Corrective Action Plans

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Management Response: Management acknowledges Finding 2025-003 and agrees that the control deficiency related to allocation of expenses within the WIOA Cluster constitutes a material weakness in internal control over compliance. This finding is distinct from Finding 2025-002 because it concerns the m...
Management Response: Management acknowledges Finding 2025-003 and agrees that the control deficiency related to allocation of expenses within the WIOA Cluster constitutes a material weakness in internal control over compliance. This finding is distinct from Finding 2025-002 because it concerns the methodology, approval, and monitoring of cost allocations affecting WIOA programs, including restrictions applicable to the Youth program, rather than the allowability of costs based on timing or period of performance. Although the identified costs were corrected, the deficiency increased the risk that shared or allocable costs could be assigned to restricted programs in a manner inconsistent with federal requirements if not detected and prevented in a timely manner. Management determined that the root causes were insufficiently detailed written procedures for allocating shared costs within the WIOA Cluster, lack of explicit documentation addressing the prohibition on transfers to or from the Youth program under 20 CFR 683.130, and inconsistent supervisory review of allocation entries before posting. Existing practices addressed cost charging generally, but they did not provide enough direction on how shared expenditures benefiting multiple WIOA funding streams should be allocated, documented, reviewed, and restricted when Youth funds were involved. To address this material weakness, management is implementing four control improvements. First, it will formalize written cost allocation policies and procedures for the WIOA Cluster that define approved methodologies, documentation standards, proportional benefit requirements, and restrictions applicable to the Youth program. Second, it will require documented supervisory review and approval of all allocation entries affecting WIOA programs before posting to the general ledger. Third, it will provide targeted training to finance, grants, and program management personnel on WIOA-specific allocation requirements, with particular emphasis on Youth program restrictions. Fourth, it will implement periodic monitoring to verify that allocations follow the approved methodology and remain consistent with federal requirements. Under the revised process, each allocation affecting WIOA programs will be supported by contemporaneous documentation identifying the nature of the cost, the programs benefiting from the expenditure, the basis used to distribute the cost, and the calculation of the amounts charged to each program. When a cost benefits multiple programs and proportional benefit can be reasonably determined, the allocation will be based on that proportional benefit. When proportional benefit cannot be determined precisely, the allocation will be supported by a reasonable documented method that is applied consistently. Allocation support must also include a compliance checkpoint confirming that no allocation results in an impermissible transfer to or from the Youth program. No allocation entry affecting WIOA programs will be recorded without documented preparer support and written supervisory review evidencing compliance with internal policy and applicable regulations. Management will also establish recurring monitoring controls to test allocations recorded during the year. On at least a quarterly basis, the Finance Director or designee will review a sample of WIOA allocation entries to confirm that the approved methodology was followed, supporting documentation was retained, supervisory approval was completed, and Youth program restrictions were observed. Exceptions identified through this monitoring process will be documented, investigated, and corrected promptly, with any necessary retraining or policy revisions implemented to prevent recurrence. Results of the monitoring process will be communicated to senior management as part of ongoing oversight of federal awards compliance. Management believes these corrective actions directly address the auditors’ recommendations and strengthen controls over allocation of expenses within the WIOA Cluster without duplicating the corrective actions described in Finding 2025-002. Responsibility for implementation will rest primarily with the Finance Director, in coordination with grants and program leadership. Management expects the enhanced policy framework, approval requirements, training, and monitoring activities to reduce the risk of noncompliant allocations, improve documentation of shared cost methodologies, and support sustained compliance with 2 CFR 200.405 and 20 CFR 683.130. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written WIOA cost allocation policies and procedures that define approved allocation methodologies, documentation requirements, proportional benefit standards, and explicit restrictions applicable to the Youth program. Finance Director; Grants Manager June 30, 2026 Approved policy and procedure document; distribution to applicable staff; retained version history. Implement a standardized allocation worksheet and review checklist for all shared costs charged to WIOA programs, including a compliance checkpoint for Youth program restrictions. Accounting Manager; Finance Director July 15, 2026 Standard allocation template; completed review checklist; sample completed allocation packages. Require documented supervisory review and approval of all allocation entries affecting WIOA programs before posting to the general ledger. Finance Director Effective immediately Signed allocation entries; reviewer signoff; journal entry support retained with monthly close documentation. Provide targeted training to finance, grants, and program personnel on 2 CFR 200.405, WIOA allocation principles, and the prohibition on transfers to or Finance Director; Compliance Officer August 31, 2026 Training materials; attendance logs; completed acknowledgements or assessments. from the Youth program under 20 CFR 683.130. Perform quarterly monitoring of a sample of WIOA allocation entries to verify adherence to the approved methodology, adequacy of support, supervisory approval, and compliance with Youth program restrictions. Finance Director; Compliance Officer Quarterly, beginning September 30, 2026 Quarterly monitoring reports; exception logs; documented corrective follow-up. Evaluate the effectiveness of the revised allocation controls and update policies, training, or monitoring procedures if deficiencies or exceptions are identified. Finance Director; Executive Leadership Semi-annually during fiscal year 2027 Management review memoranda; updated procedures; remediation tracking documentation.
Finding: 2025-002 Reportable finding considered a material weakness-Expenses incurred outside of the period of performance Effect: The organization claimed and was reimbursed for unallowable costs under 2 CFR 200.458. Failure to maintain effective controls over cost allowability increases the risk o...
Finding: 2025-002 Reportable finding considered a material weakness-Expenses incurred outside of the period of performance Effect: The organization claimed and was reimbursed for unallowable costs under 2 CFR 200.458. Failure to maintain effective controls over cost allowability increases the risk of noncompliance questioned costs, and potential repayment of federal funds. Questioned costs: Known questioned costs of $403,805 were identified by reviewing each transaction prior to the date and for the month after the award began to ensure there are no likely questioned costs. Recommendation for the organization from the auditor: • Formalize and implement written policies and procedures governing identification, approval, and accounting for pre-award costs. • Require documented written approval from the federal awarding agency prior to charging any pre-award costs to federal awards. • Provide training to program and finance personnel on Uniform Guidance cost allowability requirements, including 2 CFR 200.458 and 2 CFR 200.403. • Implement supervisory review controls to ensure costs charged to federal awards are incurred within the approval period of performance or have documented prior approval. Corrective Action Plan for Pre-award costs Management acknowledges the audit finding that pre-award costs were charged to multiple federal awards for expenses incurred before the approved period of performance beginning October 1, 2024. The costs were incurred without the required written prior approval from the Maryland Department of Labor (MD DOL), the pass-through entity. As a result, unallowable costs were reimbursed and later removed from the Schedule of Expenditures of Federal Awards (SEFA). Management determined that the issue resulted from insufficient internal controls, the absence of formal written procedures for pre-award costs, and gaps in staff understanding of Uniform Guidance requirements. To address these root causes, the organization adopted a formal written policy governing the identification, approval, documentation, and accounting of pre-award costs. The policy requires written prior approval from MD DOL before any pre-award costs may be incurred or charged to a federal award and establishes documentation, retention, and accounting standards to support compliance with 2 CFR 200.458 and 2 CFR 200.403. Third, the organization also implemented a mandatory written approval workflow requiring program and grants staff to prepare and submit a formal request to MD DOL whenever pre-award costs are anticipated. No costs may be incurred until written approval is received. Approval documentation must be retained in both the official grant file and the accounting system. This workflow is now part of the grant start-up process for all federal awards. Fourth, the organization strengthened supervisory review controls to ensure that all costs charged to federal awards fall within the approved period of performance or have documented prior approval. These controls include a pre-posting cost allowability checklist, supervisory review and approval of all federal charges, and accounting system alerts that flag costs incurred outside the period of performance. Additionally, the Compliance Officer will conduct quarterly internal compliance reviews to verify adherence to federal requirements and internal policies. Finally, the organization implemented preventive measures to ensure long-term compliance. These include maintaining a centralized grant calendar with period-of-performance dates, requiring dual review of costs charged during the first 90 days of new awards, and conducting semi-annual internal audits of federal expenditures. Any discrepancies identified will be reported to senior leadership within five business days. Management is committed to ensuring full compliance with Uniform Guidance and MD DOL requirements. All corrective actions described above have been implemented or will be fully implemented by July 31, 2026. The organization believes these actions sufficiently address the audit findings and significantly strengthen internal controls over federal award management. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Develop and implement formal Pre-award Cost Policy Finance Director June 1, 2026 Final approved policy; distribution email; policy posted to shared drive Establish mandatory written prior approval workflow Finance Director June 30, 2026 Completed approval request template; sample approval documentation; updated grant file checklist Conduct Uniform Guidance training Compliance Officer July 31, 2026 Training materials; attendance logs; post-training assessments Implement supervisory review controls Finance Director June 30, 2026 Completed checklists; system screenshots; supervisor sign-offs Perform quarterly internal compliance reviews Compliance Officer Quarterly, ongoing Quarterly review reports; corrective action memos (if applicable) Maintain centralized grant calendar Director of Performance and Compliance June 30, 2026 Updated grant calendar; access logs or distribution email Conduct semi-annual internal audits Compliance Officer Semi-annual, ongoing Internal audit reports; follow-up documentation Dual review of early-period charges Finance Director; Grants Manager July 1, 2026 Dual-review sign-off forms; documented approvals
Management Response: Management acknowledges Finding 2025-004 and agrees that weaknesses in the review and approval of expenses represent a material weakness in internal control over compliance. The reimbursement of personal credit card expenses and the charging of those transactions to federal awar...
Management Response: Management acknowledges Finding 2025-004 and agrees that weaknesses in the review and approval of expenses represent a material weakness in internal control over compliance. The reimbursement of personal credit card expenses and the charging of those transactions to federal awards resulted in unallowable costs and demonstrated a breakdown in the review process for employee reimbursements and supporting documentation. Although the known questioned costs total only $46, the broader risk is that additional unallowable, unsupported, or improperly coded expenses could be charged to federal awards if review controls are not strengthened. Management determined that the root causes included insufficiently detailed procedures for reviewing employee reimbursement requests, inconsistent verification of business purpose and allowability before reimbursement, and inadequate supervisory review of expense documentation before costs were posted to federal awards. Existing controls were not precise enough to identify personal or otherwise unallowable charges embedded within reimbursement activity, particularly when descriptions were incomplete or reviewers did not independently confirm that the expense was necessary, reasonable, properly documented, and allowable under Uniform Guidance. To address this material weakness, management is implementing a corrective action plan focused on strengthening pre-payment and pre-posting review of employee reimbursements and other expense transactions charged to federal awards. The plan includes four key actions: revising reimbursement and accounts payable procedures to require detailed support for every request; requiring documented secondary review by supervisory or finance personnel independent of the submitter; implementing exception-based review procedures for higher-risk transactions; and performing periodic post-payment monitoring to confirm that review procedures are operating effectively and that unallowable costs are promptly identified and corrected. Under the revised process, no employee reimbursement or expense charged to a federal award will be approved unless the request includes sufficient supporting documentation to allow the reviewer to determine that the cost is necessary, reasonable, allocable as applicable, consistently treated, and adequately documented in accordance with Uniform Guidance cost principles. Reviewers will be required to confirm the business purpose of the transaction, assess whether the type of cost is allowable under the terms of the award and applicable federal regulations, and verify that no personal items, duplicate charges, sales tax errors, or unsupported amounts are included. If documentation is incomplete or a charge appears questionable, the transaction will be held pending clarification, recoded to a non-federal source, or denied reimbursement as appropriate. Any unallowable expense identified after reimbursement will be promptly removed from the applicable federal award and reported through management’s corrective follow-up procedures. Management will also reinforce accountability through targeted training and oversight. Employees who prepare, review, approve, or process reimbursements and expense reports affecting federal awards will receive training on allowable cost principles, documentation expectations, and the importance of careful review under 2 CFR Part 200, including the requirement that costs be adequately documented and necessary and reasonable for the performance of the federal award. In addition, Finance will generate periodic exception reports highlighting reimbursement activity charged to federal awards, personal credit card reimbursements, and other transactions meeting defined risk criteria. These reports will be reviewed by management to identify trends, address control failures, and implement additional corrective measures when needed. Management believes these corrective actions directly address the auditors’ recommendations and strengthen controls over the review and approval of expenses charged to federal awards without repeating the corrective actions already established for pre-award costs, allocation methodology, or broader financial close procedures. Responsibility for implementation will rest primarily with the Finance Director, in coordination with accounts payable, grants, and program leadership. Management expects enhanced documentation standards, independent review requirements, exception-based oversight, and monitoring activities to reduce the risk of personal or otherwise unallowable expenses being reimbursed and charged to federal awards in future periods. Corrective Action Plan Summary Corrective Action Responsible Staff/Role Target Completion Date Evidence of Completion Revise and adopt written expense reimbursement and accounts payable review procedures requiring itemized receipts, documented business purpose, funding source identification, and explicit confirmation that requested costs are not personal in nature. Finance Director; Accounts Payable Supervisor June 30, 2026 Approved procedures; updated reimbursement forms; staff distribution records. Implement a standardized reimbursement review checklist requiring reviewer validation of allowability, Accounts Payable Supervisor; July 15, 2026 Completed checklist template; sample reviewed reimbursement business purpose, receipt support, coding accuracy, and identification of any personal or unsupported charges before reimbursement or posting to a federal award. Finance Director packages; approval signoff documentation. Require independent supervisory review and approval for all employee reimbursements and any expense transaction charged in whole or in part to a federal award, including personal credit card reimbursement requests. Finance Director Effective immediately Supervisor approval records; signed reimbursement packages; workflow evidence showing independent review. Provide targeted training for employees, supervisors, accounts payable, and grants personnel on allowable cost principles, documentation standards, and reviewer responsibilities for expenses affecting federal awards. Compliance Officer; Finance Director August 31, 2026 Training materials; attendance logs; completed acknowledgements or knowledge checks. Create periodic exception reports for reimbursement activity charged to federal awards, missing receipt transactions, unusual merchants, and other higher-risk expense patterns, and require documented management review of the results. Accounting Manager; Finance Director September 30, 2026 Exception report format; monthly or quarterly review logs; documented follow-up on exceptions. Perform quarterly post-payment monitoring of a sample of reimbursed expenses charged to federal awards to verify compliance with documentation, Compliance Officer; Finance Director Quarterly, beginning September 30, 2026 Quarterly monitoring reports; exception logs; evidence of recoding, recovery, or corrective follow-up. approval, and allowability requirements and to ensure prompt correction of any identified exceptions.
The District will implement proper control over program expenditures. Expenditures for other programs will be paid directly from those program funds, if possible.
The District will implement proper control over program expenditures. Expenditures for other programs will be paid directly from those program funds, if possible.
The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Com...
The Division is in the process of designing and implementing a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Michael Zielinski, Major, Divisional Commander.
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, and also applies to Expanded Food and Nutrition Education Programs, whic...
MANAGEMENT VIEWS AND CORRECTIVE ACTION PLAN REPORT ON FEDERAL AWARDS IN ACCORDANCE WITH THE OMB UNIFORM GUIDANCE SEPTEMBER 30, 2025 Finding 2025-001 Procurement- Lack of Cost or Price Analysis Cluster: Research and Development, and also applies to Expanded Food and Nutrition Education Programs, which is not a cluster Sponsoring Agency: National Aeronautics and Space Administration and Department of Agriculture Award Names: NASA 90NSSC24K0999 and NI22eFNEPXXXG004-0003 Award Numbers: 208905 and 385076 Assistance Listing Title: Mission Support and Expanded Food and Nutrition Education Program Assistance Listing Number: 43.009 and 10.514 Award Year: 2024 – 2025 Management notes 2025-001 is a repeat finding of 2024-001, but given the timing of the finding last year, our 2024 CAP was anticipated to be completed as of October 1, 2025. To ensure Auburn University is in compliance with 2CFR 200.324, Auburn University has implemented the following corrective action plan: In addition to our current policies that required three quotes for purchases between $15,000-$75,000 and a formal competitive bid for purchases greater than $75,000, Auburn University revised our policies to require a cost or price analysis for items greater than $250,000, documenting that the purchase is reasonable. For items greater than $250,000, we will include a certification on the Professional Services Contracts and the Sole Source request forms indicating an analysis of cost or price has occurred and that the purchase is reasonable. As part of the cost or price analysis, we will utilize available data points. In addition to our analysis, we will ensure that our reviews have been appropriately documented and included in our files. Prior to the implementation date noted below, we will review any purchases greater than $250,000 in fiscal year 2026 and ensure proper cost or price analysis is completed and documented. The corrective actions noted herein have been implemented as of October 1, 2025. Contact: Missty Kennedy Chief Procurement Officer and Executive Director Procurement and Payment Services Amy Douglas Associate VP Financial Services/Controller Completed Date: October 1, 2025
Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Heal...
Item 2025.001 - Activities Allowed or Unallowed Recommendation We recommend that the Organization consistently enforce its internal controls over payroll to ensure that the allocations are reviewed and approved by the appropriate supervisor. Repeat Finding Not a repeat finding. Action Taken The Health Center converted the payroll system from Paycom to Paylocity which has capacity for grant hours tracking. We should have compliance in three months after implementation. The first pay date using Paylocity will be 7/2/2026 covering the pay period from 6/14/2026 to 6/27/2026. In addition, The Health Center's new GL system, Sage lntacct, also has grant accounting capability. With these two systems conversions, we should be able to track time and effort compliance.
Insufficient Cash and Deficit of Unrestricted Net Position Corrective Action The Authority will analyze and evaluate charges and allocations to the Section 8 Housing Choice Voucher Program and budget administrative and applicable operating expenses of the Program within HUD’s administrative funding ...
Insufficient Cash and Deficit of Unrestricted Net Position Corrective Action The Authority will analyze and evaluate charges and allocations to the Section 8 Housing Choice Voucher Program and budget administrative and applicable operating expenses of the Program within HUD’s administrative funding limits. Additionally, the Authority will abstain from advancing Public Housing Program assets to the Section 8 Housing Choice Voucher Program. Jebidiah Jackson, Executive Director, has assumed the responsibility of executing this corrective action as of August 1, 2026.
Audit Finding Reference: 2025-003 Improve Controls over Period of Performance Planned Corrective Action: The District has strengthened its grant management and closeout procedures to ensure that all expenditures charged to federal awards are incurred, processed, and paid within the applicable period...
Audit Finding Reference: 2025-003 Improve Controls over Period of Performance Planned Corrective Action: The District has strengthened its grant management and closeout procedures to ensure that all expenditures charged to federal awards are incurred, processed, and paid within the applicable period of performance. Specifically, the District will: 1. Implement a formal grant closeout checklist that includes a review of all open purchase orders, encumbrances, unpaid invoices, and outstanding obligations prior to submission of final expenditure reports. 2. Require reconciliation of grant expenditures between the Grants Office, Special Education Department, and Business Office before final grant reports are submitted. 3. Establish periodic reviews of open encumbrances throughout the year to identify outstanding obligations and ensure timely processing of invoices. 4. Designate backup personnel and document grant management procedures to ensure continuity during staffing transitions or vacancies. 5. Require supervisory review and approval of all grant closeout documentation to verify that all allowable expenditures have been recorded and reported appropriately. 6. Provide training to personnel responsible for grant administration and financial reporting regarding federal period-of-performance requirements and grant closeout procedures. Planned Implementation Date of Corrective Action: The revised grant monitoring and closeout procedures have been implemented for all active federal grants and will be fully incoiporated into the District's grant management process beginning with the current fiscal year. Person Responsible for Corrective Action: Grants Manager Signature Derek Pinto, Assistant Superintendent of Finance
Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of...
Audit Finding Reference: 2025-001 Maintain Employee's Time and Effort Records Planned Corrective Action: The District will implement and enforce a formal time and effort reporting process for all employees whose salaries are charged to federal programs. The process will include: 1. Identification of all employees whose compensation is funded, in whole or in part, by federal awards. 2. C.ompletion of required semi-annual certifications or periodic personnel activity reports, as applicable, in accordance with Uniform Guidance requirements. 3. Review and approval of certifications bysupervisory personnel to ensure accuracy and completeness. 4. C.entralized maintenance of all certifications by the Grants Office to ensure records are readily available for audit and monitoring purposes. 5. Development of a compliance calendar with established due dates and reminder notifications for required certifications. 6. Quarterly monitoring bythe Business Office to verifythat all required certifications have been completed, reviewed, and retained. Planned Implementation Date of Corrective Action: The District has begun implementing these procedures and will have the revised process fully operational by 6/30/2026. All required certifications for the current fiscal year will be collected and maintained going forward. Person Responsible for Corrective Action: Grants Manager, Funds Analyst, Deputy Chief Financial Officer Signature Derek Pinto, Assistant Superintendent of Finance
Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedure...
Audit Finding Reference: 2025-002 Improve Procurement Procedures Planned Corrective Action: The District will strengthen its procurement procedures for federally funded purchases to ensure compliance with Uniform Guidance requirements. Specifically, the District will: 1. Revise procurement procedures to clearly identify when federal procurement requirements apply in addition to state and local procurement regulations. 2. Develop and implement a federal procurement checklist that must be completed prior to the award of any contract funded in whole or in part with federal grant funds. 3. Work with the Law Department to establish standardized contract templates containing all required federal contract provisions, including the Byrd Anti-Lobbying Amendment when applicable. 4. Require a secondary review bythe Business Office or Grants Management personnel before contract execution to verify compliance with Uniform Guidance procurement standards and required contract clauses. 5. Provide annual training to Business Office staff, grant managers, and other personnel involved in procurement activities regarding federal procurement requirements and contract provisions. 6. Conduct periodic internal reviews of federally funded procurement transactions to ensure ongoing compliance. Planned Implementation Date of Corrective Action: The revised procedures, procurement checklist, and standardized contract templates will be implemented by7 /1/2026. Training will be completed for applicable staff during the current fiscal year and prior to the initiation of future federally funded procurements. Person Responsible for Corrective Action: Assistant Superintendent of Finance Derek Pinto, Assistant Superintendent of Finance
Audit Finding Reference: 2025-004 Maintain Approved Rate Support for Employee Pay Rates and Time and Effort Support Planned Corrective Action: The District will strengthen internal controls over payroll costs charged to federal programs by implementing the following corrective measures: 1. Identify ...
Audit Finding Reference: 2025-004 Maintain Approved Rate Support for Employee Pay Rates and Time and Effort Support Planned Corrective Action: The District will strengthen internal controls over payroll costs charged to federal programs by implementing the following corrective measures: 1. Identify all employees whose salaries and wages are charged, in whole or in part, to the Child Nutrition Cluster and other federal awards. 2. Implement a formal process requiring completion of appropriate time and effort certifications in accordance with Uniform Guidance requirements and District policy. 3. Establish procedures to ensure certifications are completed in a timely manner, signed by employees and/or supervisors as required, and maintained in a centralized location. 4. Develop a compliance tracking system to monitor the collection and retention of required documentation throughout the year. 5. Conduct periodic reviews of payroll allocations to verify that payroll charges are supported by appropriate documentation and accurately reflect the work performed. 6. Provide annual training to Child Nutrition, Payroll, Human Resources, and Business Office personnel regarding federal time and effort documentation requirements and record retention responsibilities. Planned Implementation Date of Corrective Action: The District has implemented procedures to identify all federally funded employees and will require completion and retention of all applicable time and effort documentation beginning immediately and for all future reporting periods. Person Responsible for Corrective Action: HR Generalist for Cafeteria Derek Pinto, Assistant Superintendent of Finance
Corrective Actions to Be Implemented: The organization is moving from MIP Fund Accounting to QuickBooks online Advanced which will remove the multi-step data entry process currently used for time capture and payroll processing. Simultaneously, we are implementing Hourtimesheet, a Defense Contract Au...
Corrective Actions to Be Implemented: The organization is moving from MIP Fund Accounting to QuickBooks online Advanced which will remove the multi-step data entry process currently used for time capture and payroll processing. Simultaneously, we are implementing Hourtimesheet, a Defense Contract Audit Agency (DCAA) compliant time tracking system which does not allow time entries outside of each employee assigned grant allocations. It has a native integration with Quickbooks and is the gold standard for government contract compliance. • QuickBooks Online Advanced anticipated completion: June 1, 2026 • Hourtimesheet anticipated completion: September 1, 2026 Responsible Parties: Brandi Senters, Finance Director, will be responsible for implementation, with oversight from the Executive Director, Erin Broussard.
Finding 1218756 (2025-001)
Material Weakness 2025
Corrective Action Plan: Misuse of Funds – Vehicle: Pact updated its Global Vehicle Policy effective November 1, 2025. The updated Global Vehicle Policy reinforces Pact’s zero-tolerance policy. No new reports of vehicle misuse have been received since November 2025, and all the reported cases of misu...
Corrective Action Plan: Misuse of Funds – Vehicle: Pact updated its Global Vehicle Policy effective November 1, 2025. The updated Global Vehicle Policy reinforces Pact’s zero-tolerance policy. No new reports of vehicle misuse have been received since November 2025, and all the reported cases of misuse occurred prior to November 1. Pact’s updated policy complies with all applicable laws and regulations, including the organization’s internal Code of Conduct, while aligning with the objectives and scope of work for the project. Pact’s guidelines specify roles and responsibilities and role assignments; identify authorized places to obtain fuel; where to store vehicle keys; where to park vehicles; and require individuals to enter detailed records regarding the use of the vehicle into a log. Misuse of Funds – Payroll: In alignment with Pact’s core principle of continuous quality improvement, and following substantiation of the misuse in one country office, Pact developed and implemented a corrective action plan. This plan included a comprehensive quality review of existing controls to identify and address any procedural gaps in the timesheet systems to ensure the timesheet systems have a functional auditable approval trail. We have reinforced, including in Senior Management Team meetings with staff, and other trainings supervisors’ responsibility to review and verify hours worked for their staff.
Finding 2025-001 Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: Southbridge Public Schools will be creating and implementing procedures for time and effort certifications. The procedure will include use of the form distributed by the Mas...
Finding 2025-001 Condition: Time and effort certifications were not maintained for grant employees. Corrective Action Planned: Southbridge Public Schools will be creating and implementing procedures for time and effort certifications. The procedure will include use of the form distributed by the Massachusetts Department of Elementary and Secondary Education for employees who are paid by a grant and require a time and effort certification. Anticipated Completion Date: July 31, 2026 Contact: Matthew Robidoux – Business Manager
Condition Holyoke Gas & Electric (HG&E) calculated indirect costs using an incorrect total direct cost base rather than the modified total direct costs required by the grant agreement and 2 C.F.R. §200.414(f). Indirect cost was calculated based on total cost, including construction and material. Cor...
Condition Holyoke Gas & Electric (HG&E) calculated indirect costs using an incorrect total direct cost base rather than the modified total direct costs required by the grant agreement and 2 C.F.R. §200.414(f). Indirect cost was calculated based on total cost, including construction and material. Corrective Action Plan Corrective Action Planned: By December 25, 2026, HG&E will implement a formal grant administration policy that clearly defines roles and responsibilities and establishes a comprehensive framework for effective grant management. In addition, HG&E will ensure that all questions related to indirect costs and other compliance requirements are confirmed in writing. HG&E believes this approach will significantly reduce the risk of future reporting errors. Names of Contact Persons Responsible for Corrective Action: Brooke McMahon – 413-536-9318 Bill Sullivan - 413-536-9523 99 Suffolk Street Holyoke, MA 01040 Anticipated Completion Date: The Corrective Action Plan will be implemented by December 31, 2026
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures supported by federal funds. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds. Policies and procedures will be im...
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures supported by federal funds. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior to the submission of the July-September 2026 claim.
Finding 2025-061 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Block Grants for Prevention and Treatment of Substance Abuse, ALN 93.959 Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an A...
Finding 2025-061 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC), ALN 93.323 and Block Grants for Prevention and Treatment of Substance Abuse, ALN 93.959 Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS is actively pursuing the implementation of an API for the submission of FFATA data to the federal system, SAM, to improve both timeliness and accuracy through automation. This API will connect EGrAMS with SAM, enabling backend communication between the systems and allowing SAM to automatically retrieve data directly from EGrAMS. To ensure accurate reporting until the API is established, MDHHS will continue reviewing validation errors when submitting web-based information to SAM and will work with the SAM federal helpline to report federal system issues and identify interim alternatives to submit the required data. Also, MDHHS implemented an enhancement in August 2025 that validates federal funding sources in EGrAMS against their effective dates, reducing coding errors and improving data reliability. In addition, the query used to obtain certain FFATA data elements was modified during fiscal year 2026 to improve accuracy of reporting. Anticipated Completion Date December 31, 2027 Responsible Individual(s) Matt Blackburn, MDHHS Jeanette Hensler, MDHHS Rebecca Jones, MDHHS
Finding 2025-054 Adoption Assistance, ALN 93.659 - Lack of Fingerprint Background Checks Management Views MDHHS disagrees that completion of fingerprint-based background checks within 12 months of adoption finalization are a condition of eligibility for adoption assistance payments. Federal law 42 U...
Finding 2025-054 Adoption Assistance, ALN 93.659 - Lack of Fingerprint Background Checks Management Views MDHHS disagrees that completion of fingerprint-based background checks within 12 months of adoption finalization are a condition of eligibility for adoption assistance payments. Federal law 42 USC 671(a)(20) requires states to complete a fingerprint-based criminal background check before a prospective adoptive parent may be finally approved for placement; however, federal statute does not mandate additional or subsequent fingerprint-based criminal history rechecks after placement approval as a condition of eligibility for adoption assistance payments. Michigan’s Title IV-E State Plan incorporates the safety requirements mandated by federal law 42 USC 671(a)(20) and cites MDHHS policy ADM 0520 (Background Checks, Clearances, Criminal History Checks, and Fingerprinting). ADM 0520 governs all background checks, clearances, criminal history checks, and fingerprinting requirements that MDHHS must complete for foster care and adoptive home providers. The policy establishes the department’s comprehensive safety check framework and is not limited to adoption assistance eligibility determinations. Rather, ADM 0520 outlines the procedures MDHHS uses to meet federal and State safety requirements for approving and supervising foster and adoptive placements, including checks conducted both before placement approval and those completed afterward to ensure the ongoing safety and well being of children under MDHHS supervision. For all cases sampled, fingerprint based clearances were completed within 12 months of the family’s approval for placement, and documentation of these clearances is included in the adoption assistance file. Therefore, MDHHS is compliant with all applicable federal and State requirements for adoption assistance payments. Planned Corrective Action MDHHS will clarify policy to explicitly distinguish safety-driven clearances from federally required placement-approval checks, including clarification that the required prerequisite for adoptive placement and adoption assistance payments is completion of fingerprint-based clearances within 12 months of approval. Anticipated Completion Date December 1, 2026 Responsible Individual(s) Heather Williams, MDHHS Kim Borja, MDHHS Kathonya Triplett, MDHHS
Finding 2025-020 Foster Care Title IV-E, ALN 93.658 and Adoption Assistance, ALN 93.659 - Accuracy of Financial Reports Management Views MDHHS disagrees with the finding. The expenditures noted were recorded through MDHHS’s normal, federally approved Public Assistance Cost Allocation Plan cost alloc...
Finding 2025-020 Foster Care Title IV-E, ALN 93.658 and Adoption Assistance, ALN 93.659 - Accuracy of Financial Reports Management Views MDHHS disagrees with the finding. The expenditures noted were recorded through MDHHS’s normal, federally approved Public Assistance Cost Allocation Plan cost allocation process. As part of this process, certain administrative costs are not identifiable or allocable to federal programs until the allocation is completed. At that point, MDHHS recognizes these costs as expenditures in the CB-496 report in the quarter in which the allocation occurs and the costs are assigned to the grant. Consistent with this approach, MDHHS has historically reported these amounts as current quarter expenditures. MDHHS previously consulted with the U.S. Department of Health and Human Services (HHS) Administration for Children and Families (ACF) on the appropriate use of the prior quarter adjustment column, and MDHHS was verbally instructed to no longer record these administrative costs as adjustments since this is part of the normal cost allocation process. ACF approves the CB-496 reports in the federal system and ensures the final award amount reconciles with the amounts reported. This approval process supports the reporting approach used by MDHHS is both consistent with prior guidance and accepted by ACF through its approval and award process. Planned Corrective Action Although MDHHS disagrees with the finding, MDHHS sought written guidance from ACF and will follow up to obtain clarification on the appropriate reporting of administrative costs. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Rebecca Jones, MDHHS
Finding 2025-048 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS acknowledges that documentation supporting compliance with refugee c...
Finding 2025-048 Refugee and Entrant Assistance State/Replacement Designee Administered Programs, ALN 93.566 - Assistance to Ineligible Refugees Management Views LEO and MDHHS agree with the finding. Planned Corrective Action MDHHS acknowledges that documentation supporting compliance with refugee cash assistance work registry requirements must be consistently maintained in the electronic case record. The issue identified pertains to documentation of ongoing work registration requirements within the case record to maintain eligibility, noting that the clients were eligible at the time of application approval. Beginning January 2026, MDHHS implemented a monthly manual review of active cases to ensure required documentation is present. MDHHS is also pursuing a Bridges system enhancement to automate generation and storage of the DHS-4785R (Refugee Employment Program Appointment Notice) in the electronic case file. This enhancement will be submitted through the Departmental Work Intake Process for prioritization and implementation by the Bridges technical team. Anticipated Completion Date MDHHS has not yet determined an anticipated completion date because the date is dependent on the priority assigned to the system enhancement as determined by the Departmental Work Intake Process. Responsible Individual(s) Benjamin Cabanaw, LEO Nicole Adams, LEO Bethany Cabanaw, MDHHS Kent Schulze, MDHHS Mariah Schaefer, MDHHS
Finding 2025-047 Refugee and Entrant Assistance State/Replacement Designees Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. For part a., the LEO Office of Global Michigan (OGM) maintains a limited number of internal...
Finding 2025-047 Refugee and Entrant Assistance State/Replacement Designees Administered Programs, ALN 93.566 - Salesforce Security Management and Access Controls Management Views LEO agrees with the finding. For part a., the LEO Office of Global Michigan (OGM) maintains a limited number of internal Salesforce user licenses. As a result, internal user access is inherently constrained and proactively monitored based on employment status. LEO OGM’s existing process for validating continued need is tied to personnel changes: internal user access remains appropriate as long as the employee occupies a position with assigned Salesforce responsibilities, and access is removed when employees separate or move to roles that do not require use of the system. Because license allocation is strictly managed and user roles are position-based, LEO OGM has considered this process to constitute ongoing monitoring rather than an annual recertification process. However, LEO OGM acknowledges that this practice does not fully meet the specific requirement for a documented annual review as noted in SOM Technical Standard 1340.00.020.01 (Access Control Standard). Planned Corrective Action For part a., LEO OGM will formalize and implement an internal user account review process, including conducting and documenting an annual review of all user access accounts in accordance with the Access Control Standard. For part b., LEO OGM will work collaboratively with program and system administrators to strengthen controls around identifying and timely deactivating inactive internal and external user accounts. LEO OGM will establish clearer procedures, increase review frequency, and document the actions taken to ensure accounts exceeding inactivity thresholds are disabled consistently and timely. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Ben Cabanaw, LEO Nicole Adams, LEO
Finding 2025-044 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF-Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) eligibility after the birth certifica...
Finding 2025-044 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF-Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) eligibility after the birth certificate was received and the youth was determined to be Title IV-E eligible. MDHHS has already reclassified the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement, and repaying any TANF overpayments. Reconciliations between different fund sources, or recoupments for overpayments, will be created within 30 calendar days of receipt of supporting documentation and approved timely by management. All recoupment and reconciliation records will be approved by management no later than September 30 each fiscal year to ensure compliance with year-end requirements. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Nancy Berger, MDHHS
Finding 2025-043 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will issue a memo to reinforce documentation requirements for TANF eligibility determinations by September 30...
Finding 2025-043 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will issue a memo to reinforce documentation requirements for TANF eligibility determinations by September 30, 2026. The memo will clarify expectations for obtaining, uploading, and retaining all required non-financial eligibility verifications in accordance with federal regulations and MDHHS policy. MDHHS will also address each individual case-specific issue with the appropriate local office. In addition, these findings will be addressed as part of TANF mandatory audit training for local office staff scheduled in July 2026. This training will emphasize the importance of maintaining complete eligibility records, proper use of the Work and Self Sufficiency Rules (DHS-1538) form, verification of age and relationship, and timely completion of the Family Automated Screening Tool. Further, MDHHS ESA policy staff are working with the MDHHS Bridges technical team to implement a system modification during September 2026 that will enhance the application review process. Anticipated Completion Date September 30, 2026 Responsible Individual(s) Bethany Cabanaw, MDHHS Kenton Schulze, MDHHS Brian Sanborn, MDHHS Ashley Soper, MDHHS
Finding 2025-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Benefits Monitoring Program Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., for the one identified exception, MDHHS notified the MHP that the enrollment notification letter was not sent in a ti...
Finding 2025-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Benefits Monitoring Program Management Views MDHHS agrees with the finding. Planned Corrective Action For part a., for the one identified exception, MDHHS notified the MHP that the enrollment notification letter was not sent in a timely manner. To ensure compliance moving forward, the MHP Benefits Monitoring Program (BMP) care managers were provided training in February 2026 on the BMP process, emphasizing the importance of verifying that enrollment notification letters are created and sent to members within the required timeframe. MDHHS believes this is an isolated incident, however, MDHHS obtained and reviewed each MHP’s documented step-by-step enrollment process to confirm that it includes the generation and distribution of the enrollment notification letter. For part b., MDHHS implemented a monitoring process in February 2026. As part of this process, the Enrolled Research Report is reviewed weekly to ensure all required 24 month reviews are identified and completed in a timely manner. Anticipated Completion Date Completed Responsible Individual(s) Torey Schlaufman, MDHHS
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