenses. We also noted that the reports were prepared based on information provided by separate personnel, but there was no review or approval in place over reports once they are combined to check for accuracy prior to submission. Effect The Organization overdrew federal program money during the year due to duplicate invoice submission, resulting in unallowable costs being charged to the program and inaccurate financial reporting. Questioned Costs $16,303 Context With changes in the processes for grant funding, the Organization prioritized submission of invoices for reimbursement. During this prioritization, the Organization implemented a temporary process change, resulting in the duplication submission errors of five invoices and the overdraw of federal funds. The lack of appropriate review and approval allowed the duplicate submission to occur. Repeat Finding No Recommendation We recommend that Women for a Healthy Environment establish and follow a system of internal control related to the costs charged to Federal programs. The process should establish procedures and responsibilities for the documentation and review of costs incurred and charged to Federal awards. Review and approval of this documentation should be performed by a person other than the preparer prior to submission to the Federal agency. Management Response Women for a Healthy Environment has reviewed the recommendation noted above and has put additional internal controls in place related to the reimbursement drawdowns/costs charged to Federal programs. This includes ensuring that only one reimbursement is being completed each month, rather than one done at mid-month. The accounting team will continue to prepare those monthly reimbursement calculations, which will be reviewed by the Program Manager, Director of Operations, and Executive Director.
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are follow...
Trainings have been conducted during the current school year for principals, secretaries, and cooks at all schools on following correct meal patterns and point of service procedures. The current child nutrition director performs random audits and visits at all schools to make sure schools are following these procedures consistently.
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS ...
Corrective action plan: The CAPPS Financials team uses Pathlock to monitor and log privileged user activities. Pathlock maintains documentation of approvals and business justifications. Documentation of recurring privileged access reviews will be maintained as appropriate across all dedicated CAPPS Financial modules. IAM team will establish a documented process through which it will coordinate with the CAPPS Financial team to perform quarterly reviews of accounts and audit logs to strengthen privileged access provisioning. The review process will include documented approval, business justification, and periodic revalidation for all elevated roles in CAPPS Financial. Pathlock software is being used to manage single sign-on for granting privileged access to allowed users. With this software, the IAM team can grant access to a user, who would then login as themselves and then switch to the appropriate privileged role. Once the user switches to a privileged role, the Pathlock software maintains the audit log of user activity. Implementation date: February 27, 2026 Responsible persons: Daniel Kellogg, Deputy Chier Information Officer (DCIO), Infrastructure Services Leatha Marr, DCIO & Chief Product Officer, System Applications
Corrective action plan: HHSC will run quarterly expenditure reports for this grant to monitor administrative earmarking thresholds. Implementation date: July 31, 2026 Responsible person: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations
Corrective action plan: HHSC will run quarterly expenditure reports for this grant to monitor administrative earmarking thresholds. Implementation date: July 31, 2026 Responsible person: Roderick Swan, Associate Commissioner, Behavioral Health Services Operations
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security ...
Corrective action plan: ITS will: • Work with HR and Security to analyze and validate the size and scope of the late submission of access termination requests for separated employees. Communicate the analysis results and recommendations on or before May 1, 2026. • Work with the Information Security Office for continuation of periodic reconciliation of HR data and network accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Work with Human Resources to establish a schedule of periodic reconciliation for HR data and case management application accounts. Schedule for reconciliation to be established on or before May 1, 2026. • Review existing business process for offboarding separated employees and provided recommendations to HR for training and communication for staff. Recommendations to be provided by May 1, 2026. • Determine what technology solution may be needed by August 31, 2026, with consideration of effectiveness of mitigation actions, as noted above. Implementation dates: See Corrective action plan Responsible person: Angie Lindemann, Deputy Chief Information Officer
Corrective action plan: ITS Management will establish a formal, documented user access review program applicable to both privileged and non-privileged network users. Key actions include: 1. Policy Updates: Revise information technology access control policies and procedures to re-quire periodic (at ...
Corrective action plan: ITS Management will establish a formal, documented user access review program applicable to both privileged and non-privileged network users. Key actions include: 1. Policy Updates: Revise information technology access control policies and procedures to re-quire periodic (at least annual) reviews of all network user access. 2. Standardized Process and Documentation: Implement a consistent, documented review process and maintain records in a centralized repository to ensure accountability and auditability. 3. Monitoring and Oversight: Implement oversight procedures to track completion of access re-views and remediation of identified issues, with reporting to IT and information security leadership to support governance. Implementation dates: 1. Policy and procedure updates: Expected completion by April 30, 2026 2. Standardized process and repository implementation: Expected completion by May 31, 2026 3. First completed annual review under the revised process: Expected completion by June 30, 2026 Responsible persons: Tara Mitchell, Director of IT Operations Sean Peterson, Chief Information Officer
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that ...
Corrective action plan: • IT will coordinate with HR on strengthening the separation process, to include HR running separation reports quarterly and sending to IT to cross check. Will perform regular scheduled meetings to discuss the separation process/issues. • IT is testing automatic scripts that will aid in the process and will be implemented this year. • IT will document quarterly access reviews which are already done. • IT will work on enhancing automation and controls; Will utilize AI to assist. Implementation date: May 2026 Responsible person: Chris Bunton, CIO, Texas Department of Agriculture
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