Corrective Action Plans

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Finding 2025-002 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for approving timecards which includ...
Finding 2025-002 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for approving timecards which include program codes for allocation to awards. The controls in place did not operate as designed and failed to fully correct an error in five timecards of an employee’s pay to the grant. Corrective Action Plan: The time and attendance software used during this audit’s timeframe required a manual process for access to those who split their time between grants. This process required additional steps after notifying finance when a grant is added or has ended. Since the audit timeframe, GESMN has implemented a new time and attendance system which does not require this manual process, removing the potential for human error. Responsible Individuals: Milissa Orchard, Director of HR Operations Anticipated Completion Date: Completed
Finding 2025-001 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for allocating employee wages based ...
Finding 2025-001 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for allocating employee wages based on hours worked. The controls in place did not operate as designed and failed to fully correct an error in the allocation of employee pay to the grant. Corrective Action Plan: Since the audit, the payroll team has spot-checked records to ensure employees are paid accurately (regular or overtime) when retroactive corrections are made to time submissions. In addition, the payroll supervisor will provide training during the week of January 5, 2025, to ensure future retroactive corrections are accurate and the team is auditing regularly for accuracy. Responsible Individuals: Milissa Orchard, Director of HR Operations Anticipated Completion Date: Completed
NACAA has received and reviewed the draft audit report for fiscal year 2025 conducted November 25, 2025. We have provided our auditors DeLeon & Stang with a Management Response to include with the audit. This document will outline NACAA’s course of corrective action for those findings. Finding 1: Th...
NACAA has received and reviewed the draft audit report for fiscal year 2025 conducted November 25, 2025. We have provided our auditors DeLeon & Stang with a Management Response to include with the audit. This document will outline NACAA’s course of corrective action for those findings. Finding 1: The Organization charged indirect costs to the major federal program in excess of the amount permitted under its approved NICRA for the fiscal year ended September 20, 2020. In addition, amounts reported on the annual Federal Financial Report (FFR) to the federal funder were incorrect, reporting the wrong base and charged amounts. The amounts reported on the FFR did not match the actual indirect cost base and charges for fiscal year 2025. Background As noted in the audit finding, NACAA’s NICRA has historically been based on a salary and fringe benefits allocation base. During fiscal year 2025, NACAA experienced significant turnover of longtenured employees, resulting in a substantial decrease in salaries and wages and, accordingly, a reduction in the approved indirect cost rate. As a result, indirect costs were overcharged to the federal program by $96,196. The annual Federal Financial Report (FFR) submitted on November 6, 2025, was based on internal year-end reports not NACAA’s audited final numbers. The information reported as the indirect cost rates and amounts were taken from the NICRA applications for the FY24 final and FY25 provisional negotiated rates. Remediation In order to address these findings, NACAA has contacted its EPA Project Officer and Grant Specialist to discuss appropriate corrective action. We explained that NACAA is having trouble paying its overhead expenses using the current negotiated indirect cost rate of 16.84% due to the substantial changes in our staff since the rate was negotiated. NACAA’s 2025 provisional indirect costs rate was calculated based on a SWF amount of $1,306,688. At year end because of staff changes, NACAA’s 2025 SWF amount is only $950,264, which makes our base for calculating indirect costs $356,424 less than when the rate was set. The indirect cost limit based on the old SWF was $220,046, while it’s $160,024 based on the new. NACAA’s indirect costs for 2025 were $256,919. After speaking with EPA, NACAA met with its auditors and accountant to discuss corrective action. It was recommended that some of NACAA’s overhead costs that have traditionally been added to the indirect cost pool (professional fees, rent, office insurance, etc.) be charged as direct costs using NACAA’s grant-related salaries and fringe benefits to allocate expenses between direct and indirect costs. To correct the other issue related to the Federal Financial Report (FFR) errors, NACAA will work with its accountant to complete the required FFRs and other grant reports to ensure that all figures being reported at correct. Reclassifying Indirect Charges to Direct Cost Categories NACAA has contacted the EPA Grants Management team to determine if our anticipated corrective course of action would be acceptable to EPA. We have received concurrence by email that the suggestion made by NACAA’s Auditors that pro-rating costs using salary as a basis for allocating overhead charges as direct costs is reasonable. This method should be used to allocate all expenses that are “traditionally” allocated as indirect costs. NACAA is currently drafting a request to re-budget its 2026 expenses, allocating many of the expenses traditionally part of the indirect cost pool as direct expenses, pro-rating costs using salary as a basis for allocating overhead charges as direct costs. NACAA’s Project Officer needs to approve that request so an amendment can be made for the current year of NACAA’s two-year cooperative agreement. Accountability Once NACAA’s re-budgeting request has been approved, NACAA’s Operations Manager and Accountant will be responsible for ensuring that expenses are correctly allocated every month using salary as a basis for allocating overhead charges as direct costs. Please see a description of NACAA’s Time and Attendance System and Method of Fringe Benefit allocation. These will be used to determine the percentage of expenses that will be allocated as direct costs: Salaries and Wages: Time & Attendance System: NACAA’s staff complete detailed timesheets on the 15th and last day of each month. Personnel Time Allocation Policy: Traditionally, activities of the NACAA headquarters office fall into three categories: federal grant-related activities; non-grant related activities; and indirect functions. Fringe benefits are allocated into these three categories based on the number of hours worked in each. Non-grant related activities are funded by the NACAA treasury. A very modest amount of time is allocated as Indirect Salaries, Wages and Fringes. Indirect salaries are included in NACAA’s indirect cost pool. Fringe Benefits: Fringe Benefits for NACAA’s staff members include employer-paid share of payroll taxes, health, life and disability insurance and a retirement plan. NACAA allocates fringe benefits based on a fringe benefit rate and distributes them based on salaries and wages.
Planned Corrective Action: We removed all unallowable costs from our indirect cost pool to ensure full compliance with applicable cost principles. We implemented an additional layer of review during the preparation of our 2025 indirect cost rate proposal to identify and exclude any unallowable charg...
Planned Corrective Action: We removed all unallowable costs from our indirect cost pool to ensure full compliance with applicable cost principles. We implemented an additional layer of review during the preparation of our 2025 indirect cost rate proposal to identify and exclude any unallowable charges. We added a dedicated step to our monthly close process to review all new charges and determine whether any should be classified as unallowable. Anticipated Completion Date 12/31/2025. Responsible Contact Person: Katherine Page, Director of Finance
Planned Corrective Action: Our payroll system provider corrected the backend setting to prevent employees from adjusting their timecards after they have been approved and locked. We reviewed and confirmed that the system is now functioning as intended to prevent similar issues in the future. We dedu...
Planned Corrective Action: Our payroll system provider corrected the backend setting to prevent employees from adjusting their timecards after they have been approved and locked. We reviewed and confirmed that the system is now functioning as intended to prevent similar issues in the future. We deducted the overage amount from the November 2025 invoice to reimburse the agency in full. Anticipated Completion Date 11/17/2025 & 12/31/2025. Responsible Contact Person: Katherine Page, Director of Finance
Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures for allocating expenses to grants to ensure only allowable expenses are charged to the grant. Completion Date: Immediately
Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures for allocating expenses to grants to ensure only allowable expenses are charged to the grant. Completion Date: Immediately
Significant Deficiency in Internal Controls over Compliance for Allowable Costs/Cost Principles Finding Summary: The Organization did not maintain documentation to support payroll timesheet approvals. Responsible Individuals: Danielle Smith, Executive Director Corrective Action Plan: Payroll procedu...
Significant Deficiency in Internal Controls over Compliance for Allowable Costs/Cost Principles Finding Summary: The Organization did not maintain documentation to support payroll timesheet approvals. Responsible Individuals: Danielle Smith, Executive Director Corrective Action Plan: Payroll procedures will be updated to incorporate this process and the Organization will maintain documentation of payroll timecard approval to support payroll amounts allocated to the federal award. Anticipated Completion Date: June 2026
The Utility will review and write a more detailed version of procurement policies to ensure complete and continuous compliance with the requirement in the Uniform Guidance
The Utility will review and write a more detailed version of procurement policies to ensure complete and continuous compliance with the requirement in the Uniform Guidance
Finding 1173183 (2025-001)
Material Weakness 2025
P33
IL
Finding 2025-001 Allowable Costs/Cost Principles (Material Weakness) Condition: Compensation – personal services: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or the actual time spent was used as a basis for allocating personnel charges to the...
Finding 2025-001 Allowable Costs/Cost Principles (Material Weakness) Condition: Compensation – personal services: For this program, there was no evidence that actual employee time was tracked, reviewed and approved, or the actual time spent was used as a basis for allocating personnel charges to the grant before payroll period ending February 28, 2025. Correction Action Planned: • Effective March 1, 2025, each location used a time sheet for tracking actual hours worked on grants. This time sheet includes all grants that the employee worked on and non-grant time. The time sheet is signed by the employee and reviewed and approved by the employee’s supervisor ensuring time spent on grant is accurately recorded. • The People & Operations Manager retains completed time sheets together with other expenditure support for grant reimbursement. The contract accountants review the actual salary expense against initial budgeted grant expense and make necessary adjustments to charges to reflect accurate salary expense for each grant. The Controller or Principal from the contract accounting firm reviews and approves grant accounting adjustments prior to completion of changes. Completion Date: March 1, 2025 Name of Contact Person Responsible for the Plan: Nuwan Samaraweera, COO
Significant deficiency in Internal Control over Compliance and Questioned Costs Corrective Action Plan: Training will be provided to campuses and departments as well as Finance staff on the beginning and end dates of services and/or items to be purchased with grant funds. The Grant Development depar...
Significant deficiency in Internal Control over Compliance and Questioned Costs Corrective Action Plan: Training will be provided to campuses and departments as well as Finance staff on the beginning and end dates of services and/or items to be purchased with grant funds. The Grant Development department will reiterate to all grant program managers the beginning and end dates of the grants they manage to ensure compliance. Estimated Completion Date: February 28, 2026 Management Contact: Pamela Evans, Senior Executive Director of External Funding & Grant Development
Recommendation: The County should establish oversight and review procedures to ensure the amounts reported on the Oregon Health Authority Public Health Division Expenditures and Revenue Reports are accurate and adequately support the expenditures allowable under the grant. Views of Responsible Offic...
Recommendation: The County should establish oversight and review procedures to ensure the amounts reported on the Oregon Health Authority Public Health Division Expenditures and Revenue Reports are accurate and adequately support the expenditures allowable under the grant. Views of Responsible Officials and Planned Corrective Actions: The county understands this finding. The county will employ a system to ensure timely reporting that includes additional oversite of the program by the Health Director that ensures the reports are accurate and expenditures are allowable under the grant.
AUDITEE’S CORRECTIVE ACTION PLAN As required by 2 CFR 200.511, the Petal School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Costs for the year ended June 30, 2025: Finding Correction Action Plan De...
AUDITEE’S CORRECTIVE ACTION PLAN As required by 2 CFR 200.511, the Petal School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Costs for the year ended June 30, 2025: Finding Correction Action Plan Details 2025-001 a. Name of Contact Person Responsible for Corrective Action: Kristi Fimiano – Chief Financial Officer b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, including compliance with all federal grant requirements. c. Anticipated Completion Date: Immediately.
FINDING 2025-003 Finding Subject: Education Stabilization Fund – Internal Controls Contact Person Responsible for Corrective Action: Mendy Shrout Contact Phone Number and Email Address): (765) 795-4664 / mshrout@cloverdale.k12.in.us Views of Responsible Officials: We concur with the finding. Descrip...
FINDING 2025-003 Finding Subject: Education Stabilization Fund – Internal Controls Contact Person Responsible for Corrective Action: Mendy Shrout Contact Phone Number and Email Address): (765) 795-4664 / mshrout@cloverdale.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Corporation Treasurer will review and initial payroll distribution report as reviewed. Anticipated Completion Date: February 1, 2026
FINDING 2025-001 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person(s) Responsible for Corrective Action: Mendy Shrout & Billy Boyette Contact Phone Number and Email Address(es): (765) 795-4664 / mshrout@cloverdale.k12.in.us & bboyette@cloverdale.k12.in.us Views of Responsib...
FINDING 2025-001 Finding Subject: Child Nutrition Cluster – Internal Controls Contact Person(s) Responsible for Corrective Action: Mendy Shrout & Billy Boyette Contact Phone Number and Email Address(es): (765) 795-4664 / mshrout@cloverdale.k12.in.us & bboyette@cloverdale.k12.in.us Views of Responsible Officials: Option 1: We concur with the finding. Description of Corrective Action Plan: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Payroll distribution reports will be periodically reviewed and initialed by the Corporation Treasurer to assure employees paid are working in the cafeteria. Eligibility Cafeteria Managers will initially enter eligibility information into the POS (Harmony). The Food Service Director or Café Office Manager will sign off on the reports as records are entered. Reporting Food Service Director will provide the reports to the Corporation Treasurer or the Café Office Manager on a monthly basis for review. The reviewer will then initial the documents. Anticipated Completion Date: February 1, 2026
Finding 1172971 (2025-001)
Material Weakness 2025
FINDING 2025-001 – Significant Deficiency in Internal Control over Compliance Description of Finding: The State Funding Agency audited the Child Nutrition program and found that the school food authority (SFA) was charged an indirect cost rate less than provided for in the indirect cost rate agreeme...
FINDING 2025-001 – Significant Deficiency in Internal Control over Compliance Description of Finding: The State Funding Agency audited the Child Nutrition program and found that the school food authority (SFA) was charged an indirect cost rate less than provided for in the indirect cost rate agreement and there was no document explaining how the difference would be handled with the nonprofit school food service account. They also identified that food expenses were included in the direct cost base. Food is considered a distorted fund and is not to be included in the direct cost base. Statement of Concurrence or Nonconcurrence: The Agency agrees with this finding during the Audit period and has made the necessary corrections. Corrective Action: The Organization has implemented procedures outlining how discrepancies will be managed. These procedures will be shared with relevant personnel, and training sessions will be conducted to ensure full compliance. Additionally, we have recalculated the indirect costs for FY2025, excluding the food expenses from the direct cost base. This recalculated amount was reflected in the revised financial reporting. Name of Contact Person: Richard Carmelich, Chief Operations Officer Projected Completion Date: June 30, 2025 QUESTIONED COSTS 1. There was $41,868 in questioned costs as a result of the 2025-001 audit finding. The Organization agreed that the cost was unallowable and revised the financial reporting to the satisfaction of the auditing State agency.
November 21, 2025 CORRECTIVE ACTION PLAN (Concerning Finding 2025-001) Contact person responsible for corrective action: Jennifer Lawcewicz, Superintendent Corrective Action: The Essex North Supervisory Union will take the following actions to address finding 2025-001- Activities Allowed and Allowab...
November 21, 2025 CORRECTIVE ACTION PLAN (Concerning Finding 2025-001) Contact person responsible for corrective action: Jennifer Lawcewicz, Superintendent Corrective Action: The Essex North Supervisory Union will take the following actions to address finding 2025-001- Activities Allowed and Allowable Costs: 1. Essex North Supervisory Union has created a purchasing and procurement procedure manual with detailed procedures. 2. The business manager and superintendent have shared this document with all employees that are involved in purchasing. 3. The business manager and the superintendent will have regular meetings with the principal and grants manager to ensure that all procedures are being followed. 4. All invoices will continue to be reviewed by the business manager or the superintendent. 5. Purchase Orders will be issued prior to invoice when applicable. Anticipate completion date: Currently in place and happening
The City of Herrin is aware of the need to produce a schedule of expenditures of federal awards. Management is going to incorporate proper training and education on the information and amount that must be outlined in the schedule of expenditures of federal awards. The City of Herrin will prepare a s...
The City of Herrin is aware of the need to produce a schedule of expenditures of federal awards. Management is going to incorporate proper training and education on the information and amount that must be outlined in the schedule of expenditures of federal awards. The City of Herrin will prepare a schedule of expenditures of federal awards annually as part of the year­end closing process each year and provide the schedule and all backup used to prepare it to the audit firm during the financial audit process. These Corrective Steps were complete and implemented by December 15, 2025.
Action Taken enCircle has officially adopted the policy that gift cards provided to foster parents will not be submitted for reimbursement until the receipts are returned by the parents. If they do not spend the entire amount, only the amount spent will be requested for reimbursement and enCircle wi...
Action Taken enCircle has officially adopted the policy that gift cards provided to foster parents will not be submitted for reimbursement until the receipts are returned by the parents. If they do not spend the entire amount, only the amount spent will be requested for reimbursement and enCircle will cover the difference from non-federal funds. enCircle is also considering other methods of helping parents purchase clothes for foster placements. Further, enCircle has evaluated the use of all allocation methods for expenses that impact federal grants and will be limiting allocations to only clearly explicit expenses to ensure only programmatic costs are billed. Further, enCircle has created a new service code within its Chart of Accounts to track programmatic administration costs separate from overall administration costs.
We have reviewed procedures and plan to make the necessary changes to improve reporting timeliness. Staff will update its internal policy to submit the FFATA within 30 days of execution of the CDBG annual budget, Annual Action Plan, and subaward agreements, along with any amendments to these agreeme...
We have reviewed procedures and plan to make the necessary changes to improve reporting timeliness. Staff will update its internal policy to submit the FFATA within 30 days of execution of the CDBG annual budget, Annual Action Plan, and subaward agreements, along with any amendments to these agreements. Contact Person, Title, Phone Number Christopher Gibbons, Interim Director of Community Development, (712) 890-5358 Anticipated Date of Completion January 30, 2026
Iowa Healthiest State Initiative respectfully submits the following corrective action plan for the year ended September 30, 2025. Audit period: October 1, 2024 – September 30, 2025 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently...
Iowa Healthiest State Initiative respectfully submits the following corrective action plan for the year ended September 30, 2025. Audit period: October 1, 2024 – September 30, 2025 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Finding – Federal Award Programs Audits United States Department of Agriculture Finding 2025-001: Cash Management Recommendation: BerganKDV recommends Management review compliance requirements for understanding and developing procedures to ensure adherence to cash management requirements. Action Taken: Management acknowledges the finding related to the timing of federal drawdowns and updated procedures to ensure that funds are only drawn after allowable expenses have been incurred. If the United States Department of Agriculture has questions regarding this plan, please contact Jami Haberl at (515) 650-6854. Sincerely, Jami Haberl, MPH, MHA Executive Director Iowa Healthiest State Initiative
Condition: Costs included on the 6/30/25 2025 Title I ISBE expenditure report included costs paid after 6/30/25. Recommendation: We recommend implementing an additional process to reconcile the budgeted amount to the general ledger totals and reconciling those to expenditure reports before submissio...
Condition: Costs included on the 6/30/25 2025 Title I ISBE expenditure report included costs paid after 6/30/25. Recommendation: We recommend implementing an additional process to reconcile the budgeted amount to the general ledger totals and reconciling those to expenditure reports before submission of ISBE grant reports. Management Response: The District will consider implementing an additional reconciliation process and will take necessary steps to review expenditures in the general ledger against expenditures reported to ISBE. Anticipated Date of Completion: June 30, 2026
Condition: The District submitted budgeted expenditures for reimbursement instead of actual expenditures in Title I, Grant Year 2024. Questioned costs of $5,448. Recommendation: We recommend reconciling the budgeted amount to the general ledger totals and reconciling those to expenditure reports bef...
Condition: The District submitted budgeted expenditures for reimbursement instead of actual expenditures in Title I, Grant Year 2024. Questioned costs of $5,448. Recommendation: We recommend reconciling the budgeted amount to the general ledger totals and reconciling those to expenditure reports before submitting. Management Response: The District will take necessary steps to review the budgeted cost of items and the amount recorded in the general ledger against the expenditure reports before submitting the final grant reports. Anticipated Date of Completion: June 30, 2026
HQS inspections will be documented in each tenant’s file in accordance with applicable standards, along with the corresponding inspection log maintained by the PHA. Any required reinspection will also be completed and documented accordingly in the tenant’s file.
HQS inspections will be documented in each tenant’s file in accordance with applicable standards, along with the corresponding inspection log maintained by the PHA. Any required reinspection will also be completed and documented accordingly in the tenant’s file.
Management at SAHA PM notes its responsibility to establish and maintain effective internal control over financial reporting to provide reasonable assurance that transactions are properly recorded, processed, and summarized to permit the preparation of reliable financial statements in accordance wit...
Management at SAHA PM notes its responsibility to establish and maintain effective internal control over financial reporting to provide reasonable assurance that transactions are properly recorded, processed, and summarized to permit the preparation of reliable financial statements in accordance with generally accepted accounting principles (“GAAP”). We plan to establish a checklist for the property accounting team that includes a comparison of gross rent potential to the HUD approved rent schedule.
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should implement a strategy of using time and effort documentation in determining payroll costs charged to grants, including use of backward-looking reconciliations when necessary. Explanation of disagreement with a...
Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should implement a strategy of using time and effort documentation in determining payroll costs charged to grants, including use of backward-looking reconciliations when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the Organization is in the process of implementing a policy to track time and effort of all employees based on actual time spent by grant. Some employees work directly with tenants on a HUD funded grant on a regular basis, but all employees may work directly with a tenant on a HUD funded grant or may perform administrative work specifically on a HUD funded grant from time to time. Therefore, all employees will track time spent with tenants or specifically with a grant in the Yardi Tenant Contact system. • Housing Support Staff and Management will document grant allocations as required. • Backoffice employees, such as those working in HR or Accounting, will be allocated to Admin and Support within the HUD funded grant, based on time spent. • Maintenance employees can be allocated to tenants based on units and work orders. • Formal review of payroll and grant allocations, based on time sheets, will take place by March 30th 2026, and on a monthly basis going forward. Potential true-up to take place after each review. Name(s) of the contact person(s) responsible for corrective action: Susan Keshen, Fractional CFO Planned completion date for corrective action plan: March 31, 2026
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