Corrective Action Plans

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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.
Condition: The District reported expenses on the IDEA Flow Through excpenditure report that were claimed in another grant. Recommendation: We recommend to review for duplicate or unallowable expenses before entering into the expenditure report and submiting. Management Response: The District will re...
Condition: The District reported expenses on the IDEA Flow Through excpenditure report that were claimed in another grant. Recommendation: We recommend to review for duplicate or unallowable expenses before entering into the expenditure report and submiting. Management Response: The District will review the general ledger for duplicate or unallowable expenses before submitting quarterly reports. Anticipated Date of Completion: June 30, 2026
Management agrees with the finding. The weakness occurred due to the implementation of a change in the accrual process not initially being fully documented as an additional task in the billing workflow. Our corrective action plan is as follows: • Rectify the financial impact of the identified duplic...
Management agrees with the finding. The weakness occurred due to the implementation of a change in the accrual process not initially being fully documented as an additional task in the billing workflow. Our corrective action plan is as follows: • Rectify the financial impact of the identified duplicated cost (which is isolated to a single billing period) via a billing adjustment to ensure the net reimbursement of program expenses by the relevant funder is accurate. • Document the rationale for the payroll accrual and its subsequent reversal, and the individual steps required at each stage of the billing and review processes. The CFO, Controller and Grant Billing Manager are responsible for implementing this action plan which will be complete by end of December 2025. In the interim, the payroll accrual and reversal process is being subject to particular and focused review during the monthly billing process to ensure compliance while we implement the long-term plan.
Allowable Costs - Special Education Cluster (IDEA) (Significant Deficiency - Other Matter) Description of Finding 1 employee’s pay rate was not updated to reflect the new fiscal year 2025 collective bargaining agreement for their specific union after its implementation in December 2024. Although ret...
Allowable Costs - Special Education Cluster (IDEA) (Significant Deficiency - Other Matter) Description of Finding 1 employee’s pay rate was not updated to reflect the new fiscal year 2025 collective bargaining agreement for their specific union after its implementation in December 2024. Although retroactive pay for hours worked prior to ratification was correctly calculated and paid, the payroll system continued using the prior contract’s rate for all subsequent pay periods through the end of the school year. This occurred due to a failure in the payroll update process following contract implementation. Statement of Concurrence or Nonconcurrence Management agrees with the finding. Corrective Action The Board of Education will implement additional controls over payroll updates and establish a documented process for updating pay rates immediately after contract ratification. Additionally, review and verification of rate changes, along with periodic reconciliation against approved salary schedules or union agreements, should be performed to ensure accuracy and compliance. Name of Contact Person Christian Strickland, BOE Chief Operating Officer Projected Completion Date June 30, 2025
Finding 1167594 (2025-002)
Material Weakness 2025
SIGNIFICANT DEFICIENCIES, 2025-002 Allowable Costs and Activities: There is an audit recommendation that the District implement internal control processes and procedures to ensure that each purchase has a purchase order and an approved invoice at the time of payment, clearly indicating pre-approval ...
SIGNIFICANT DEFICIENCIES, 2025-002 Allowable Costs and Activities: There is an audit recommendation that the District implement internal control processes and procedures to ensure that each purchase has a purchase order and an approved invoice at the time of payment, clearly indicating pre-approval for the purchase and coding to ensure it is charged to the correct accounts. Corrective Action: The District already has a requisition/purchase order system in place and will expand it to ensure purchases are pre-approved and that invoices are approved and that the purchase is coded to the appropriate fund. Anticipated Completion Date: This corrective action has already been implemented. Status: Completed.
2025-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires progra...
2025-002 Significant Deficiency over Activities Allowed and Unallowed and Allowable Costs/Cost Principles The auditors recommend that the County implements a review control over weekly timesheets to ensure the timesheets include all program time coded on the day sheets. NCDHHS policy requires program salaries to be allocated and supported by payroll and attendance records for individuals. There is no disagreement with this audit finding. Annual day sheet training is now required for all staff that submit day sheets. Additionally, all new hires are required to complete day sheet training prior to submitting their first entry. A PowerBI dashboard has been created and released in June 2025 to pull data from both Workday (the County’s system of record) and our daysheet system, ISSI that provides supervisors the ability to show discrepancies between entries in real time. The County will also conduct random reviews monthly. Any discrepancies identified will be provided to staff leadership for support and correction. Additional reviews will be conducted for those staff with identified errors until released by leadership. Semi-annual reports will be provided to HHS Senior Leadership members to show trends and compliance with day sheet and timesheet entries. These reports will be created in December and June of each year. Person responsible for correction action: Leigh Anderson, HHS Business Administrator Completion date: The County has already implemented these changes.
Finding 2025-001 – Allowable Costs The BOCES concurs with the finding 2025-001. Corrective Action: The BOCES will implement the following corrective actions to be completed by November 30, 2025: 1. The BOCES will develop and implement new written policies and procedures for time and effort reporting...
Finding 2025-001 – Allowable Costs The BOCES concurs with the finding 2025-001. Corrective Action: The BOCES will implement the following corrective actions to be completed by November 30, 2025: 1. The BOCES will develop and implement new written policies and procedures for time and effort reporting. 2. All grant-funded employees will receive training on the new procedures. 3. The BOCES will implement a new system to track and certify employee time. Contact Person: Daniel Henner, Business Administrator (315) 796-9902 dhenner@herkimer-boces.org
The finance department will monitor federal budgets within GAPS and will do timely budget amendments with the SDE in order to make sure that all federal expenditures are spent within the proper function and object codes in GAPS.
The finance department will monitor federal budgets within GAPS and will do timely budget amendments with the SDE in order to make sure that all federal expenditures are spent within the proper function and object codes in GAPS.
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Two instances were identified where the approval over the expense occurred after the check was...
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: Two instances were identified where the approval over the expense occurred after the check was written. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on the proper sequence of approval and release of checks. Where appropriate, procedures may be modified to ensure proper approval is obtained and documented, prior to checks being delivered to clients. Anticipated Completion Date: December 31, 2025
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