Corrective Action Plans

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The District Director of Student Services will monitor and make sure that all personnel who serve under federal programs have their time properly documented using semi-annual certification forms or other appropriate time and effort methods.
The District Director of Student Services will monitor and make sure that all personnel who serve under federal programs have their time properly documented using semi-annual certification forms or other appropriate time and effort methods.
Planned corrective actions: Heritage implemented a new system, however Heritage continues to encounter mistakes on correctly completing the time & efforts due to the differences in length of faculty contracts. Heritage continues to work on the process to improve with further training. Name of Respon...
Planned corrective actions: Heritage implemented a new system, however Heritage continues to encounter mistakes on correctly completing the time & efforts due to the differences in length of faculty contracts. Heritage continues to work on the process to improve with further training. Name of Responsible Party: 1. Rachel Castijella, Grant Accountant 2. Terri Slack, Fiscal Agent 3. Ivan Banks, Interim Provost 4. Joanne Fernandez, Controller 5. Sagrario Armenta Jimenez, CFO 6. Dr. Christopher Gilmer, President Anticipated completion date: 6/30/2026
Planned corrective actions: Heritage implemented a new system, however Heritage continues to encounter mistakes on correctly completing the time & efforts due to the differences in length of faculty contracts. Heritage continues to work on the process to improve with further training. Name of Respon...
Planned corrective actions: Heritage implemented a new system, however Heritage continues to encounter mistakes on correctly completing the time & efforts due to the differences in length of faculty contracts. Heritage continues to work on the process to improve with further training. Name of Responsible Party: 1. Rachel Castijella, Grant Accountant 2. Terri Slack, Fiscal Agent 3. Ivan Banks, Interim Provost 4. Joanne Fernandez, Controller 5. Sagrario Armenta Jimenez, CFO 6. Dr. Christopher Gilmer, President Anticipated completion date: 6/30/2026
Planned Corrective Action: Heritage implemented a new system, however Heritage continues to encounter mistakes on correctly completing the time & efforts due to the differences in length of faculty contracts. Even though DOE noted that “this finding resolved and closed.”, Heritage continues to work ...
Planned Corrective Action: Heritage implemented a new system, however Heritage continues to encounter mistakes on correctly completing the time & efforts due to the differences in length of faculty contracts. Even though DOE noted that “this finding resolved and closed.”, Heritage continues to work on the process to improve with further training. Name of Responsible Party: 1. Rachel Castijella, Grant Accountant 2. Terri Slack, Fiscal Agent 3. Ivan Banks, Interim Provost 4. Joanne Fernandez, Controller 5. Sagrario Armenta Jimenez, CFO 6. Dr. Christopher Gilmer, President Anticipated Completion Date: 6/30/2026
AHC has fully implemented enhanced reconciliation procedures to ensure that all grant drawdowns are reconciled to the general ledger prior to submission, with supporting documentation retained electronically. Quarterly internal audits of drawdown packets are conducted to ensure compliance with feder...
AHC has fully implemented enhanced reconciliation procedures to ensure that all grant drawdowns are reconciled to the general ledger prior to submission, with supporting documentation retained electronically. Quarterly internal audits of drawdown packets are conducted to ensure compliance with federal requirements. These improvements eliminate timing discrepancies and strengthen federal cash management controls. All federal expenditures year-to-date have been verified. It is important to note that AHC did not maintain a single consolidated record of drawdown support but instead retained multiple supporting documents. Despite this documentation issue, all drawdowns were found to be in compliance with HRSA guidelines and were determined to represent allowable costs.
CONDITION: During the calendar year 2024, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fash...
CONDITION: During the calendar year 2024, the City did not utilize a formal general ledger system of accounting to track the financial activity (financial position and results of operations) for several ‘Funds’ held at the City. The activity of these funds is either 1) maintained in spreadsheet fashion similar to a checkbook used in personal finances, 2) recorded partially (expenses only with no revenue), or 3) not tracked at all. As these funds are not maintained using the City’s accounting software package, management does not have the ability to efficiently generate financial reports necessary to provide management with the proper fiscal oversight. This condition included the American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund. However, it should be noted that City personnel were able to prepare spreadsheets to document which expenditures were utilized to prepare the necessary quarterly reporting requirements to the Department of Treasury. This is a repeat finding (2023-002) from the prior year. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include maintaining a formal general ledger system of accounting to track the activity of all ‘Funds’ maintained by the City. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City is continuing to assess the current workload and expertise of the City’s business office personnel in an effort to determine a feasible timeframe to continue the process of creating a formal general ledger system of accounting for all City ‘Funds’ that are not already entered into the software accounting system. The timeframe for completion of this review will occur during the first nine months of calendar year 2026 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the maintaining of a formal general ledger system of accounting for all ‘Funds’ of the City.
CONDITION: During the calendar year 2024, the City did not record the necessary adjustments to the various ‘Fund’ general ledgers of the City to properly reconcile the balance sheet accounts, such as cash, receivables, payables, and payroll-related liabilities to the underlying supporting documentat...
CONDITION: During the calendar year 2024, the City did not record the necessary adjustments to the various ‘Fund’ general ledgers of the City to properly reconcile the balance sheet accounts, such as cash, receivables, payables, and payroll-related liabilities to the underlying supporting documentation available at the City (which includes reconciliations of cash prepared independently by City personnel but do not agree to amounts reported in the various general ledgers). This included ‘Funds” containing significant federal funding such as the City’s Community Development Block Grant (CDBG) Program and American Rescue Plan Act (ARPA) funding known as the Coronavirus State and Local Fiscal Recovery Fund.CONDITION (Continued): As a result, the financial position and results of operations as shown throughout the calendar year were inaccurately stated. However, it should be noted that the Community Development Department of the City and other City personnel maintain separate financial reporting for these federal funds, independent of the aforementioned ‘Fund’ general ledgers sufficient to ascertain the revenues and expenditures of the federal programs. This is a repeat finding (2023-001) for the prior year. CRITERIA: Prudent internal control procedures in the areas of general ledger management and financial reporting include the reconciliation of all general ledger account balances to underlying supporting documentation monthly with independent oversight and approval as part of the process. In specific as it relates to federal programs, Section 2 CFR 200.403(g) of the Uniform Guidance requires that federal costs must be adequately documented which would include the applicable general ledgers of the City. MANAGEMENT’S CORRECTIVE ACTION PLAN: Management of the City is continuing their review of the recommended options as presented by the Audit Firm’s recommendation for feasibility considering current manpower, expertise, and budgetary constraints. In addition, the City plans to ensure that written procedures for all accounting functions are implemented, reviewed and updated as necessary with the objective of ensuring that all balance sheet account balances are supported by the underlying documentation available at the City. The timeframe for completion of this review will occur during the first nine months of calendar year 2026 with the intention of having the City be in full compliance with Section 2 CFR 200.403(g) of the Uniform Guidance which requires federal costs to be adequately documented which would include the applicable general ledgers of the City.
Finding #2024-002: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.599 – Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with th...
Finding #2024-002: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.599 – Lack Inadequate Documentation and Lack of Independent Review of Expenditures Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. MCC has updated the Financial Process Procedure to include language related to receipt management, and allowable and disallowed grant expenses. MCC has created a Travel Reimbursement Procedure that addresses approval of Director expenses. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators
Finding 2024-001: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.399 – Lack of Required Written Policies Corrective Action: We agree with the recommendation. We do currently require co...
Finding 2024-001: Grant Program: Department of Health and Human Services – National Institutes for Health Research and Development Cluster – Cancer Control – Assistance Listing #93.399 – Lack of Required Written Policies Corrective Action: We agree with the recommendation. We do currently require complete supporting documentation for all expenditures. Montana Cancer Consortium (MCC) has updated the Financial Process Procedure to include language related to receipt management, allowable and disallowed grant expenses, and timing of payment requests. Timeline: This was implemented on December 1, 2025. Responsible Parties: MCC Director, Principal Investigators
CORRECTIVE ACTION PLAN April 10, 2025 M.C. College Preparatory School of Wisconsin, Inc., respectfully submits the following corrective action plan for the year ending June 30, 2024. Walkowicz, Boczkiewicz & Co., S.C. 1800 East Main Street, Suite 100 Waukesha, WI 53186 AUDIT PERIOD: June 30, 2024 Th...
CORRECTIVE ACTION PLAN April 10, 2025 M.C. College Preparatory School of Wisconsin, Inc., respectfully submits the following corrective action plan for the year ending June 30, 2024. Walkowicz, Boczkiewicz & Co., S.C. 1800 East Main Street, Suite 100 Waukesha, WI 53186 AUDIT PERIOD: June 30, 2024 The findings from the June 30, 2024, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF EDUCATION MATERIAL WEAKNESS 2024-001 Elementary and Secondary School Emergency Relief Fund - COVID-19 – CFDA No. 84.425 Condition: During the audit of submitted claims, it was found that there was a lack of sufficient review procedures to ensure proper verification of costs. Specifically, several instances of duplicated expenditures were identified within the claims. The same costs were submitted more than once for reimbursement, resulting in questioned costs. Criteria: The Organization's internal controls should require that claims be thoroughly reviewed for accuracy and completeness before submission. This includes verifying that costs are not duplicated and ensuring proper documentation supports each expenditure. Additionally, the previously submitted claims included in the period of performance should be monitored to prevent duplication. Cause: The review process did not involve cross-checking with previous claims or documentation to identify and prevent the submission of duplicate costs. Effect: As a result of inadequate claim reviews, the organization has submitted claims containing duplicated costs. These duplicated expenditures have resulted in questioned costs, which may need to be refunded. The failure to detect and prevent such errors could lead to non-compliance with funding requirements. Questioned costs: $505,820 Auditor’s recommendation: It is recommended that the organization implement a more thorough review process for all submitted claims. This should include cross-checking current claims against previous claims to detect and prevent duplicated costs. A system should be implemented to track claims and associated costs more effectively, ensuring that no expenditure is claimed more than once. Action Taken: M.C. College Preparatory School of Wisconsin, Inc.’s Management has completed the transition to a new payroll system with enhanced process controls as of December 2024. This system enables the organization to isolate funding source allocations at the individual employee level, thereby preventing expenses from being attributed to more than one source. Final programming and control reviews are scheduled for completion prior to June 30, 2025. Further, Management has reviewed the questioned costs with the local education authority and has submitted qualified replacement expenses for all amounts initially submitted in error. As a result, no refund is required, and the applicable financial reserve will be released in the upcoming fiscal year. If the Department of Education has questions regarding this plan, please call Alfred Keith IV at 414-264-6000. Sincerely yours, Alfred Keith IV Chief Education Officer
The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will se...
The Village of Whitehouse will work with our outside Engineers to ensure that all compliance items are being addressed in all initial meetings for projects using Federal Funds. This will ensure that all policies and procedures are put into place prior to the start of the project. The Village will seek out training on federal procurement compliance requirements.
Management is in the process of implementing policies and procedures to ensure cost incurred for the delivery of meals to children are allowable and reasonable.
Management is in the process of implementing policies and procedures to ensure cost incurred for the delivery of meals to children are allowable and reasonable.
Finding Reference: 2024-003 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Given this finding, the Agency will review monthly its application of the approved provisional indirect cost rate to all grants, contracts, a...
Finding Reference: 2024-003 Views of Responsible Officials and Planned Corrective Actions The Agency agrees with this finding and recommendation as presented. Given this finding, the Agency will review monthly its application of the approved provisional indirect cost rate to all grants, contracts, and other agreements covered by 2 CFR 200. Management has taken corrective action by ensuring that all indirect cost allocations remain within the approved 22% rate and has also participated in additional financial training to strengthen compliance and oversight. The Agency will proceed in the following scope of work:  Ensure indirect charges follow the applicable cost principles per 2 CFR 200, Appendix IV, and grant agreement.  Receive permission from funders for indirect charges over the allocation of the indirect costs per the grant agreement.  Review the grant performance period of the CSBG that ends September 30, 2025.  Obtain a revised budget approval, if necessary, for any line budgeted items that exceed 20% of the total award based on the original awarded contract upon close out of the grant at the end of the period of performance. Name of the contact person responsible for corrective action: Michael Young, President, (301) 274-4474. Planned completion date for corrective action plan: December 31, 2025
Finding Number: 2024-007 Finding Title: Allowable Costs/Cost Principles – Cost Allocation Plan Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: The County has contracted with a new vendor to prepare its Cost Allocation Plan effec...
Finding Number: 2024-007 Finding Title: Allowable Costs/Cost Principles – Cost Allocation Plan Name of Contact Person Responsible for Corrective Action: Dillon Hayes, County Administrator Corrective Action Planned: The County has contracted with a new vendor to prepare its Cost Allocation Plan effective in 2025. Anticipated Completion Date: Completed August 2025
During a December 13, 2024 conference call with FEMA, Texas Department of Emergency Management (TDEM) and Ernst & Young (EY), potential reimbursement for overheads was discussed. FEMA representatives could not clearly state if overheads would be allowable. FEMA representatives recommended including ...
During a December 13, 2024 conference call with FEMA, Texas Department of Emergency Management (TDEM) and Ernst & Young (EY), potential reimbursement for overheads was discussed. FEMA representatives could not clearly state if overheads would be allowable. FEMA representatives recommended including them for consideration. Both construction and material overheads were included in the initial reimbursement request. The day before the submission deadline FEMA requested clarification on the construction overheads. Given the time constraint, the Cooperative agreed to withdraw the construction overhead amount from the submission. No additional information was requested on the material overheads. Written confirmation will be requested from FEMA for any future overhead cost reimbursement requested.
The Cooperative submitted the reimbursement request to the Federal Emergency Management Agency (FEMA) for equipment costs based on a conservative (less cost) approach using actual mileage costs. The hourly data submitted to FEMA was identified as not used for the reimbursement request. This informat...
The Cooperative submitted the reimbursement request to the Federal Emergency Management Agency (FEMA) for equipment costs based on a conservative (less cost) approach using actual mileage costs. The hourly data submitted to FEMA was identified as not used for the reimbursement request. This information was only provided to demonstrate that the mileage-based cost was less than the hourly calculation. The hourly reimbursement data was a draft and it was indicated that the costs for aerial/digger equipment units were not included. FEMA opted to change the request to use the hourly calculation just prior to the submission deadline leaving no time for further discussion or analysis. A fully completed hourly based cost reimbursement request would have resulted in a higher requested amount and the hourly variance identified would have been negligible. Any future submissions will be based on the hourly approach and will be thoroughly reviewed.
Auditee Response and Corrective Action Plan: Management concurs with the finding. The Organization should design and implement a comprehensive review process for all significant general ledger accounts to ensure that they are reconciled to underlying supporting documentation in a continuous and time...
Auditee Response and Corrective Action Plan: Management concurs with the finding. The Organization should design and implement a comprehensive review process for all significant general ledger accounts to ensure that they are reconciled to underlying supporting documentation in a continuous and timely manner throughout the fiscal year.
2024-005 - In October 2023, NYSHCR implemented a new software system, requiring all Local Administrators to transition to the Emphasys Elite system. In 2025, NYSHCR determined that the Waiting List Reports for prior periods could not be regenerated due to system limitations. This issue was related t...
2024-005 - In October 2023, NYSHCR implemented a new software system, requiring all Local Administrators to transition to the Emphasys Elite system. In 2025, NYSHCR determined that the Waiting List Reports for prior periods could not be regenerated due to system limitations. This issue was related to the software system itself and was not the result of any error or omission by RUPCO. The NYS HCR Procedure Manual, released on July 14, 2025 (page 47), instructs Local Administrators to retain copies of all sort/draw reports when selecting applicants from the Waiting List. Moving forward, The Director of Housing Choice Voucher (Section 8) will maintain records of all sort/draw reports in accordance with NYSHCR guidance to ensure full compliance and ease of verification.
Finding: Material weakness in internal control over period of performance Corrective action: Pacific Forum will incorporate policies into expense management and financial reporting guidelines to ensure all expenditure is completed within the period of performance and reviews by management are proper...
Finding: Material weakness in internal control over period of performance Corrective action: Pacific Forum will incorporate policies into expense management and financial reporting guidelines to ensure all expenditure is completed within the period of performance and reviews by management are properly documented. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Finding: Material weakness in internal control over allowable costs and compliance with requirement for written documentation of transactions review required for federally funded awards Corrective action: PFI has adopted a policy to document transaction reviews. Email approval documentation is requi...
Finding: Material weakness in internal control over allowable costs and compliance with requirement for written documentation of transactions review required for federally funded awards Corrective action: PFI has adopted a policy to document transaction reviews. Email approval documentation is required for all transactions, including initial approval by the Program Director and final approval by the Executive Director. This policy will be incorporated into PFI expense management policy guidelines. Completion Date: February 1, 2026 Responsible Individual: Executive Director
Management will complete the audit filing with the federal audit clearinghouse by the deadline going forward.
Management will complete the audit filing with the federal audit clearinghouse by the deadline going forward.
09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period:...
09.744060 Basic Field Grant Grant Period: 1/1/2024 – 12/31/2024 Contract Number: 744060 U.S Department of Justice 16.575 Victims of Crime Act Grant Periods: 10/1/23-9/30/24 and 10/1/24 – 9/30/25 Contract Number: 4055104; 4055105 Supreme Court of Texas Basic Civil Legal Services Program Grant Period: 9/1/2023 – 8/31/2025 Contract Number: 26030 2024-003 Internal Controls and Compliance over Allowable Costs and Activities – Payroll (Material Weakness and Material Noncompliance) Recommendation: We recommend the Organization review its timekeeping policies and procedures and provide additional training to employees to ensure time sheets are retained for all payroll transactions to support the allocation of compensation. We also recommend the Organization review and refine its policies to reconcile the percentage of hours charged on the time sheets to the budget estimates used to bill Federal and State grantors. This should be done in conjunction with monthly or quarterly billings (or other determined regular interval), at fiscal year end, and at the end of the grant year (if different from the Organization’s fiscal year). Corrective Action: AVDA implemented a formal Timekeeping and Payroll Compliance Policy in June 2025. All employees funded by Federal or State grants are now required to complete bi-weekly electronic functional time sheets that identify time spent on tasks by budgeted grant(s). Supervisors must review and approve all time sheets prior to submission. The Director of Finance will reconcile budget estimates to actual hours monthly, and quarterly reviews will ensure accuracy in allocations. Training on grant timekeeping standards (2 CFR §200.430) was provided to all program directors and staff in July 2025. Responsible Parties: - Lisa Mikosh, Director of Finance - Marcello Gonzales, Bookkeeper - Maisha Colter, CEO (policy approval and oversight) Date Corrected: August 15, 2025
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs ...
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs against program requirements and other relevant background documentation. For finding 2024-012, Cayuga will review relevant lease terms and program requirements. If, upon full evaluation, Cayuga Centers concurs that such costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. For steps to resolve the underlying control deficiency asserted or implied in this finding, please see Cayuga Centers’ response to Findings 2024-001 through 006 above.
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs ...
Cayuga Centers will confer with its auditors to ensure it has a full list of general ledger (GL) transactions regarding which these findings are asserted. For finding 2024-011, Cayuga Centers will assess whether each transaction does, in fact, represent a capital cost and will assess all such costs against program requirements and other relevant background documentation. For finding 2024-012, Cayuga will review relevant lease terms and program requirements. If, upon full evaluation, Cayuga Centers concurs that such costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs. For steps to resolve the underlying control deficiency asserted or implied in this finding, please see Cayuga Centers’ response to Findings 2024-001 through 006 above.
As discussed above Cayuga Centers has engaged grants management advisors who will assist in evaluating this specific finding. To the extent that the finding merely asserts that indirect cost bases were improperly calculated in prior periods, please see Cayuga Centers’ response and actions steps with...
As discussed above Cayuga Centers has engaged grants management advisors who will assist in evaluating this specific finding. To the extent that the finding merely asserts that indirect cost bases were improperly calculated in prior periods, please see Cayuga Centers’ response and actions steps with respect to findings 2024-001 through 006. If, upon full evaluation, Cayuga Centers concurs that indirect costs were improperly charged, it will address the matter with its primary funding agency as part of broader resolution of any unallowable costs.
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