Corrective Action Plans

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DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in month...
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in monthly unit meetings. DHS will complete targeted Medical Assistance case reviews, and a review of system (Gateway) designs will be conducted to identify any necessary changes, updates, and additional improvements.
To strengthen interagency coordination and ensure continued regulatory clarity, the Agency will revise the existing Memorandum of Understanding (MOU) between DHS and DBHDD. The updated MOU will formally define and document the respective roles and responsibilities of each entity related to Federal F...
To strengthen interagency coordination and ensure continued regulatory clarity, the Agency will revise the existing Memorandum of Understanding (MOU) between DHS and DBHDD. The updated MOU will formally define and document the respective roles and responsibilities of each entity related to Federal Funding Accountability and Transparency Act (FFATA) reporting requirements, consistent with 2 CFR Part 170 and applicable Uniform Guidance provisions. The revised agreement will specifically address the responsibility for FFATA subaward reporting, required data elements and documentation, data transmission timelines, and points of contact and accountability. DBHDD will formally revise Policy 17-102, Federal Funding Accountability and Transparency Act (FFATA) Preparation and Submission, to establish comprehensive procedures for FFATA reporting requirements as a pass-through entity. The revised policy will define standardized protocols, prescribe reporting timelines, specify required subaward data elements, and clearly designate points of contact to ensure the timely and accurate exchange of information necessary to maintain full compliance with FFATA reporting obligations. Also, beginning in November 2025, DBHDD implemented a proactive data-sharing process to support timely FFATA reporting. DBHDD has been providing the DHS Director of Finance with all relevant information pertaining to subawards of $30,000 or more, including the associated subaward data elements for ALN 93.667, within the statutory reporting timeframe. This process was implemented to enhance transparency, promote timely reporting, and eliminate any potential ambiguity regarding data exchange responsibilities. DBHDD believes these actions further strengthen interagency coordination and reinforce compliance with applicable federal reporting requirements. The Agency will revise the existing Memorandum of Understanding (MOU) between DHS and DBHDD upon expiration of the current agreement. The revised MOU will formally incorporate clarified roles and responsibilities related to FFATA reporting requirements, ensuring alignment with 2 CFR Part 170 and applicable Uniform Guidance provisions. At present, formal data transmission protocols are in place between the agencies to support timely and accurate FFATA reporting.
DHS Division of Family and Children Services (DFCS), Temporary Assistance for Needy Families (TANF) program, will review existing TANF and expense statement review policies, and provide refresher training on these policies and applicable forms for staff at all levels of eligibility. TANF management ...
DHS Division of Family and Children Services (DFCS), Temporary Assistance for Needy Families (TANF) program, will review existing TANF and expense statement review policies, and provide refresher training on these policies and applicable forms for staff at all levels of eligibility. TANF management will complete targeted case reviews to ensure that all applicable documentation is included in the file, and peer reviews will be initiated. In addition, a review of the Gateway System will be conducted, and any required form(s) will be updated and included in the case file, if required.
GOHS Management sought guidance from our NHTSA Regional Director, and steps were put in place to report all subawards for FFY2025 and FFY2026. FFATA reporting recently migrated all data entry to SAM. The GOHS Finance Director had Administrator access ONLY to SAM.gov not data entry, the CFO @ DPS had...
GOHS Management sought guidance from our NHTSA Regional Director, and steps were put in place to report all subawards for FFY2025 and FFY2026. FFATA reporting recently migrated all data entry to SAM. The GOHS Finance Director had Administrator access ONLY to SAM.gov not data entry, the CFO @ DPS had to grant data entry access and the GOHS staff began entering all the sub-recipients who were awarded a GOHS Grant of more than $30,000.00 for Federal Fiscal year 2025 and Federal Fiscal year 2026. The GOHS Finance Director noted that previous years FFATA entries were missing in SAM.gov. (no one in the Agency had data entry access). The GOHS Finance Director will ask for data entry access for another employee in the finance division, so the prior year's subawards can be added and GOHS will be in complete compliance with FFATA. To address this finding, GOHS Management will develop and implement formal written FFATA reporting procedures outlining identification of reportable subawards, required data elements, reporting timelines and assigned responsibilities. GOHS will centralize responsibility for FFATA reporting within the GOHS Finance department, with a designated secondary reviewer to ensure appropriate oversight and segregation of duties.
In response, the TCSG Office of Workforce Development has created a “FFATA Subaward Reporting and Tracking Form”. This form will be used to document each subaward that is entered into the SAM.gov federal website, listing each subaward by its FAIN Number, award amount connected to the corresponding F...
In response, the TCSG Office of Workforce Development has created a “FFATA Subaward Reporting and Tracking Form”. This form will be used to document each subaward that is entered into the SAM.gov federal website, listing each subaward by its FAIN Number, award amount connected to the corresponding FAIN number, and the staff member responsible for the subaward submission. This document will be created and provided by the staff member submitting the subawards in SAM.gov. Management within the OWD Grants and Finance Unit will review and confirm and the subawards in SAM.gov as indicated by the FFATA Subaward Reporting and Tracking Form. Upon confirmation by management, the form will be signed and dated. The new FFATA Subaward Reporting and Tracking Form will be emailed directly to DOAA.
GDOL now freezes the overpayment data at the end of every month so we can conduct periodic reconciliation of the overpayment records. This will allow discrepancies to be identified faster and resolved before the deadline to submit the report for the specified period. GDOL consults with USDOL’s natio...
GDOL now freezes the overpayment data at the end of every month so we can conduct periodic reconciliation of the overpayment records. This will allow discrepancies to be identified faster and resolved before the deadline to submit the report for the specified period. GDOL consults with USDOL’s national 227 reporting specialists on an ongoing basis to work towards a reconciliation of previously submitted reports. Federal regulations require an actual person to review and establish fraudulent overpayments. Due to the volume of claims and the number of cross matches to be performed on all state and federal pandemic programs, it requires multiple GDOL staffing levels to manually review all cross matches, requiring increased levels of state and federal funding. The crossmatch process is conducted using a software which runs a systematic check against weeks in a quarter for which benefits are paid, and wages are reported during the same quarter. Although the program may detect weeks paid and wages reported, this alone is not indicative of an overpayment. Therefore, the process involves verification correspondence being sent to both the claimant and the employer, as applicable, to verify the status of employment, the wages earned as well as the weeks in which an individual worked and earned the wages. Based on responses, an assessment is made to determine if an overpayment exists and subsequent actions are taken accordingly. We are prohibited from assuming a match is an overpayment. It is not an overpayment until we have completed a full investigation and provided due process to all parties. The Department has a significant number of pending and potential overpayment investigations that may result in either a non-fraud or fraud determination. We are utilizing merit and time-limited staff to maximize productivity by conducting fact-finding interviews, assessing case details, creating overpayments in the system, and making overpayment determinations. The statutes provide that an overpayment be established up to four years after such occurrence, act, or omission. Additionally, GDOL has procured a vendor to build and implement a modernized UI system slated to be launched in 2026. We will continue to utilize available resources to investigate and establish overpayments in the legacy system as quickly as possible and will continue to do so within the program parameters in the new system. Throughout CY 2025, GDOL participated in quarterly meetings with United States Department of Labor (USDOL) and other regional states to discuss fraud, overpayment issues and best practices used. These meetings will continue in CY2026.
We have documented our procedure for performance reporting so that reports are appropriately reviewed and approved prior to submission.
We have documented our procedure for performance reporting so that reports are appropriately reviewed and approved prior to submission.
GDOL acknowledges that this is a repeat finding from prior years. While the issue has been partially resolved, the Department provides the following response. Claimants who established PUA entitlement with a weekly benefit amount (WBA) greater than the minimum amount, or who were later determined to...
GDOL acknowledges that this is a repeat finding from prior years. While the issue has been partially resolved, the Department provides the following response. Claimants who established PUA entitlement with a weekly benefit amount (WBA) greater than the minimum amount, or who were later determined to be ineligible, did so based on wages self-reported by the claimant and/or wages reported by the employer. Under the CARES Act, claimants were required to submit proof of wages only; however, if proof was not provided, federal guidance permitted payment only at the minimum WBA and did not allow for disqualification of benefits solely due to lack of documentation. For PUA claims initially established at a higher WBA without sufficient proof, the WBA was subsequently reduced to the minimum amount as required. To date, the claimants cited in this finding have not provided the required documentation. The identified PUA claim was adjusted accordingly, and an Overpayment has been established. Disaster Unemployment Assistance (DUA) claims are established under a similar framework as PUA claims, with one key difference: payment requests are currently submitted via paper certification forms. Claimants submit these requests by mail, fax, or email. Because this process is manual, there is an increased risk of misfiling or errors, as occurred in the DUA claim identified. To address these findings and strengthen program integrity, GDOL has implemented and will continue implementing corrective actions and additional safeguards. As system deficiencies were identified, mitigation measures were implemented as quickly as possible to reduce the risk of improper payments. In addition, GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated processes and corrective controls cannot be easily implemented. As a result, numerous tasks, including the validation and processing of all PUA and DUA documentation to determine eligibility, must be performed manually by staff. As a long-term measure to strengthen internal controls and improve overall UI program administration, GDOL has partnered with a vendor to implement a modernized UI system. This new system will offer enhanced eligibility determination, improved payment controls, and technological safeguards to support both current and future unemployment programs. Migration to the modernized system is expected in late 2026.
GDOL’s current UI Tax system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated financial record-keeping processes and corrective controls cannot be easily implemented. As a long-term solution to strengthen internal controls and enhance...
GDOL’s current UI Tax system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated financial record-keeping processes and corrective controls cannot be easily implemented. As a long-term solution to strengthen internal controls and enhance overall UI program administration, GDOL has contracted with a vendor to implement a more efficient method for maintaining documentation of taxes due and received. Migration to the modernized system is anticipated in late 2026. A review of the thirteen accounts identified the source of each payment, the amounts remitted, and the associated tax account allocations. Our records showed all payments, except for one, were submitted electronically via ACH Debit or ACH Credit. These ACH transactions are reflected as components of the total daily ACH Debits or Credits shown on the agency’s bank statement spreadsheets for the dates associated with the payments. The Contribution Tax amount represents only a portion of the total tax due. Therefore, the payment amount and the Contribution Tax amount may differ.
As of August 2025, we transferred all FFATA reporting duties to the Director of Operations and Systems. The Director of Operations and Systems hired a staff member in January 2026 to assist with FFATA reporting. All FFATA reporting moved from USA Spending to SAM.gov during fiscal year 2025. The migr...
As of August 2025, we transferred all FFATA reporting duties to the Director of Operations and Systems. The Director of Operations and Systems hired a staff member in January 2026 to assist with FFATA reporting. All FFATA reporting moved from USA Spending to SAM.gov during fiscal year 2025. The migration to SAM.gov caused delays as a result of the account setup process that were out of our control, but we anticipate being current on all FFATA reporting by June 30, 2026.
Identifying Number: 2025-002 Finding: The Organization should have effective internal controls around reporting to LSC, to ensure timely reporting in accordance with 45 CFR 1644. Corrective Action Taken or Planned: CVLAS’ Director of Operations shall institute an administrative calendar containing a...
Identifying Number: 2025-002 Finding: The Organization should have effective internal controls around reporting to LSC, to ensure timely reporting in accordance with 45 CFR 1644. Corrective Action Taken or Planned: CVLAS’ Director of Operations shall institute an administrative calendar containing all required reports due LSC. The Executive Director and the Director of Development are responsible for ensuring that all reports are timely filed in accordance with LSC regulations. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: December 31, 2026
2025-002 Staffing for Adequate Fire and Emergency Response (SAFER) – CFDA No. 97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal co...
2025-002 Staffing for Adequate Fire and Emergency Response (SAFER) – CFDA No. 97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebeca Holden Planned completion date for corrective action plan: 06/30/26 If the Tennessee Comptroller of the Treasury has questions regarding this plan, please call Rebecca Holden at 931-451-0782
Finding 2025-001: Significant Deficiency in Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Actions Taken and Planned: Washington Alliance for Better Schools is reimbursing the passthrough agency for the identified questioned costs, at their direc...
Finding 2025-001: Significant Deficiency in Internal Control over Activities Allowed or Unallowed and Allowable Costs/Cost Principles Corrective Actions Taken and Planned: Washington Alliance for Better Schools is reimbursing the passthrough agency for the identified questioned costs, at their direction, and has adjusted the financial statements and schedule of expenditures of federal awards as of and for the year ended August 31, 2025, accordingly. In addition, to prevent future errors, as part of the grant invoicing process, management will implement a formal reconciliation of amounts billed to federal programs to supporting documents for reimbursable costs incurred. Anticipated Completion Date: August 31, 2026 Contact Person: Emily Yim President and CEO 206-393-4918 emilyy@wabsalliance.org
Finding 1213949 (2025-011)
Material Weakness 2025
Creek County will work with all offices making sure that a proper invoice is attached on all purchase orders. Educating Offices that there is a difference in a quote verses an invoice. The County Clerk will make sure that there are multiple eyes on the purchase orders to ensure that this is caught b...
Creek County will work with all offices making sure that a proper invoice is attached on all purchase orders. Educating Offices that there is a difference in a quote verses an invoice. The County Clerk will make sure that there are multiple eyes on the purchase orders to ensure that this is caught before payment is issued.
The Town will implement written procedures requiring the development and maintenance of project‑specific budgets for all federal awards, including FEMA emergency response and recovery projects. Project budgets will be prepared in accordance with approved scopes of work and used to monitor expenditur...
The Town will implement written procedures requiring the development and maintenance of project‑specific budgets for all federal awards, including FEMA emergency response and recovery projects. Project budgets will be prepared in accordance with approved scopes of work and used to monitor expenditures throughout the life of the award. The Town will provide training to applicable staff on federal grant budgeting requirements and designate responsibility for budget preparation and monitoring.
Finding 1213721 (2025-006)
Material Weakness 2025
Management agrees and acknowledges the delay in issuing the financial statements. Contributing factors included staffing transitions, adjustments to policies and financial software, and the need for additional time to complete year end reconciliations. The City has since implemented process improvem...
Management agrees and acknowledges the delay in issuing the financial statements. Contributing factors included staffing transitions, adjustments to policies and financial software, and the need for additional time to complete year end reconciliations. The City has since implemented process improvements, earlier preparation of key schedules, and expanded cross training among staff. These actions are expected to support timely completion of future financial reports.
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.044 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the freque...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Aging Cluster – Special Programs for the Aging, Title III, Part B – Assistance Listing No. 93.044 Recommendation: We recommend that the Organization consider updating its cost allocation methodology and process to reduce the frequency of manual adjustments based on review of individual time records and expense data and maximize the use of automated allocations that are calculated in a consistent manner that ensure costs are applied uniformly to respective benefited activities, and that are reflective on employees’ time and effort records. We also recommend that the Organization maintain contemporaneous documentation supporting all cost allocations. Lastly, the Organization could consider removing LSC from the general fund into its own fund, and using fringe benefit rate and indirect cost rate allocation methods to simplify its cost allocation process. Explanation of Disagreement With Audit Finding: Management partially agrees with this finding. First, 45 CFR Part 1635 codifies the timekeeping requirement. CLS keeps track of every case and time dedicated by staff in strict compliance with this requirement. Manual adjustments primarily result from planned internal reconciliations and reviews designed to ensure the accuracy of CLS allocations. These reconciliations are conducted on a monthly basis and form an integral part of the Organization’s internal control framework. Action Taken in Response to Finding: Additionally, with respect to the Native American grant transactions, CLS implemented the necessary correction to the referenced percentage effective beginning in 2026. Name of the Contact Person Responsible for Corrective Action: Silvia Zelaya, Finance Director Planned Completion Date for Corrective Action Plan: January 2027
The City will implement a policy directing City staff that, if allowed, grant applications should include the option to charge indirect costs for the execution of the grant work. Upon grant application submissions, the department submitting the grant will coordinate with the Senior Finance Analyst t...
The City will implement a policy directing City staff that, if allowed, grant applications should include the option to charge indirect costs for the execution of the grant work. Upon grant application submissions, the department submitting the grant will coordinate with the Senior Finance Analyst to provide indirect cost rates and/or charges. As it relates to CDBG and HOME Program Grants, the Finance and Administration Department, in conjunction with the Community Development Director, will conduct a year-end review to ensure allowable indirect costs are appropriately charged. Personnel Responsible for Implementation: Meredith Elguira, Carol Molina, Ralston Turner Position of Responsible Personnel: Interim Community Development Director, Interim Finance and Administration Director, Senior Finance Analyst Expected Date of Implementation: April 30, 2026
Management will update its procurement policies and procedures to require formal evidence that suspension and debarment checks are completed prior to entering into contracts. This will include requiring staff to sign/initial, and date SAM.gov verification screenshots or reports, or alternatively, ob...
Management will update its procurement policies and procedures to require formal evidence that suspension and debarment checks are completed prior to entering into contracts. This will include requiring staff to sign/initial, and date SAM.gov verification screenshots or reports, or alternatively, obtain vendor certifications confirming their status. Training will be provided for relevant personnel to ensure consistent implementation of the revised procedures.
Finding Number: 2025-002 Condition: DWIHN’s internal controls were not sufficiently designed and/or operating effectively to prevent the submission of unallowable costs for reimbursement under the federal award. Planned Corrective Action: Program and finance staff responsible for the approving and p...
Finding Number: 2025-002 Condition: DWIHN’s internal controls were not sufficiently designed and/or operating effectively to prevent the submission of unallowable costs for reimbursement under the federal award. Planned Corrective Action: Program and finance staff responsible for the approving and processing of FSR’s have been informed of the need to review FSR’s in greater detail before they are submitted, approved, and payment occurs. A more detailed review of the FSR’s and adherence to established policies and procedures will eliminate the risk of errors and omissions. Contact person responsible for corrective action: Vice President of Finance and Director of Grants and Community Engagement Anticipated Completion Date: August 7, 2025
FINDING 2025-016 Name of Responsible Individual: Director of Post Award Compliance and Training Christina Flood, Budget Analyst Corrective Action: Monthly Settlement Reports are used to reconcile actual expenses. An outdated spreadsheet was previously used to convert travel expenses, which resulted ...
FINDING 2025-016 Name of Responsible Individual: Director of Post Award Compliance and Training Christina Flood, Budget Analyst Corrective Action: Monthly Settlement Reports are used to reconcile actual expenses. An outdated spreadsheet was previously used to convert travel expenses, which resulted in incorrect exchange rate calculations. The team has implemented an updated conversion process. Going forward, the Sponsored Program Office Team will review and approve the exchange rates to ensure they are reasonable, accurate, and applied consistently. Anticipated Completion Date: June 30, 2026
FINDING 2025-014 Name of Responsible Individual: Assistant Vice President for Post Award Corrective Action: The University initiated the Effort Certification process to capture the full calendar year 2025 in April 2026. This represents a one-time extended certification period designed to include pre...
FINDING 2025-014 Name of Responsible Individual: Assistant Vice President for Post Award Corrective Action: The University initiated the Effort Certification process to capture the full calendar year 2025 in April 2026. This represents a one-time extended certification period designed to include previously uncertified periods that had concluded, specifically the second half of FY25 (January–June 2025) and the first half of FY26 (July–December 2025). In May 2025, the non-accounting functions of Grants and Contracts Accounting at Howard University were transitioned to the Office of Research, Sponsored Programs Office. During this organizational transition, the University prioritized the completion and accuracy of all costing allocations to ensure payroll data was complete and reliable for effort certification purposes. This period was also utilized to identify and resolve any backlog of costing allocations and award charges and stabilize the Office of Research. Addressing these items ensured that effort reflected complete and accurate payroll activity, thereby enabling Principal Investigators to appropriately review and certify their effort. The Sponsored Programs Office (SPO) now leads post-award financial oversight and collaborates with Human Resources (HR) and Finance to ensure designated personnel are identified and granted system access to enter costing allocations and labor cost transfers in Workday. In addition, in response to the auditor’s recommendation to enhance internal controls and ensure timely monitoring of effort reporting, Howard University has implemented the following corrective actions: Hired Dedicated Departmental Support – Six College Research Administrators (CRAs) and an Associate Director of CRA’s were hired to support high-volume research colleges. The CRAs ensure timely and accurate labor cost transfers, effort certification, and costing allocation entries during award setup and throughout the award lifecycle. Enhanced Effort Reporting Process – SPO will lead improvements to the effort certification process, including: • Advance communication to PIs, CRAs, and Deans outlining certification deadlines • Clear guidance on when labor cost transfers may occur outside the certification cycle • Reinforcement that all effort changes must be reflected in the effort system to ensure alignment with payroll. • Training – Targeted training will be delivered to Principal Investigators, CRAs, and other research stakeholders to support consistent application of policies and procedures. Monitoring and Oversight – Monthly and quarterly reconciliation reports will be developed to track and validate timely and accurate payroll allocations for research personnel. Anticipated Completion Date: August 30, 2026
Finding 1211188 (2025-002)
Material Weakness 2025
Syntiro
ME
We agree with the finding and we will be reviewing and implementing the recommendations accordingly. We are committed to ensuring no duplication of costs across reporting periods and compliance with allocability requirements under Uniform Guidance on a prospective basis. This corrective action plan ...
We agree with the finding and we will be reviewing and implementing the recommendations accordingly. We are committed to ensuring no duplication of costs across reporting periods and compliance with allocability requirements under Uniform Guidance on a prospective basis. This corrective action plan will be implemented by June 30, 2026.
Finding 1211187 (2025-001)
Material Weakness 2025
Syntiro
ME
We agree with the finding and will review and implement the recommendations accordingly. We are committed to ensuring proper application of indirect costs, avoiding duplication of costs across reporting periods, and maintaining compliance with allocability requirements under Uniform Guidance on a pr...
We agree with the finding and will review and implement the recommendations accordingly. We are committed to ensuring proper application of indirect costs, avoiding duplication of costs across reporting periods, and maintaining compliance with allocability requirements under Uniform Guidance on a prospective basis. This corrective action plan will be implemented by June 30, 2026.
As of March 2026, management has implemented controls that properly support the distribution of personnel charges. In addition, documentation is being obtained and retained to substantiate these charges and a new procedure of documenting the review process to help ensure these errors are corrected b...
As of March 2026, management has implemented controls that properly support the distribution of personnel charges. In addition, documentation is being obtained and retained to substantiate these charges and a new procedure of documenting the review process to help ensure these errors are corrected before submission to the grantors has been implemented.
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