Corrective Action Plans

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Findings #2025-001 and #2025-005 – Material Weakness. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA...
Findings #2025-001 and #2025-005 – Material Weakness. Applicable federal programs: U. S. Department of Health and Human Services, 93.566, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Passed through Texas Office for Refugees: 10/01/24 – 09/30/25, FFY2025-27946V-ASA RSS, 10/01/24 – 09/30/25, FFY2025-27946V-AUSAA-RSS, 10/01/24 – 09/30/25, FFY2025-27946V-CMA, 10/01/24 – 09/30/25, FFY2025-27946V-RSS, Passed through United States Conference of Catholic Bishops: 10/01/24 – 09/30/25, 25RSI13A, Passed through U. S. Committee for Refugees: 10/01/24 – 09/30/25, RHP-2025-YMCA-Houston TX-03, 93.567, Refugee and Entrant Assistance Voluntary Agency Programs, Passed through U. S. Committee for Refugees and Immigrants: 10/01/24 – 09/30/25, 2502VARVMG, 10/01/23 – 09/30/24, 2402VARVMG, 93.676, Unaccompanied Alien Children Program, Passed through U. S. Committee for Refugees and Immigrants: 01/01/25 – 12/31/25, 90ZU0630-02. Condition and context: During the planning phase of the audit, management disclosed that amounts reported as employee withholdings on Form 941 had been intentionally manipulated by the former payroll director resulting over reporting withholdings to the Internal Revenue Service. Management did not have a formal reconciliation process in place to compare Form 941 to the payroll register and general ledger, nor was there a periodic reconciliation of the payroll register to the general ledger. The absence of these independent reconciliation controls allowed the misstatement to occur and not be detected in a timely manner. In our testing of 110 payroll transactions, we identified the following exceptions: Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 1 out of 40 payroll transactions tested utilized the incorrect pay rate. Unaccompanied Alien Children Program (ALN 93.676) – 1 out of 40 payroll transactions tested utilized the incorrect pay rate. Refugee and Entrant Assistance State/Replacement Designee Administered Programs (ALN 93.566) – 1 out of 40 payroll transactions tested was incorrectly charged to the program. Additionally, in testing the reconciliation of payroll expense recorded in the payroll register to the amount recorded in the general ledger system, an error of $349,000 was identified. The error was related to credit card charges erroneously being recorded to payroll expense. Recommendation: Policies and procedures should be designed and implemented to prepare a formal reconciliation of Form 941 to the payroll register and the general ledger and a reconciliation between the payroll register and the general ledger. Additionally, procedures should be strengthened over the review of pay rates utilized in the payroll system and the allocation of payroll to cost centers and government programs. Planned corrective action: Management acknowledges the deficiency identified in the execution and precision of payroll reconciliation processes. During the audit planning phase, management disclosed that a former payroll director intentionally manipulated employee withholding amounts reported on Form 941 in prior periods. While reconciliation procedures between the payroll register, general ledger, and Form 941 filings were in place, they were not performed with sufficient precision and consistency to detect the misstatement in a timely manner. Additionally, audit testing identified isolated instances of incorrect payrates and program allocations, as well as a misclassification of approximately $349,000 related to credit card return charges recorded to accrued payroll; management has confirmed this item represents a classification error and not an issue impacting payroll processing or employee compensation. In response, management has refined reconciliation procedures to require more detailed comparison across systems, established clearer expectations for investigation and resolution of variances, and enhanced documentation standards to evidence the level of review performed. Management has also strengthened oversight of payroll activity, including review of payrates and allocation of payroll costs to programs, and will continue to monitor these controls to ensure they are operating with an appropriate level of precision and consistency. In May 2026, an interim leadership structure was established in response to the departure of the Chief Financial Officer. During this interim period management is assessing departmental functions and organizational structure to better align responsibilities and further strengthen internal controls in the areas noted above. Responsible officer: Lauren Rome, VP of Financial Operations/Interim CFO. Estimated completion date: June 15, 2026.
2025-003 Inadequate Contract Review Name of Contact Person: Samantha Hurd, DSS Director Corrective Action: The Deaprtment of Social Services will implement new review procedures to verify that all certifications and provisions are included in contracts for the purchase of services. Proposed Completi...
2025-003 Inadequate Contract Review Name of Contact Person: Samantha Hurd, DSS Director Corrective Action: The Deaprtment of Social Services will implement new review procedures to verify that all certifications and provisions are included in contracts for the purchase of services. Proposed Completion Date: May 31, 2026.
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisor...
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisory review.
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisor...
Views of Responsible Officials and Planned Corrective Action Management agreed with the findings and indicated that corrective actions were implemented in January 2026 to ensure employee time is properly tracked and allocated by program, including updated timesheet procedures and enhanced supervisory review.
U.S. Department of Agriculture 2025-007 Weakness in Internal Controls Over Compliance of Allowable Costs/Cost Principles of Payroll Disbursements Federal Program: Child Nutrition Cluster — USDA Commodities (15.550), School Breakfast Program (10.553), National School Lunch Program (10.555), Summer Fo...
U.S. Department of Agriculture 2025-007 Weakness in Internal Controls Over Compliance of Allowable Costs/Cost Principles of Payroll Disbursements Federal Program: Child Nutrition Cluster — USDA Commodities (15.550), School Breakfast Program (10.553), National School Lunch Program (10.555), Summer Food Service Program for Children (10.559) Management agrees with the finding and has reviewed the payroll items identified during the audit and has taken corrective action to address schedule discrepancies and unsupported payroll entries. Management has conducted a review of employee schedules within the timekeeping system to ensure alignment with payroll records and has corrected errors identified. Management plans to continue performing periodic reviews of payroll data to identify potential discrepancies and to take corrective action as needed. Management will also evaluate identified payroll discrepancies on a case‑by‑case basis to determine whether recovery or adjustment is appropriate. Person responsible: Christin Legros, Director of Finance Expected completion date: June 2026
Finding 2025-001 Fiscal year in which the finding occurred: 2025 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: U.S. Department of Labor Contact person responsible for the corrective action: Michael Brey Description of Audit Finding: An effective internal control system w...
Finding 2025-001 Fiscal year in which the finding occurred: 2025 Pass-Through Entity, if pass-through or Federal Grantor Agency, if direct: U.S. Department of Labor Contact person responsible for the corrective action: Michael Brey Description of Audit Finding: An effective internal control system was not designed or implemented at the Organization related to payroll and incentives/subscriptions to ensure compliance with requirements related to the grant agreements and Allowable Costs/Cost Principles compliance requirements. Corrective Action to be Taken: Beginning in April 2026, the organization has changed the process to record payroll to be charged to the grant. A spreadsheet has been created to track each payroll register and the amounts paid to each employee assigned to the grant. This data will be tracked throughout the year and checked against the payroll amount allowed per the grant budget. If any adjustments are required, that will happen in June and December. The payroll spreadsheet will be reviewed by a second employee to validate the spreadsheet is correct. Beginning in February 2026 the organization has corrected the subscription pricing to $1,500 per eligible shop. Additionally, the organization identified that certain shop incentives were being overcharged to the grant due to sales tax being added to the tool kit. The organization has adjusted the composition on the tool kit to reduce the amount including sales tax to be under the $8,500 allowable limit. Any excess incentive awarded in 2026 will not be submitted to the DOL for reimbursement from the grant. The tracking file for shop incentive awards is reviewed by the Controller. Correcting adjustments will be made to the grantor financial reports in 2026 to correct the overcharged payroll costs and incentives/subscription costs identified in 2025 and to properly reflect the cumulative grant expenditures in accordance with Allowable Costs/Cost Principles compliance requirements. Grantor financial reports will be reviewed by a second employee. Anticipated completion date: New process in place effective 4/1/26.
Agency personnel will ensure costs that are charged to federal awards were incurred during the applicable period of performance and recorded in the correct period.
Agency personnel will ensure costs that are charged to federal awards were incurred during the applicable period of performance and recorded in the correct period.
Non-compliance with Allowable Cost/Cost principle: a) Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, ...
Non-compliance with Allowable Cost/Cost principle: a) Recommendation: We recommend that the Organization strengthen its internal controls over the coding, approval, and review of expenditures included in the Health Center Program to ensure compliance with Uniform Guidance allowable cost principles, including establishing procedures to systematically identify and exclude late fees, finance charges, and other penalty-type costs from federal awards, and providing training to finance and program staff on allowable versus unallowable costs. b) Planned corrective action: Agreed. Invoices are to be coded appropriately to ensure properassignment to grants. This exercise will include assigning late fees and other non-allowable expenses to general funds. c) Contact person responsible for corrective action: Steven Mayers d) Anticipated completion date: Implemented immediately, 6/10/2026 e) Status of implementation: Implemented.
Finding 2025-004 – Activities Allowed/Allowable Costs/Cost Principles Management agrees with the finding regarding activities allowed, allowable costs, and compliance with federal cost principles. The Housing Authority has reviewed its procedures related to processing and approving program expenditu...
Finding 2025-004 – Activities Allowed/Allowable Costs/Cost Principles Management agrees with the finding regarding activities allowed, allowable costs, and compliance with federal cost principles. The Housing Authority has reviewed its procedures related to processing and approving program expenditures and recognizes the need to strengthen internal controls and documentation standards. Management will implement additional review procedures to ensure expenses charged to HUD programs are properly supported, allowable under program requirements, and accurately allocated to the appropriate funding source. Corrective actions will include enhanced supervisory review of invoices and disbursements, improved supporting documentation practices, and periodic monitoring of program expenditures. Management will also continue coordination with the fee accountant and auditor to ensure compliance with Uniform Guidance and HUD requirements. The Housing Authority will provide additional staff training regarding allowable costs and documentation requirements to reduce the risk of future noncompliance. Responsible Party: Executive Director and Operations Accountant Expected Completion Date: September 30, 2026
Finding Number: 2025-002 Finding Name: Allowable Costs Finding Condition(s): During testing of allowable costs, we identified shared payroll and other costs charged to federal programs for which adequate support for the cost allocation methodology was not maintained. Specifically, allocation schedul...
Finding Number: 2025-002 Finding Name: Allowable Costs Finding Condition(s): During testing of allowable costs, we identified shared payroll and other costs charged to federal programs for which adequate support for the cost allocation methodology was not maintained. Specifically, allocation schedules and underlying documentation supporting how payroll allocation percentages were determined were incomplete or unavailable. As a result, we were unable to conclude that all sampled costs were allocated to the federal programs in proportion to the relative benefit received. Name of Contact Person(s): Mark Yates, Interim CFO, 312-479-5395 Corrective Action(s): Management will retain detailed allocation support and maintain its allocation methodology in accordance with applicable requirements. This documentation will be preserved to support the development and implementation of the management corrective action plan and to demonstrate consistency and compliance going forward. Anticipated Completion Date: May 31, 2026. Management agrees with the finding. The issue resulted from a system conversion and transition between payroll providers. Moving forward, management will ensure that appropriate documentation is consistently maintained and retained to support all payroll-related transactions.
Finding 2025-003-Allowable Costs/Cost Principles and Activities Allowed and Unallowed - Significant Deficiency in Internal Controls over Compliance and Non-Compliance Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: De...
Finding 2025-003-Allowable Costs/Cost Principles and Activities Allowed and Unallowed - Significant Deficiency in Internal Controls over Compliance and Non-Compliance Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: Department of Treasury Pass-Through Agencies: State of Oregon and Multnomah County Responsible Party: Jeanne Stromberg, Major- Divisional Finance Secretary- Cascade Division 916-501-6374 RESPONSE: Management will implement a review and approval of the billing submissions to prevent duplicate submission of expenses and perform a review of billing submissions by the senior accountant monthly to prevent duplicate submission of costs. Effective Date: November 2026
Finding 2025-001 -Allowable Costs/Cost Principles and Activities Allowed and Unallowed and Special Test - Drawdowns of Home/Home ARP Funds - Material Weakness in Internal Controls over Compliance Federal Program: Home Investment Partnerships Program (HOME) Assistance Listing Number: 14.239 Year(s): ...
Finding 2025-001 -Allowable Costs/Cost Principles and Activities Allowed and Unallowed and Special Test - Drawdowns of Home/Home ARP Funds - Material Weakness in Internal Controls over Compliance Federal Program: Home Investment Partnerships Program (HOME) Assistance Listing Number: 14.239 Year(s): 2025 Federal Agency: Department of Housing and Urban Development (HUD) Pass-Through Agencies: Idaho Housing and Finance Association Responsible Party: Jeanne Stromberg, Major- Divisional Finance Secretary- Cascade Division 916-501-6374 RESPONSE: Management will implement review and approval of drawdown requests to ensure approval of drawdown expenses for payroll and non-payroll related expenses. Effective Date: November 2026
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our a...
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our approval process. Currently, the President reviews invoices prior to signing the checks, thereby signaling approval. Moving forward, in addition to this review, the President will also confirm approval by initialing the invoice itself. Beyond this initial next step, PTV will also review its current Fiscal Policy to consider implementation of an approval process that allows other authorized approvers the authority to review expenses up to certain thresholds. Policy development at this level requires Finance Committee involvement and full Board approval, so it may take several months to fully implement a new process. We appreciate the opportunity to continue to strengthen PTV’s internal controls and financial operations.
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our a...
The Organization acknowledges and concurs with the auditor’s finding as discussed within the Schedule of Findings and Questioned Costs for the year-ended September 30, 2025. During the audit for PTV’s fiscal year 2025, it was determined that we should add an additional layer of confirmation to our approval process. Currently, the President reviews invoices prior to signing the checks, thereby signaling approval. Moving forward, in addition to this review, the President will also confirm approval by initialing the invoice itself. Beyond this initial next step, PTV will also review its current Fiscal Policy to consider implementation of an approval process that allows other authorized approvers the authority to review expenses up to certain thresholds. Policy development at this level requires Finance Committee involvement and full Board approval, so it may take several months to fully implement a new process. We appreciate the opportunity to continue to strengthen PTV’s internal controls and financial operations.
Management agrees with the finding and acknowledges that internal controls over inventory issuance were not consistently followed by an individual. While procedures existed requiring documentation of pick tickets, compliance with these procedures was not adequately enforced on a small number of tran...
Management agrees with the finding and acknowledges that internal controls over inventory issuance were not consistently followed by an individual. While procedures existed requiring documentation of pick tickets, compliance with these procedures was not adequately enforced on a small number of transactions. The Cooperative has begun strengthening its internal control processes to ensure that all inventory withdrawals are properly authorized and documented prior to release. In addition, management will implement monitoring procedures, including periodic reviews of inventory documentation, to ensure compliance with established controls. Training will also be provided to all relevant personnel to reinforce proper procedures and the importance of adherence to internal control requirements. Management expects these corrective actions to be fully implemented by May 15, 2026.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that Comanche County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that Comanche County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work toward assessing and identifying risks to design written county-wide controls.
The Board of County Commissioners will work toward assessing and identifying risks to design written county-wide controls.
Management will implement reconciliation procedures to ensure that payroll allocations recorded to federal award programs are supported by and agree to actual time records prior to recording journal entries to the general ledger. A supervisory review process will be established to periodically compa...
Management will implement reconciliation procedures to ensure that payroll allocations recorded to federal award programs are supported by and agree to actual time records prior to recording journal entries to the general ledger. A supervisory review process will be established to periodically compare time card data against payroll journal entries to identify and resolve discrepancies on a timely basis.
Management will continue to strengthen year-end and subsequent review procedures over invoices and employee reimbursements to ensure expenditures are recorded in the appropriate reporting period and within the applicable grant period. Additional controls will be implemented to monitor submission dea...
Management will continue to strengthen year-end and subsequent review procedures over invoices and employee reimbursements to ensure expenditures are recorded in the appropriate reporting period and within the applicable grant period. Additional controls will be implemented to monitor submission deadlines for employee reimbursement requests to prevent recording expenditures in periods other than those in which the related costs were incurred.
Management will formally document the CEO and CFO approval of all pay rate changes. Anticipated Completion Date: May 11, 2026
Management will formally document the CEO and CFO approval of all pay rate changes. Anticipated Completion Date: May 11, 2026
LSC-Basic Field Grant Significant Deficiency Internal Control over Compliance and Other Matters - Reporting Recommendation: We recommend that the Organization implement adequate controls to ensure the timely submission of the required grantor reports. If delays, with the submission of a report, occu...
LSC-Basic Field Grant Significant Deficiency Internal Control over Compliance and Other Matters - Reporting Recommendation: We recommend that the Organization implement adequate controls to ensure the timely submission of the required grantor reports. If delays, with the submission of a report, occur, we recommend that the Organization notifies its grantor and obtains an extension of the report due date. There is no disagreement with the audit finding. Action planned in response to finding: Essex-Newark Legal Services Project, Inc agrees that it will timely advise grantors when a delay in the timely submission of a report is anticipated. Name of the contact person responsible for corrective action: Felipe Chavana, Executive Director Planned completion date for corrective action plan: Effectively Immediately.
Condition: During our review of the Wisconsin Medicaid School-Based Services Program, the School District was unable to provide adequate supporting documentation for quarterly payroll costs reported to Medicaid. Additionally, the District could not provide a complete and reliable population of payro...
Condition: During our review of the Wisconsin Medicaid School-Based Services Program, the School District was unable to provide adequate supporting documentation for quarterly payroll costs reported to Medicaid. Additionally, the District could not provide a complete and reliable population of payroll transactions attributable to the Medicaid program to support payroll sampling procedures. Plan: The District will strengthen its internal controls over payroll reporting for the Medicaid School- Based Services Program by: establishing and maintaining detailed supporting documentation for all payroll costs claimed; developing procedures to ensure a complete and auditable payroll population can be generated for each reporting period; and providing training to staff responsible for Medicaid payroll reporting and documentation. Management should implement corrective actions to ensure future Medicaid payroll claims are fully supported and compliant with program requirements. Anticipated Date of Completion: The District will correct this for the 2025-2026 school year. Name of Contact Person: Nicki Ells, Business Manager Management Response: The Adams-Friendship School District accepts the plan for the Corrective Action listed above and does not dispute anything.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.
The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.
All credit card purchases charged to grants from January 1, 2025 to December 31, 2025 will be reviewed for allowability and accuracy and any unallowable or inaccurate charges charged to grants will be reversed. All program staff with federal grant responsibilities or with credit card expense approva...
All credit card purchases charged to grants from January 1, 2025 to December 31, 2025 will be reviewed for allowability and accuracy and any unallowable or inaccurate charges charged to grants will be reversed. All program staff with federal grant responsibilities or with credit card expense approval responsibilities will be required to attend an internal training session which will include training regarding what expenses are permissible under government grant guidelines. The Financial Controller will perform internal reviews of all credit card charges to identify and reclassify unallowable or inaccurate expenses before they are charged to a grant.
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