Corrective Action Plans

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Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating...
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the project and related expenses submitted to FEMA for reimbursement. Resolution: Management will develop and implement additional internal controls to ensure that adequate documentation is retained to evidence the design and operating effectiveness of controls over FEMA-related expenditures. These internal controls will be designed to ensure that expenses included in FEMA grant applications are complete, accurate, and allowable in accordance with program requirements. Specifically, management will implement a reconciliation process comparing detailed application expenses to the corresponding final paid invoices or payroll expenditures. As part of this process, each expense will be reviewed and annotated to confirm its allowability under FEMA guidelines. The reconciliation will be subject to review and approval by the Cottage Health Vice President of Finance prior to submission of the FEMA application. Evidence of this review and approval will be formally documented and retained. Contact Person: Lawrence Thomas, Vice President of Finance Anticipated Completion Date: December 31, 2026 (The entity has not incurred expenditures under the FEMA program subsequent to the period under audit. Accordingly, the corrective actions described above will be implemented on a prospective basis, contingent upon the entity incurring future FEMA-related expenditures).
Program(s): Supplemental Nutrition Assistance Program (SNAP), Medical Assistance Program; Foster Care Title IV-E Program 10.561 / 93.778 / 93.658 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing of 1,524 and 1,521 random momen...
Program(s): Supplemental Nutrition Assistance Program (SNAP), Medical Assistance Program; Foster Care Title IV-E Program 10.561 / 93.778 / 93.658 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing of 1,524 and 1,521 random moment study participants reported in quarters one and two, respectively, two individuals were reported on the first quarter time study report that were terminated or resigned prior to the start of the respective quarter. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will continue to monitor its procedures for giving timely notice of an individual’s termination or resignation to other departments, as implemented in July 2025. Additionally, the County will ensure departments are reviewing the information provided to granting agencies. Hennepin County Employee Responsible for the CAP: Samantha Braun Planned Completion Date for CAP: 07/31/2026
Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case ...
Program(s): Supplemental Nutrition Assistance Program (SNAP) 10.561 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following instance of noncompliance in the sample of sixty case files tested: • One MAXIS case file did not have a re-determination of eligibility performed within the 12-month period. • One MAXIS case file did not have documentation of income verification. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will strengthen internal controls over inputs used to determine eligibility to ensure they are correctly entered and the information required by the contract is retained in the County’s records. Hennepin County Employee Responsible for the CAP: Jennifer Frey, Human Services Area Manager for SNAP Planned Completion Date for CAP: December 1st, 2026
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files t...
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files tested: • In one patient file selected for testing, the sliding fee discount applied was incorrect due to the patient’s income not being entered correctly in Epic, resulting in an inaccurate FPL calculation and associated discount classification. • In one patient file selected for testing, based on support provided and the SFDS, an incorrect discount class was applied, and the County was not able to provide documentation demonstrating how annual income/household size supported the applied discount classification. Hennepin County’s Corrective Action Planned in Response to Finding: Develop a required form for all case aides to use and uniformly determine “annual income”. The EPIC Financial Assistance Module (FAM) recently implemented will maintain record of patient financial calculations / conversations and will include upload of the financial income form. Determination of the proper patient discount is automated in FAM and will reduce chance of incorrect rate setting. Hennepin County Employee Responsible for the CAP: Baye D Diouf, Chief Financial Officer Planned Completion Date for CAP: September 30, 2026
View of Responsible Officials and Planned Corrective Actions: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner moving forward.
View of Responsible Officials and Planned Corrective Actions: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner moving forward.
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations re...
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations regarding ethical behavior through training and communications. HealthXP proactively reports and investigates allegations of fraud and raises awareness of the actions to be taken when fraud is suspected. The HealthXP Global Internal Audit and Investigations team shares lessons learned from its work. Given the challenging operating environments in which HealthXP implements its programs, fraud remains an ongoing risk that HealthXP actively monitors, investigates, and mitigates.
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit wil...
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on recording expenses within the correct accounting period. HealthXP delivers in person training to its global finance and program staff and will continue to offer training during 2026 to address such issues.
VPI has merged with VARC and will evaluate their current way to allocate the time for personnel that are not directly charged to a specific program. VPI hasn't found a viable solution yet, but will continue to look for options. VPI will be changing managed IT partner as part of the merger and will s...
VPI has merged with VARC and will evaluate their current way to allocate the time for personnel that are not directly charged to a specific program. VPI hasn't found a viable solution yet, but will continue to look for options. VPI will be changing managed IT partner as part of the merger and will seek recommendations from them. VARC also uses a different time collection methold which may provide better information. Person Responsible: Jim Patten, CFO Timing for Implementation: This will continue to be evaluated going forward
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management ...
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management review. In addition, the Authority should train relevant personnel on these policies and perform ongoing monitoring to confirm that federal expenditures are reviewed and documented in accordance with applicable grant requirements. Management’s Response: Management acknowledges the recommendation. The Authority will evaluate its existing processes and controls over the use of federal funds and consider whether additional written guidance and/or enhancements to current procedures are warranted to address, as applicable, cost allowability, procurement requirements, approval responsibilities, documentation and record retention, subrecipient or vendor oversight, reimbursement request preparation and review, and periodic management review of federal expenditures. Based on the results of this evaluation, the Authority will communicate any clarifications, reminders, and/or targeted training to relevant personnel involved in administering, approving, recording, or requesting reimbursement for federal expenditures, as deemed necessary. Management will also consider whether additional monitoring activities are warranted to help confirm that federal expenditures are reviewed, approved, and supported by appropriate documentation in accordance with applicable grant requirements.
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsib...
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Hospital will establish an annual audit readiness timeline working backward from the Uniform Guidance submission deadline (the earlier of thirty (30) calendar days after receipt of the auditors’ reports or nine months after the end of the audit period, June 30). The timeline will include target dates for the completion of year-end closing procedures, the delivery of auditor-requested schedules and supporting documentation, audit fieldwork, review of the draft report, and submission of the reporting package and Data Collection Form to the Federal Audit Clearinghouse in advance of the deadline. 2. Monthly closing discipline will be maintained throughout the fiscal year so that year-end balances, account reconciliations (including patient accounts receivable aging, the allowance for credit losses, and grants receivable), and audit support schedules are substantially complete at year end and available for timely delivery to the auditors. 3. The Chief Financial Officer will monitor the status of the audit timeline monthly beginning in October of each fiscal year, and any delay against the established milestones will require a documented recovery plan to return the process to schedule. 4. The Single Audit Reporting Package and Data Collection Form for the year ended September 30, 2025 will be submitted to the Federal Audit Clearinghouse immediately upon issuance of the final audit report. Anticipated Completion Date October 31, 2026
Corrective Action Plan: In our opinion, the matter resulted in human error and does not rise to the level of a finding. We believe the matter would be more appropriately addressed through disclosure in the financial statement footnotes rather than being reported as a finding. The Revenue Manager wil...
Corrective Action Plan: In our opinion, the matter resulted in human error and does not rise to the level of a finding. We believe the matter would be more appropriately addressed through disclosure in the financial statement footnotes rather than being reported as a finding. The Revenue Manager will enter the salaries from the payroll register into the allocation spreadsheet. The Sr. Accounting Manager will review the salaries and sign off on the allocation spreadsheet confirming the accuracy of the salaries.
Finding Timesheets charged to federal programs were processed without documented supervisory approval in certain instances. Corrective Action Planned In 2026 and going forward, all staff and Department Director timesheets will be approved by an independent supervisor prior to payroll processing. Con...
Finding Timesheets charged to federal programs were processed without documented supervisory approval in certain instances. Corrective Action Planned In 2026 and going forward, all staff and Department Director timesheets will be approved by an independent supervisor prior to payroll processing. Contact Person Nicole Babcock Anticipated Completion Date Implemented June 2026; ongoing monitoring thereafter.
Finding 2025-002 – Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action: The City is in the process of updating a...
Finding 2025-002 – Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action: The City is in the process of updating and adopting written policies and procedures that are in compliance with Uniform Guidance. Anticipated Completion Date: December 31, 2026 Responsbile Official: John Szymanski, City Manager
Management agrees with the finding. The District will implement procedures requiring supervisory review and approval of all employee time charged to the SLFRF program. Employees will maintain supporting documentation for grant-related activities, and management will perform and document periodic rev...
Management agrees with the finding. The District will implement procedures requiring supervisory review and approval of all employee time charged to the SLFRF program. Employees will maintain supporting documentation for grant-related activities, and management will perform and document periodic reviews to verify that reported hours are accurate, adequately supported, and allocable to the grant. These procedures will help ensure payroll costs charged to the SLFRF program comply with federal requirements.
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review th...
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review the process to re-establish time-and-effort reporting through the timesheet entry process and the consolidation of time-and-effort information into reporting that can be easily summated by department/project and uploaded to MIP · Determine the allocation and cost distribution methods needed and the resulting detail reporting needed to substantiate the allocation methods used for propriety · Reinstitute the timesheet entry process by project/cost code and train staffing at an upcoming All Staff meeting to reset the view of timesheets and their importance of timesheet tracking to minimize errors for cost allocation purposes · Have staff begin using timesheets in Paylocity (by December 1st) · Complete update of Fiscal Policies Manual (inclusive of Cost Allocation methodology and philosophy) and timely reviews (i.e. at a minimum semiannually or with major program changes/contracts) to ensure no substantive changes needed to policy or actions needed to ensure appropriate accounting updates
Management will strengthen controls over expenditures charged to federal awards to ensure that only allowable costs are posted to federally funded program cost centers. Specific actions include: • Reviewing and revising federal expenditure approval procedures and coding. • Increased monitoring of tr...
Management will strengthen controls over expenditures charged to federal awards to ensure that only allowable costs are posted to federally funded program cost centers. Specific actions include: • Reviewing and revising federal expenditure approval procedures and coding. • Increased monitoring of transactions charged to federal awards. • Implementing enhanced supervisory review of costs charged to federal awards. • Providing training to accounting and program personnel regarding Uniform Guidance allowable cost requirements.
2025-003 – Allowable Costs Corrective Action: Implement a process to ensure that unallowable costs are not charged to the grants. Person Responsible: Executive Director, Seth Kirshenberg Estimated corrective action completion date: Fiscal year 2026\
2025-003 – Allowable Costs Corrective Action: Implement a process to ensure that unallowable costs are not charged to the grants. Person Responsible: Executive Director, Seth Kirshenberg Estimated corrective action completion date: Fiscal year 2026\
The Society of American Foresters has enhanced their exis􀆟ng expense recogni􀆟on controls for event-related invoices by reques􀆟ng more detailed vendor invoices that clearly iden􀆟fy the event and applicable service period, implemen􀆟ng addi􀆟onal review for vendors with recurring or overlapping billing ...
The Society of American Foresters has enhanced their exis􀆟ng expense recogni􀆟on controls for event-related invoices by reques􀆟ng more detailed vendor invoices that clearly iden􀆟fy the event and applicable service period, implemen􀆟ng addi􀆟onal review for vendors with recurring or overlapping billing arrangements, and reinforcing current invoice review procedures to ensure that the period of benefit is adequately documented, par􀆟cularly for transac􀆟ons occurring near year-end. These enhancements are intended to further strengthen the Society’s already effec􀆟ve control environment and support consistent and accurate recogni􀆟on of event expenses in accordance with federal requirements and GAAP.
Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for rev...
Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for review at the time of audit. Method of Implementation: The district will improve the filing and retention of payroll timesheets and resolutions authorizing payroll expenses for federal programs. All payroll documentation will be properly maintained and made readily available for review at the time of audit.
Finding 2025-003: Lack of Authorization for Expenses - The Organization is currently updating their approval process and including an additional approval form. This form will require accounts payable staff to verify that the expense has appropriate signatures before any federal grants are charged.
Finding 2025-003: Lack of Authorization for Expenses - The Organization is currently updating their approval process and including an additional approval form. This form will require accounts payable staff to verify that the expense has appropriate signatures before any federal grants are charged.
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal con...
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal controls over the application of indirect cost rates to federally funded awards. Although corrective actions were initiated following the prior year's finding, the College has identified opportunities to enhance the review and monitoring of indirect cost rate calculations to ensure consistent compliance with Uniform Guidance. Going forward, the accounting group, in collaboration with the Office of Sponsored Programs, will maintain the current federally negotiated indirect cost rates, apply approved rates to applicable awards, and perform periodic reviews to verify that the correct rates are consistently applied. Timeline for Implementation of Corrective Action Plan: The College will finalize written procedures governing the application and review of indirect cost rates, implement a documented review process for indirect cost calculations prior to posting, and provide guidance to employees responsible for grant accounting. These actions will be completed by September 30, 2026. Management will periodically monitor compliance to ensure indirect cost rates are applied accurately and in accordance with federal requirements.
The Organization is aware of the requirements and will attempt to compile the information necessary to assure its compliance with this in the future.
The Organization is aware of the requirements and will attempt to compile the information necessary to assure its compliance with this in the future.
2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before i...
2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before indirect costs are charged to the grant. A grant expenditure tracking process will be established to monitor direct and indirect costs against the approved budget throughout the grant period. The Chief Financial Officer will review indirect cost calculations and budget-to-actual expenditures monthly to ensure expenditures remain within approved budget limitations and comply with applicable federal regulations and grant requirements. This CMHSP will create grant management policies and procedures, outside of the County of Lapeer’s grant management policy, to include documented reviews of indirect cost calculations, monthly budget monitoring, and supervisory approval of grant expenditures to ensure compliance with federal awards. Responsible Party: Emma McQuillan, Chief Financial Officer Anticipated Completion Date: 09/30/2026
Finding 1223673 (2025-002)
Material Weakness 2025
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 200...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Department of Agriculture, Assistance Listing #: 10.561 – State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP Cluster), Passed through Houston-Galveston Area Council, Contract Number: 20020, Contract Year: 10/01/25 - 09/30/26. Condition and context: During our testing of 40 federal and state payments to childcare providers under the Houston-Galveston Area Council contract, we noted that 1 childcare provider was paid at an incorrect provider rate resulting in an overpayment of $9.10. Recommendation: Re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Corrective action: BakerRipley will re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the 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 the County receives to ensure that proper internal controls are implemented.
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