Corrective Action Plans

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Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the program...
Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the programs in a manner that did not align with the allocation methodology outlined in the 2022–2023 cost allocation plan submitted to MDHHS. Furthermore, the plan lacked explicit certification and contained minor errors and omissions. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Regina Greear Terri Daniels Anticipated completion date: July 2026 Planned Corrective Action: Upon identification, the City worked with the Michigan Department of Health and Human Services (MDHHS) and obtained approval and acceptance of the indirect cost calculation. The City will continue to work with MDHHS to ensure full compliance. The City has initiated a review of its indirect cost allocation methodology to ensure compliance. Management is updating the cost allocation calculation to document the approved allocation method and ensure the method is in accordance with the approved plan. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements.
1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The Elementary Principal will work to ensure that time and effort reports are completed. 3. Official Responsible for Ensuring CAP Jennifer Stefan, Elementary P...
1. Explanation of Disagreement with Audit Finding There is no disagreement with the audit finding. 2. Actions Planned in Response to Finding The Elementary Principal will work to ensure that time and effort reports are completed. 3. Official Responsible for Ensuring CAP Jennifer Stefan, Elementary Principal, is the official responsible for ensuring corrective action of the deficiency. 4. Planned Completion Date for CAP The planned completion date for the CAP is June 30, 2026. 5. Plan to Monitor Completion of CAP The School Board will be monitoring this CAP.
For ALN 93.958, the discount fee was not properly calculated and/or documented on the Financial Assessment Form for 3 of the 60 clients tested. Additionally, 4 of the 60 clients tested on the Block Grant for Mental Health had dates that did not fall within one year after the FAF completion. For ALN ...
For ALN 93.958, the discount fee was not properly calculated and/or documented on the Financial Assessment Form for 3 of the 60 clients tested. Additionally, 4 of the 60 clients tested on the Block Grant for Mental Health had dates that did not fall within one year after the FAF completion. For ALN 93.959, 1 of the 60 clients tested on the Block Grant for Prevention and Treatment of Substance Abuse did not have a completed FAF and 1 of the 60 tested had a missing client signature. For ALN 93.788, 1 of the 40 clients tested on Opioid STR Program did not have a completed FA. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 90% of the time. We have identified that some of the missing FAs are a result of Telehealth appointments and clients not coming into the office. As a corrective action, the Client Service Specialist will be trained by their managers to ensure data is entered accurately and how to properly apply the FAs. SMA will also include the completion of the Financial Assessment Form both at admission and annually with data to be reviewed monthly by the managers. In addition, we will be working with IT to identify a way to collect the FAs from clients that utilize Telehealth services. Reporting will be sent out monthly and if out of compliance the managers will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.
The Town recognized its lack of understanding of Uniform Guidance as it relates to federal grant programs and hired an outside consultant on August 16, 2022, to administer the federal grants to ensure that the Town would comply with allfederalprogram requirements. The Town was led to believe that th...
The Town recognized its lack of understanding of Uniform Guidance as it relates to federal grant programs and hired an outside consultant on August 16, 2022, to administer the federal grants to ensure that the Town would comply with allfederalprogram requirements. The Town was led to believe that they were in compliance with all federal program requirements. This is the second year of both federal grant programs, and the Town is just being made aware of the suspension and debarment requirement. It should be noted that all contractors and the consultant are not on the suspension and debarment lists.
All payments to contractors and vendors for the Water Sector Program are reviewed and approved by the outside consulting firm prior to payment. The outside consultant directs the Clerk as to the amount to pay and who to pay. The outside consultant acknowledged that they made the error in instructing...
All payments to contractors and vendors for the Water Sector Program are reviewed and approved by the outside consulting firm prior to payment. The outside consultant directs the Clerk as to the amount to pay and who to pay. The outside consultant acknowledged that they made the error in instructing the Town to make the payment. The State of Louisiana was contacted by the outside consultant to discuss the corrective action plan. The State advised the consultant to not make any corrections to the pay request that they would “bagout” the overpayment. Before the next pay request, the contractor returned the overpayment which was deposited into the Town’s Water Sector grant bank account.
The Town recognized its lack of understanding of Uniform Guidance as it relates to federal grant programs and hired an outside consultant on August 1 6, 2022, to administer the federal grants to ensure that the Town would comply with all federal program requirements. The Town was led to believe that...
The Town recognized its lack of understanding of Uniform Guidance as it relates to federal grant programs and hired an outside consultant on August 1 6, 2022, to administer the federal grants to ensure that the Town would comply with all federal program requirements. The Town was led to believe that they were in compliance with all federal program requirements. The Town will develop, formally adopt, and implement written policies and procedures to comply with Uniform Guidance (2 CFR 200).
The District has revised and resubmitted the Final Expenditure Report for the Title I School Improvement (a) grant and will repay the unallowable costs to DESE. In addition the District will ensure that its procedures and the Uniform Guidance requirements are being followed regarding allowable trave...
The District has revised and resubmitted the Final Expenditure Report for the Title I School Improvement (a) grant and will repay the unallowable costs to DESE. In addition the District will ensure that its procedures and the Uniform Guidance requirements are being followed regarding allowable travel expenses.
CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a system for documenting time and effort in a manner that complies with Federal requirements w...
CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a system for documenting time and effort in a manner that complies with Federal requirements which involves timesheets that record actual time spent on a funding source and are accompanied by supervisory approvals. This system has been formally documented in the FY 26 update to the CIF Financial Policy and includes annual training for staff responsible for managing payroll allocations and Federal reporting. Charges to Federal awards for salaries and wages are now based on records that accurately reflect the work performed. The records are supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The records support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity.
Significant Deficiency Item 2025-007 - Cash Management - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we...
Significant Deficiency Item 2025-007 - Cash Management - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that there is no evidence of review and approval of drawdowns from the Health Center Program Cluster and the supporting records. Recommendation: We recommend that LBUCC implement a policy that requires all drawdowns and supporting documents to be reviewed and that such review and approval be documented. Action Taken: LBUCC revised the drawdown policy which now includes a review and approval from the CFO and the process is documented. Effectivity Date: Implemented 12/3/2025.
Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 Dur...
Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC charged salaries to the Section 330 grant based on pre-determined allocations or budget rather than actual hours worked. LBUCC utilized timesheets that reflect the allocations as its time and effort documentation. Recommendation: We recommend that LBUCC implement a time and effort reporting system that tracks actual hours worked on each program or grant. We recommend that they require supervisors to review and approve the actual time spent on grant activities and that such review and approval be documented. Action Taken: LBUCC will implement a time and effort reporting system to include a semi-annual certification for all employees funded by the HRSA 330 grant and a time card reporting system for those funded by multiple grants. Effectivity Date: Time and effort reporting will be implemented in January 2026 and fully in place by 1/31/2026
Material Weakness Item 2025-003 - Period of Performance - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8/-ICS46163-03-01 During our audit,...
Material Weakness Item 2025-003 - Period of Performance - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8/-ICS46163-03-01 During our audit, we noted that LBUCC drew down $190,688 of federal grant funds under the Section 330 program for the budget period beginning June 1, 2024 to reimburse salary expenses incurred in May 2024. Recommendation: We recommend that LBUCC implement procedures to ensure that all drawdowns are supported by expenses incurred strictly within the grant's approved period of performance and train staff on grant compliance requirements. Action Taken: A change in the process to draw down funds has been implemented to determine that the funds were incurred in the proper funding period rather than the period it was paid. Effectivity Date: Process change was implemented 12/1/2025.
Inadequate documentation over time and effort Actions Planned - The District has met with the administrative team and expressed the necessity to follow all documentation requirements. Administrative duties changed during the fiscal year and the position overseeing the federal program was unaware of ...
Inadequate documentation over time and effort Actions Planned - The District has met with the administrative team and expressed the necessity to follow all documentation requirements. Administrative duties changed during the fiscal year and the position overseeing the federal program was unaware of the requirement to document the time spent between state and federal activity. Official Responsible - Business Manager and Superintendent of Schools Planned Completion Date - December 31st, 2025 Disagreement with Finding - None - ISD #701-Hibbing concurs with the findng. Plan to Monitor - Further training and updates will be shared with the adminsitrative team as well as paryoll personel to ensure approriate documentaiton is provided.
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.566, Passed through Texas Office for Refugees, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Contra...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.566, Passed through Texas Office for Refugees, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Contract #’s: FFY2024-27947V-CMA and FFY2025-27947V-CMA, Contract years: 10/23-09/24 and 10/24-09/25. Condition and context: Interfaith Ministries’ policies and procedures for verifying the completeness of documentation includes ensuring the acknowledgement of receipt of a debit card by the client is maintained in the client file. In a sample of 33 client files tested for refugee cash assistance program, we noted one client who received a debit card in February 2025 did not have the acknowledgement receipt in the client file. Recommendation: Emphasize adherence to established policies and procedures to ensure acknowledgement of receipt of a debit card by the client is maintained in the client file. Planned corrective action: With the implementation of the Refugee Cash Assistance (RCA) Debit Card program by TXOR, our organization established the policy that client case files must contain a copy of the Debit Card Activation Page with the client’s signature and the date the card was delivered to the client as required by TXOR. Our program team will re-emphasize these policies through additional staff training to ensure compliance with the established policy and procedures for the RCA Debit Card program. Additionally, our compliance department will establish procedures to perform periodic reviews to ensure that the client files are complete. Responsible officer: Ali Al Sudani, Chief Program Officer and Terry Merriett, VP of Quality Assurance & Compliance. Estimated completion date: December 1, 2025.
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Co...
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Compliance Officer will be designated to oversee policy implementation and annual updates. Standard operating procedures will be issued for relevant departments, and mandatory staff training will be conducted. These actions will be completed by March 31, 2026, with ongoing monitoring through quarterly compliance meetings. Anticipated Completion Date: March 31, 2026
REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria wi...
REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders are sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The Finance Manager reviews the timecard allocations and populates the hours charged to the grant per the timecard on to the salary allocation spreadsheet. The salary allocation spreadsheet is utilized in completing the reimbursement request. The timecards and the allocation spreadsheet are included in the reimbursement request. Beginning in January 2026, the salary allocation spreadsheet and timecards will be reviewed and signed off by the Director of Outpatient Programs as part of the reimbursement request approval process. Additionally, timecard approval compliance for prior periods will be reviewed during Bailey-Boushay weekly leadership meetings. Person Responsible: Rob Hays, Executive Director – Bailey-Boushay House Expected Completion: January 2026
No. 2025-001 Subject: Allowable Costs and Activities ‐ Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Byron Jones, CFO Phone Number: (480) 270-5438 Anticipated Completion Date: June 30, 2026 Corrective Action: We will strengthen internal co...
No. 2025-001 Subject: Allowable Costs and Activities ‐ Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Byron Jones, CFO Phone Number: (480) 270-5438 Anticipated Completion Date: June 30, 2026 Corrective Action: We will strengthen internal controls over employee time coding by implementing enhanced review procedures to ensure only allowable Child Nutrition activities are charged to the grant. Supervisors and the accounting team will review all payroll coding charged to the Child Nutrition Cluster to verify that the employee’s position and duties align with approved grant activities. These improved internal procedures will provide proper compliance over allowable costs. We will also conduct an annual audit of all grant-funded employee positions at the start of each school year, reviewed by the grants team, HR, and accounting, to verify the accuracy of all employee costing allocations to federal grants and to ensure any miscoding errors are identified and corrected in a timely manner.
FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA)-Earmarking Contact Person Responsible for Corrective Action: Chelsea Yon Contact Phone Number and Email Address: 812-354-8731 cyon@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective A...
FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA)-Earmarking Contact Person Responsible for Corrective Action: Chelsea Yon Contact Phone Number and Email Address: 812-354-8731 cyon@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Treasurer of Pike County School Corporation will work with Exceptional Children’s Co-op on proportionate share expenditures. PCSC will also track those expenditures in a separate line along with revenue received for the proportionate share. Anticipated Completion Date: This method was implemented in the 2025-2026 school year and will continue with each school year as needed.
ST. LANDRY PARISH HOUSING AUTHORITY 509 Carriere St. Washington, LA 70589 Phone No. (337) 826-7207 Fax No. (337) 826-0760 HOUSING AUTHORITY OF ST. LANDRY PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Corrective Action Plan Finding: Finding 2025-001-Per Diem Improperly Paid Condit...
ST. LANDRY PARISH HOUSING AUTHORITY 509 Carriere St. Washington, LA 70589 Phone No. (337) 826-7207 Fax No. (337) 826-0760 HOUSING AUTHORITY OF ST. LANDRY PARISH, LOUISIANA CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2025 Corrective Action Plan Finding: Finding 2025-001-Per Diem Improperly Paid Condition: Expenditures must be ordinary and necessary, and in accordance with the mission statement terms outlined in the Authority’s Annual Contributions Contract (ACC). Section 14 (B) states “No funds of any project may be used to pay any compensation for the services of members of the HA Board of Commissioners.” Corrective Action Planned: I am Angela Beverly, Executive Director and Designated Person to answer this finding. We will comply with the auditor’s recommendation. Person responsible for corrective action: Angela Beverly, Executive Director Telephone: (337) 826-7207 Housing Authority of St. Landry Parish Fax: (337) 826-0760 509 Carriere St. Washington, LA 70589 Anticipated Completion Date: June 30, 2026
During the fiscal year ending June 30, 2026, the finance department and purchasing department led by Veronica Koller, CFO, will work to revise the current procurement policy to ensure that it complies with the Uniform Guidance.
During the fiscal year ending June 30, 2026, the finance department and purchasing department led by Veronica Koller, CFO, will work to revise the current procurement policy to ensure that it complies with the Uniform Guidance.
Finding 1167986 (2025-001)
Material Weakness 2025
Single Audit Corrective Action Plan 20-Month Audit Period Ending August 31, 2025 Finding: During review of payroll allocations charged to the Education Innovation and Research, #U411C190093, the auditor identified an overcharge of approximately $702.05. This was caused by a formula error in the spre...
Single Audit Corrective Action Plan 20-Month Audit Period Ending August 31, 2025 Finding: During review of payroll allocations charged to the Education Innovation and Research, #U411C190093, the auditor identified an overcharge of approximately $702.05. This was caused by a formula error in the spreadsheet used to prepare monthly invoices. A VLOOKUP in the staff allocation tab swapped the Rippling employee IDs for two employees with the same last name, resulting in the wrong salary amount being pulled into the allocation calculation. Although monthly staff allocations were reviewed and signed off, this specific formula mismatch was not detected. The grant had already been closed when this error was discovered. Corrective Action: We will implement a validation check within our allocation spreadsheet that requires the reviewer to verify the unique Rippling employee ID number, not a match on last name, before approving payroll allocations. Additionally, for any future Federal awards, we will add an annual salary cross-check to ensure that the salary in the allocation schedule matches the actual salary on record. Contact Person: Reyana Hill, Accounting Manager, reyana.hill@code.org Resolution of Questioned Costs: Management has notified the Department of Education of the $702.05 overpayment and has requested instructions for remitting the funds back to the Government. The repayment will be made within 30 days of receiving instructions.
The District will be utilizing the consulting service with Julian & Grube in the future.
The District will be utilizing the consulting service with Julian & Grube in the future.
Management has implemented a year-end reconciliation for all grant funds. Due to the timing of this grant - the District was able to capture the overpayment in the August 2025 expenditure report and therefore, no overpayment was owed. The District does not expect this finding to repeat again.
Management has implemented a year-end reconciliation for all grant funds. Due to the timing of this grant - the District was able to capture the overpayment in the August 2025 expenditure report and therefore, no overpayment was owed. The District does not expect this finding to repeat again.
Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following is the finding as noted in the Northern Michigan University Single Audit Act Compliance report for the year ended June 30, 2025, and corrective action to be completed. 2025-001 – Lack of Drawdown Revi...
Pursuant to federal regulations, Uniform Administrative Requirements Section 200.511, the following is the finding as noted in the Northern Michigan University Single Audit Act Compliance report for the year ended June 30, 2025, and corrective action to be completed. 2025-001 – Lack of Drawdown Review Procedures Auditor Description of Condition and Effect. The University did not have documented review procedures in place for federal grant drawdowns under the Research and Development cluster. Drawdowns were processed without a formal review or approval process to verify that amounts requested were based on allowable expenditures. This deficiency increases the risk of drawing federal funds in excess of actual expenditures or for unallowable costs, potentially resulting in noncompliance with federal regulations. Auditor Recommendation. The University should implement formal review procedures for all federal grant drawdowns, including enhancing policies around reviewing drawdowns, designated reviewers, and system controls to ensure drawdowns are accurate, allowable, and properly supported. Corrective Action. The University is developing formal grant drawdown review procedures that outlines required documentation and review steps around federal grant drawdowns. Responsible Person. Jamie Beauchamp, Controller Anticipated Completion Date. January 31, 2026.
Management's response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identified and authorization in efforts to minimize potential error going forward.
Management's response: Management concurs with the finding. Corrective Action Plan: Management will re-evaluate controls around cost identified and authorization in efforts to minimize potential error going forward.
Grant Cash Management – Community Development Block Grants Condition: 2 CFR 200.403 of the Uniform Guidance mandates that only necessary, and allowable costs be drawn down off of federal grants. During the audit, we found that the Water Plant Construction project had construction invoices being draw...
Grant Cash Management – Community Development Block Grants Condition: 2 CFR 200.403 of the Uniform Guidance mandates that only necessary, and allowable costs be drawn down off of federal grants. During the audit, we found that the Water Plant Construction project had construction invoices being drawn down from two grant sources, resulting in total draw request exceeding total expenses. Corrective Action: The City understands what happened and will work on developing and implementing procedures to ensure that all invoices are not drawn beyond the amount expended. Contact Person Responsible for Corrective Action: John Dantzer, City Manager Anticipated Completion Date: This issue will be corrected moving forward.
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