Corrective Action Plans

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The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant com...
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant compliance is verified prior to payment. It also includes assessing the need for increased monitoring to ensure initial program reviews are complete and accurate. This remediation effort was finalized on June 30, 2025, following the September 2024 transaction in question. Additionally, the Department plans to review the remediation plan with all relevant staff again this season. This will ensure that all supporting documentation is thoroughly vetted and that expenditures comply with the applicable award period of performance.
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving in...
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving invoices for Highway Safety Cluster grants, with a specific focus on the period of performance. This training plan will be revisited and reviewed with all staff involved by April 2026.
The Department of Local Affairs (Department) agrees with the recommendation to strengthen internal controls over the financial management of federal Coronavirus Capital Projects Fund grant expenditures and the accuracy and completeness of the Exhibit K1, Schedule of Federal Assistance. The Departmen...
The Department of Local Affairs (Department) agrees with the recommendation to strengthen internal controls over the financial management of federal Coronavirus Capital Projects Fund grant expenditures and the accuracy and completeness of the Exhibit K1, Schedule of Federal Assistance. The Department will develop a corrective action plan that includes enhanced procedures for the performance of year-end estimates/accruals. The Department will create and implement staff training for staff that are responsible for preparing and reviewing the estimates/accruals, the Exhibit K1, grant transactions and enhancements.
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, reco...
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, recorded training and corresponding training materials based on current, informal processes on completion of the rate update form to be submitted to the Department's fiscal agent, Gainwell Technologies. Since FY2024, the Waiver and Fee Schedule Rates section has implemented a multilevel secondary review process prior to any rate change submission to ensure accuracy in rate update submissions. The Rates section has also worked closely with other internal partners to formalize informal update processes for quality assurance and maintenance of a minimal error percentage. The Rates section has also implemented a post-implementation data analysis review of all rate update submissions to ensure the update was implemented as directed and expected to ensure accountability on behalf of the Department's fiscal agent Gainwell Technologies. The Rates section is currently in process of documenting and formalizing all rate update processes and policies for future training and process maintenance.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and ...
The Department agrees with the recommendation and will strengthen internal controls over Medicaid eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring the development and implementation of Department-approved Corrective Action Plans. These plans will be required to address root causes related to income and resource calculation, documentation of eligibility determinations, and household composition, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are appropriately addressed.
FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of C...
FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Katie Elliott Contact Phone Number and Email Address: katieelliott@lssc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: While the School Corporation completed the required Time and Effort logs, a time study was not completed and documented to justify the allocation of costs related to the compensation and fringe benefits of the food service director. The School Corporation Food Service Director is now documenting the hours spent each day completing food service activities. Anticipated Completion Date: This Corrective Action Plan will be put in effect January 2026.
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. Completion Date Ongoing
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. Completion Date Ongoing
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have ...
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have been reviewed and approved for grant allocation. Completion Date The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management. The Center will also ask employee supervisors to sign their subordinates’ time distributions through a desktop computer and avoid mobile approvals to reduce the number of glitches in saving.
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. The Center will also review its process for keying ...
Contact Person Aaron Moss, Board President Corrective Action Plan The Center will review its process for keying amounts and percentages from employee time distributions into the allocation spreadsheet that is used to allocate expenses to the grant. The Center will also review its process for keying amounts into the Mutual of America contribution portal. Completion Date Ongoing
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have ...
Contact Person Aaron Moss, Board President Corrective Action Plan The Center’s Office Manager will initial all invoices to signal that they have been reviewed and approved for payment. The Center’s employee supervisors will sign all of their subordinates’ time distributions to signal that they have been reviewed and approved for grant allocation. Completion Date The Center implemented an internal control in January 2025 to ensure all invoices are reviewed and approved by management. The Center will also ask employee supervisors to sign their subordinates’ time distributions through a desktop computer and avoid mobile approvals to reduce the number of glitches in saving.
Corrective Actions Taken or Planned: Management concurs with the auditor’s assessment that this was a control oversight and a breakdown in the internal control system for payroll documentation, rather than intentional noncompliance. As part of our federal grant closeout efforts, we have taken the fo...
Corrective Actions Taken or Planned: Management concurs with the auditor’s assessment that this was a control oversight and a breakdown in the internal control system for payroll documentation, rather than intentional noncompliance. As part of our federal grant closeout efforts, we have taken the following steps to address the deficiency: •After-the-Fact Certifications: As of this response, WETA has obtained ten after-the-factemployee certifications confirming that the payroll allocations for FY 2025 accurately reflectthe effort performed. These certifications are on file and available for review. •Managerial Oversight Confirmation: The Director of Production Operations has provided writtenconfirmation that monthly allocation decisions were discussed with project managers andreflected in payroll actions, though these reviews were not formally documented at the time. •Policy Review and Update: Management is currently reviewing and updating internal policiesto ensure that documentation procedures align with operational practices. These updates willrequire contemporaneous certification and documentation of payroll allocations for any futurefederal or restricted awards. •Training and Controls: We are developing additional training to reinforce documentationexpectations and strengthen internal controls among finance and operational staff. Completion Date: January 31, 2026 Contact Person: Dorian Davis Title: Corporate Controller Phone Number: (703) 998-2216
Finding No. 2025-005: Internal Controls over Payroll Responsible Individuals: Trista Olney, Business Manager Corrective Action Plan: The District will make every effort to review payroll hours before payroll is posted. Anticipated Completion Date: Fiscal year 2025
Finding No. 2025-005: Internal Controls over Payroll Responsible Individuals: Trista Olney, Business Manager Corrective Action Plan: The District will make every effort to review payroll hours before payroll is posted. Anticipated Completion Date: Fiscal year 2025
2025-001 – Allowable Activities/Allowable Costs Contact Person Responsible for Corrective Action: Wendy Bradstreet, RSU29 Business Manager Corrective Action: RSU29 has taken the following actions to address finding 2025-001: The district has been implementing new procedures and processes as of Febru...
2025-001 – Allowable Activities/Allowable Costs Contact Person Responsible for Corrective Action: Wendy Bradstreet, RSU29 Business Manager Corrective Action: RSU29 has taken the following actions to address finding 2025-001: The district has been implementing new procedures and processes as of February 1, 2026, to correct the issues in question to comply with CFR(s): 2 CFR 200.303, to make sure we remain in compliance with OMB guidelines. Findings have been shared with the Food Services Director and training has been utilized from guidance and resources provided by the Maine Department of Education Nutrition Services site which include financial training and procurement practices and resources provided by the USDA School Nutrition Program regulations (7 CFR Part 210, 215, 220). Internal approvals have been revised to have not only the Food Service Director approving purchases, but an approval from the district Business Manager prior to payment of invoices to vendors. A copy of the OMB Circulars containing the CFR guidelines have been received and reviewed by the Business Manager and applicable grant managers/coordinators to implement a more stringent internal control process and procedure to ensure all requirements are followed. The Business Manager has updated the district’s Food Service Director and central office staff of applicable guidelines to ensure compliance of all projects that is being paid for by federal and/or state funding. Anticipated Completion Date: June 30, 2026.
FINDING 2025-003 Subject: COVID -19 - Education Stabilization Fund – Activities Allowed and Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Allison Vanover, Corporation Treasurer. Contact Phone Number 812-246-3375 Email Address: avanover@scsc.school Views...
FINDING 2025-003 Subject: COVID -19 - Education Stabilization Fund – Activities Allowed and Unallowed, Allowable Costs/Cost Principles Contact Person Responsible for Corrective Action: Allison Vanover, Corporation Treasurer. Contact Phone Number 812-246-3375 Email Address: avanover@scsc.school Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Corporation will implement and consistently apply a standardized two-level review and approval process for all grant reimbursements to ensure proper accounting, documentation, and compliance. The grants administrator (or designee) will prepare and conduct the initial review of each grant reimbursement to verify that all expenses and receipts contain the correct accounting information, are properly documented, and are recorded in the appropriate accounts within the Financial Management System (FMS). The Corporation Treasurer (or designee) will perform an independent secondary review of all grant reimbursements, including a review of supporting documentation and account coding, and will provide final approval and signature as evidence of authorization. On a monthly basis, grant accounts will be reviewed by the grants administrator for accuracy and completeness, with the Corporation Treasurer (or designee) conducting a secondary monthly review to confirm accuracy and compliance. This two-level review process ensures adequate segregation of duties, strengthens internal controls, and provides documented oversight of all grant reimbursement activity. Anticipated Completion Date: The ESSER grant is finished. If we were to receive this grant in the future, Silver Creek School Corporation would apply the procedures in the corrective action plan.
FINDING 2025-005 Finding Subject: Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Audit Findings: Significant Deficiency, Other Matter Contact Person Responsible for Corrective Action: Chrystal Street Contact Phone Number and Email Address: cstreet@crothersville.k1...
FINDING 2025-005 Finding Subject: Subject: COVID-19 - Education Stabilization Fund - Allowable Costs/Cost Principles Audit Findings: Significant Deficiency, Other Matter Contact Person Responsible for Corrective Action: Chrystal Street Contact Phone Number and Email Address: cstreet@crothersville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The district has implemented procedures requiring written documentation whenever federally funded materials, equipment, or property are reassigned, repurposed, or disposed of due to project changes. This documentation includes the reason for the change, approval by district administration, the new use or location of the materials, and verification that the use remains allowable under the grant. These records will be maintained with grant documentation and reviewed as part of internal control procedures to ensure compliance moving forward. Anticipated Completion Date: January 2026
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2025-001: • Aspire Indiana Health continues to focus on reviews of the rental assistance calculation forms to make sure future issues are caught before submission • Aspire Indiana Health u...
Findings Reported by Uniform Guidance – The following steps have been taken or will be taken to address Finding 2025-001: • Aspire Indiana Health continues to focus on reviews of the rental assistance calculation forms to make sure future issues are caught before submission • Aspire Indiana Health upon discovery of the errors corrected within the system and plan to reverse out the dollars received in future drawdowns for this program
Finding 1176705 (2025-001)
Material Weakness 2025
here is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Start Early used a payroll system that, after a pay period was locked for processing, would not allow supervisors who missed timecard approvals to go back and approve after the period was locked...
here is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Start Early used a payroll system that, after a pay period was locked for processing, would not allow supervisors who missed timecard approvals to go back and approve after the period was locked. As a result, Start Early used a manual, time-consuming process to receive these approvals outside of the payroll system. While all approvals were received via this process, due to the manual nature, not all approvals were received timely. In early fiscal year 2026, Start Early changed to a new payroll system which allows for supervisors to go back to prior periods for their sign offs. Start Early will implement a process to, no less than monthly, remind supervisors that had previously missed their timecard approvals to go back and approve to ensure timeliness. Name(s) of the contact person(s) responsible for corrective action: David Paul, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by June 30, 2026.
Findings #2025-001 and #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Supporting Effective Instruction State Grants, Assistance Listing #: 84.367A, Contract #’s: S367A230041 and S367A240041. Condition and context: During our tes...
Findings #2025-001 and #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Supporting Effective Instruction State Grants, Assistance Listing #: 84.367A, Contract #’s: S367A230041 and S367A240041. Condition and context: During our testing of GAAP and FASRG coding, we identified 5 of 72 non- payroll transactions coded to the incorrect period, and 5 of 49 non-payroll transactions coded to the incorrect object or function code. Recommendation: Reemphasize current policies and procedures to ensure proper coding of disbursements based on the period and the organization’s chart of accounts and FASRG codes. Planned corrective action: Great Hearts America – Texas concurs with the findings. While the noted errors were immaterial, management recognizes the importance of consistent expense recognition and coding accuracy to ensure compliance with TEA, PEIMS and financial reporting standards. To strengthen controls, management has implemented the following actions: 1) Month-End Cutoff Procedures: The Finance Department will issue enhanced month-end closing guidance emphasizing invoice cutoff dates, accrual requirements, and proper period recognition. 2) AP Supervisor Review: The Accounts Payable Supervisor will conduct a secondary review of all significant invoices processed to confirm proper period recognition. 3) Coding Accuracy Checks: The Accounts Payable Supervisor will perform periodic sampling of expense transactions to verify correct Function, Object, and PIC coding. 4) Training: Refresher training will be provided to campus and department staff responsible for coding transactions to ensure understanding of chart of accounts structure. Responsible officer: Stacey Lawrence, Interim Chief Financial Officer. Estimated completion date: Procedures will be implemented during fiscal year 2026 month-end close and reinforced through staff training in January 2026.
orrective Action Planned: Management will implement a documentation retention policy to ensure approvals of allocations of time for employees are maintained. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: As of July ...
orrective Action Planned: Management will implement a documentation retention policy to ensure approvals of allocations of time for employees are maintained. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: As of July 2025, a process was implemented to record the proper allocations of time for employees; in addition, a form was developed to record any subsequent changes.
Corrective Action Plan: While Elkhorn Slough Foundation performs SAM.gov suspension and debarment checks for all contracted vendors, documentation evidencing these checks was not consistently maintained. The Foundation will implement enhanced documentation and record‑retention procedures to ensure v...
Corrective Action Plan: While Elkhorn Slough Foundation performs SAM.gov suspension and debarment checks for all contracted vendors, documentation evidencing these checks was not consistently maintained. The Foundation will implement enhanced documentation and record‑retention procedures to ensure verification records are retained in compliance with the Foundation’s Procurement Policy and 2 CFR § 180.995. Contact Person: Mark Silberstein, Executive Director and Administrative Director with review by outside CPA. Contact: 831‐728‐5939 Anticipated Completion: June 30, 2026
Federal Program: Department of Homeland Security Assistance Listing: 97.036 Federal Agency: COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Entity: State of Tennessee Grant Award Number: All FEMA Projects (Projects 435263,550461, 684580) Award Per...
Federal Program: Department of Homeland Security Assistance Listing: 97.036 Federal Agency: COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Entity: State of Tennessee Grant Award Number: All FEMA Projects (Projects 435263,550461, 684580) Award Period: Project 435263: 1/1/2020-7/31/2021 Project 550461: 1/1/2020-7/31/2021 Project 684580: 8/1/2020-6/30/2022 Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. All expenses claimed were eligible and were reviewed by management prior to the submission. The control issue identified is due to the lack of evidence to support approval. Should management have a future FEMA claim we will retain additional audit evidence to enable auditor reperformance of the controls regarding approval of expenditures. Paula Yarbrough, VUMC Director – Grants and Contracts will be responsible for the implementation by fiscal year-end 2026.
The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added...
The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added communication levels to ensure that more than one person received communication between ASD and agency divisions. The ASD division has implemented better communication lines between the ASD division and the agency divisions which will resolve this issue. With more than one person receiving the information and additional training on ensuring that all reconciling items are addressed timely the agency general ledger will remain clean and in balance with allowable expended posted to the correct Chatfield’s.
The Agency's management agrees with this finding. During the upcoming fiscal year, the Controller, Kimberly Houghton-Bryan, will work with various departments within the Agency including HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the U...
The Agency's management agrees with this finding. During the upcoming fiscal year, the Controller, Kimberly Houghton-Bryan, will work with various departments within the Agency including HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the Unaccompanied Alien Children (UAC) grant where possible. Allocation methods that are allowable under the funding sources will be reviewed for implementation. Methods, such as quarterly time studies, direct recording of time or other methods will be considered to ensure there is supporting documentation. The approved budget is also monitored on a monthly and/or quarterly basis and compared to the UAC approved budget. The allocation process as well as other accounting processes relating to New Horizons are being reviewed and the Accounting which had been outsourced is being brought internally. The Agency will be performing reviews of the internal allocation methodology, at least every other quarter-end. This enhancement will be implemented by March 31,2026. Note: Implementation of corrective action is taking place under the new Financial Controller, Kimberly Houghton-Bryan who recently acquired the role January 2026. Under her leadership, the changes she is making will be complete for Fiscal year 2026-2027 and will be a work in progress for fiscal year 2025-2026.
The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required t...
The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required timeframes going forward.
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