Corrective Action Plans

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Finding 567696 (2024-025)
Significant Deficiency 2024
Finding 2024-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action During fiscal year 2024, MDHHS improved the payment review process prior to manual input into the Medic...
Finding 2024-025 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Insufficient Respite Payment Controls Management Views MDHHS agrees with the finding. Planned Corrective Action During fiscal year 2024, MDHHS improved the payment review process prior to manual input into the Medical Services Administration Manual Payment System (MSAPay) to help ensure there are no improper payments, as demonstrated by no improper payments identified for fiscal year 2024. MDHHS will develop and implement a post payment review process for the final respite payments that were entered into MSAPay during December 2024 and anticipates completion by September 30, 2025. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Crystal Kline, MDHHS Jessica Bowen, MDHHS Elaina Brown, MDHHS
Finding 567695 (2024-024)
Significant Deficiency 2024
Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 20...
Finding 2024-024 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - Grant Reimbursement Approval Procedures Management Views EGLE agrees with the finding. Planned Corrective Action The EGLE Water Resources Division’s (WRD) administration staff adjusted their review process in April 2024 to comply with overall EGLE guidance that all reimbursement requests should be reviewed by a program representative and financial representative to ensure payments are made for activities authorized by the grant agreement. However, WRD had not fully completed the retroactive review of payments for fiscal year 2024. This has since been corrected and all retroactive reviews to ensure compliance with program technical specifications were completed as of May 1, 2025. Anticipated Completion Date Completed Responsible Individual(s) Phil Argiroff, EGLE Amy Hicks, EGLE
Finding 567694 (2024-023)
Significant Deficiency 2024
Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure ...
Finding 2024-023 Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 - PTMS Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT EIM and Office of Passenger Transportation will collaborate and provide oversight to ensure that Public Transportation Management System (PTMS) user access is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process which will include obtaining, verifying, and documenting the written approval for all identified users by the designated System Security Administrators. Access will be modified/removed, as appropriate, based on responses or removed for non-responders prior to the end of each six-month period for privileged users and each fiscal year for all other users. Anticipated Completion Date September 30, 2025 Responsible Individual(s) Sandy Lovell, MDOT Gina Huhn, MDOT Jean Ruestman, MDOT Kyle Nelson, MDOT Andy Esch, MDOT
Finding 567688 (2024-022)
Significant Deficiency 2024
Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Service...
Finding 2024-022 Highway Planning and Construction, ALN 20.205 - AASHTOWare Security Management and Access Controls Management Views MDOT agrees with the finding. Planned Corrective Action MDOT’s Office of Enterprise Information Management (EIM), Bureau of Field Services-Construction Field Services Division, and Bureau of Development-Design Division will collaborate and provide oversight to ensure that user access for the American Association of State Highway and Transportation Officials software (AASHTOWare) Preconstruction and Construction & Materials modules is reviewed semiannually for privileged accounts and annually for all other accounts. MDOT will implement an improved process, which will be facilitated by the designated System Security Administrators, and access will be modified or removed, as appropriate, prior to the end of each six-month period for privileged users and annually for all other users. Anticipated Completion Date January 1, 2026 Responsible Individual(s) Mark Shulick, MDOT Dan Burns, MDOT Kristin Schuster, MDOT Dee Parker, MDOT Lindsey Renner, MDOT Jason Gutting, MDOT Kyle Nelson, MDOT Andy Esch, MDOT
Finding 567666 (2024-019)
Significant Deficiency 2024
Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information t...
Finding 2024-019 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Change Management Process Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS discussed the change management documented requirements with the information technology (IT) contractor during April 2025 to ensure all testing is documented appropriately. MDHHS has updated the Michigan Women, Infants, and Children Information System (MI-WIC) Change Management Controls process to include a review of each change to ensure it has successfully completed all components of the change management process prior to completion of associated release activities. Anticipated Completion Date Completed Responsible Individual(s) Kristina Brady, MDHHS Bagya Kodur, MDHHS
Finding 567665 (2024-018)
Significant Deficiency 2024
Finding 2024-018 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Access Controls Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action DTMB implemented a process in November 2024 to review privileged accounts with direct ...
Finding 2024-018 WIC Special Supplemental Nutrition Program for Women, Infants, and Children, ALN 10.557 - MI-WIC Access Controls Management Views MDHHS and DTMB agree with the finding. Planned Corrective Action DTMB implemented a process in November 2024 to review privileged accounts with direct database access semiannually. Anticipated Completion Date Completed Responsible Individual(s) Nathan Buckwalter, DTMB
Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the...
Finding-001 Allowable Activities – Significant deficiency in internal controls over compliance (HOPWA Payroll Allocation) Management Response The organization recognizes the importance of ensuring that payroll allocations are properly supported by approved documentation. To address this finding, the agency has implemented the following corrective actions: • Annual training on grant-specific timekeeping and payroll allocation requirements hasbeen instituted for all employees whose salaries are charged to grants. • Updated Standard Operating Procedures (SOPs) have been issued to program directorsand payroll administrators outlining the necessary approval and documentation processfor payroll allocations. • Supervisory review and certification of payroll allocation reports have been implementedto ensure compliance with approved grant allocations prior to payroll processing. Training sessions will be held on: June 10, 2025 • June 10, 2025 (initial training session for all HOPWA-funded staff) • Refresher training will be scheduled annually each June going forward. Responsible Staff: Controller and Program Directors Implementation Date: June 2, 2025
View Audit 360187 Questioned Costs: $1
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended S...
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2024 Finding Reference Number: 2024-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of expenditures to support activities allowed or unallowed, allowable costs/cost principles, reporting and special tests and provisions related to amounts reimbursed for the project worksheet as it relates to the FEMA disposition requirements for COVID-19 related supplies. As a result, Management was reimbursed by FEMA for expenditures that were not in compliance with the FEMA disposition requirements which resulted in a questioned costs of $480,606. Corrective Action Plan: Management will develop and implement an additional layer of review in future FEMA project worksheet submissions to ensure expenditures reporting for reimbursement in the FEMA project worksheet comply with the FEMA disposition requirements. Management will work with FEMA to refund the questioned costs and discuss the extent of the additional courses of action. Management will ensure this is performed through the closeout process of the project worksheet with FEMA. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: June 30, 2025
View Audit 360181 Questioned Costs: $1
Finding 2024-003 Lack of Internal Control over Activities Allowed or Unallowable and Allowable Costs/Cost Principles Name of Contact Person: Alexis Russell, Human Resources Corrective Action: The Human Resources Department will conduct an internal audit of active employee documentation for all maj...
Finding 2024-003 Lack of Internal Control over Activities Allowed or Unallowable and Allowable Costs/Cost Principles Name of Contact Person: Alexis Russell, Human Resources Corrective Action: The Human Resources Department will conduct an internal audit of active employee documentation for all major departments. All active employees within these departments will be required to submit updated voluntary deduction forms. Additionally, department directors will be responsible for submitting and renewing Personnel Action Forms for all employees under their supervision, with all renewals effective no later than October 1st of each year. Proposed Completion Date: The internal audit of documentation for all active employees within major MIC departments will be completed no later than August 31, 2025. All active employees in these departments will be required to submit updated voluntary deduction forms by August 31, 2025. Directors of major MIC departments will be responsible for the submission of Personnel Action Forms for all active employees under their supervision, with all renewals required to be effective no later than October 1, 2025.
View Audit 360172 Questioned Costs: $1
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure tha...
Recommendation — We recommend that management ensure that records are retained to support the validity of expenses charged to federal programs. Views of Responsible Officials and Planned Corrective Actions — Management agrees with the finding and in the future will take steps to retain or insure that access to records continues to be available.
2024-005 – ALN 14.872 – Public Housing Capital Fund Program – Allowable Costs Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action pl...
2024-005 – ALN 14.872 – Public Housing Capital Fund Program – Allowable Costs Planned Corrective Action: The Executive Director acknowledges the finding and is following the auditor’s recommendation as presented in the Audit Report. Issues are a result of prior management, and a corrective action plan is in place to address these weaknesses and deficiencies. Person Responsible for Correction of Finding: Christy Amacher, Executive Director Anticipated Completion Date: September 30, 2025
View Audit 360091 Questioned Costs: $1
Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If d...
Although the Academy has internal controls in place for approvals on journal entries, payments, transfers, and other disbursements, we will improve our processes in the following ways: • We will ensure a signature and date are included on all paperwork needing review and approval going forward. If documents are electronic, there must be an electronic signature with a time stamp included. • We have brought on a State and Federal Grants Consultant to ensure all required grant related paperwork is completed and saved in a shared location with the Finance Team.
Finding 567384 (2024-001)
Significant Deficiency 2024
Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Part...
Planned Corrective Action: Housing Compliance team will immediately train staff on the requirement to ensure that retainages are paid prior to draws from the HOME Treasury account. Retainage reimbursements will require additional verification in AMS to ensure payments are processed. Responsible Party: Cynthia Rogers-Ellickson, Director – Housing & Community Development Planned Implementation Date: June 13, 2025
View Audit 360057 Questioned Costs: $1
Elementary and Secondary School Emergency Relief – Assistance Listing No. 84.425U, 84.425W Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability ...
Elementary and Secondary School Emergency Relief – Assistance Listing No. 84.425U, 84.425W Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases, along with adding controls to ensure that the item purchased was received by the District. CLA also recommends the District review its payroll process and identify payroll tasks that could be reassigned to other district personnel or consider implementing additional review procedures specifically focused on payroll and related fringe benefit costs claimed on federal and state grants. CLA also recommends the District review its grant reporting processes and implement internal controls to help ensure that there is adequate segregation of duties in regards to grant reporting including special reports. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: District staff will accumulate as much of the information required for federal and state awards as we can and reconcile the revenue and expenditures information to the general ledger for these awards. Name(s) of the contact person(s) responsible for corrective action: Adrian Foster, Brooke Rosemeyer Planned completion date for corrective action plan: Ongoing.
Finding 2024-002 – Allowable costs – payroll Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization charged payroll costs to the federal award programs using a set percentage based on budget and not based on employee’s actual time or effort amongst various programs. Recomm...
Finding 2024-002 – Allowable costs – payroll Assistance Listing #: 93.243 Condition: During fiscal year 2024, the Organization charged payroll costs to the federal award programs using a set percentage based on budget and not based on employee’s actual time or effort amongst various programs. Recommendation: We recommend the Organization make changes overall its timekeeping processes to ensure that payroll costs accurately reflect the work performed and if budget estimates are utilized, that they are reconciled and trued up on a consistent basis. Action Taken: NFFCMH has made changes overall to the Federation’s timekeeping processes to ensure that payroll costs accurately reflect the work performed. The Organization is acting upon different guidance it has received, and as of the date this audit is released, the contract this finding addresses is currently scheduled to end on 08/30/2025. NFFCMH will continue our current practice through the end of this same contract, and we will review any potential change to same upon renewal or extension of this contract.
Finding 567134 (2024-002)
Significant Deficiency 2024
A review of SRC's policies and procedures will be completed and if necessary, will be updated to put additional controls in place to ensure appropriate personnel are reviewing and approving submitted employee work arrangements. Training will be provided, as applicable, for any changes that may be ma...
A review of SRC's policies and procedures will be completed and if necessary, will be updated to put additional controls in place to ensure appropriate personnel are reviewing and approving submitted employee work arrangements. Training will be provided, as applicable, for any changes that may be made. Contact Person Responsible for Corrective Action: Janna Nelson, Director, Human Resources Completion Date: Review of policy and procedures will be completed by September 30, 2025.
Finding 567133 (2024-001)
Significant Deficiency 2024
SRC is in the fifth year of an anticipated five-year period to verify the existence of tangible assets. This review includes validation of the status of active tangible assets as well as those withdrawn from active use to identify differences between physical life and depreciable life. Once this is...
SRC is in the fifth year of an anticipated five-year period to verify the existence of tangible assets. This review includes validation of the status of active tangible assets as well as those withdrawn from active use to identify differences between physical life and depreciable life. Once this is complete SRC will update our policies and procedures to incorporate the process of periodically analyzing and reviewing our useful life matrix to determine whether useful lives are valid or if adjustments are required. SRC provides additional training to employees responsible for capital. SRC’s policy states that residual value will be recognized consistent with FAR 31.205-11 which states, “for tangible personal property, only estimated residual values that exceed ten percent of the capitalized cost of the asset need be used in establishing depreciable costs”. SRC’s capital asset policy and Disclosure Statement do not set a standard ten percent residual value. SRC demonstrated that there have been no instances of salvage value of any amount recovered at tangible asset disposition. SRC agrees the system defaults to zero percent salvage value but disagrees this is indicative of a deficiency as the system provides for the flexibility to adjust the salvage value to the appropriate amount, as applicable. Remaining outstanding corrective action, which entails reviews of our policies and procedures will take place by September 30, 2026. Contact Person Responsible for Corrective Action: Lisa Kennedy, Director, Corporate Controller Completion Date: All corrective action will be implemented by September 30, 2026.
Finding: 2024-003 - Suspension and Debarment – Verification Auditor Description of Condition and Effect: The Township was unable to provide evidence that one of the vendors selected for testing was not suspended, debarred, or otherwise excluded at the time the Township hired the vendor to provide g...
Finding: 2024-003 - Suspension and Debarment – Verification Auditor Description of Condition and Effect: The Township was unable to provide evidence that one of the vendors selected for testing was not suspended, debarred, or otherwise excluded at the time the Township hired the vendor to provide goods or services. While none of the vendors tested appeared to be suspended or debarred, documentation does not exist to support that the Township verified its vendors paid with federal dollars were not suspended or debarred prior to contracting with them. Auditor Recommendation: We recommend that the Township review its written policies and procedures over federal awards to ensure that the appropriate suspension and debarment evidence of verifications are retained for all vendors providing goods or services in excess of $25,000. Corrective Action: We acknowledge the finding of immaterial noncompliance and the identified significant deficiency in our internal controls related to compliance with suspension and debarment requirements. We take this matter seriously and are committed to strengthening our compliance processes. Relevant personnel will undergo updated training on suspension and debarment procedures, including use of the SAM.gov exclusion database. Responsible Person: Tracy Watkins, Finance Director Anticipated Completion Date: December 31, 2025
2024-002 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that none of the semi-annual financial reports selected for testing included documentation that they were subjecte...
2024-002 - Lack of Independent Review and Approval of Reporting Auditor Description of Condition and Effect: During our audit procedures over the Township's reporting process, we noted that none of the semi-annual financial reports selected for testing included documentation that they were subjected to an independent review and approval prior to submission in order to detect and correct potential errors or omissions. As a result of this condition, the Township was exposed to an increased risk that the reports filed could contain errors and not be detected and corrected on a timely basis. Auditor Recommendation: We recommend that the Township establish procedures to ensure that all reports are subject to review and approval by an independent employee prior to submission, and that the review and approval is adequately documented.   Corrective Action: We acknowledge the finding of significant deficiency in internal controls over compliance. While the matter is not considered to be material to the overall compliance requirements, we recognize the importance of maintaining robust internal controls to ensure full adherence to applicable regulations and policies. The Township is in the process of ensuring relevant personnel are informed and adequately trained on updated compliance processes. We will also increase periodic reviews and monitoring activities to ensure sustained compliance and timely identification of potential issues. Responsible Person: Tracy Watkins, Finance Director Anticipated Completion Date: December 31, 2025
Finding 567094 (2024-002)
Significant Deficiency 2024
Yankton Transit will become familiar with the requirements of CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on those policies and procedures. Currently, we have changed the debit cards to credit cards for proper approval and complete support for t...
Yankton Transit will become familiar with the requirements of CFR, §200.313(a) and will establish internal control policies and procedures and will train staff on those policies and procedures. Currently, we have changed the debit cards to credit cards for proper approval and complete support for the transactions that occur monthly.
Finding 2024-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Grantor: United States Department of Homeland Security Assistance Listing No.: Assistance Listing 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disas...
Finding 2024-001 – Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Period of Performance Federal Grantor: United States Department of Homeland Security Assistance Listing No.: Assistance Listing 97.036, COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Grantor: Indiana Department of Homeland Security Federal Award Period of Performance: March 1, 2020 – May 11, 2023 A material weakness was identified related to internal controls over payroll expenses charged to FEMA funds, subject to the Uniform Guidance (UG) audit. This guidance requires internal controls to comply with the terms of the federal award as well as with the "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control—Integrated Framework" issued by COSO. The finding was a compliance matter and did not result in any questioned costs. Community Foundation of Northwest Indiana, Inc. and Subsidiaries (CFNI) acknowledges the finding related to the lack of documented review and approval of all timecards for payroll expenses charged to federally funded programs. In line with industry standards, CFNI prioritizes timely payroll processing and does not delay payroll for outstanding timecard approvals. While this is not a recurring issue and did not result in any questioned costs, CFNI recognizes the importance of ensuring compliance with all federal requirements. To address this finding and prevent recurrence, CFNI is implementing a comprehensive policy that mandates timely review and approval of all timecards associated with payroll expenses charged to federal grants. Additionally, CFNI is establishing a formal process to monitor adherence to this policy, including regular audits and detailed documentation of the review process. CFNI is committed to strengthening internal controls, improving oversight, and ensuring full compliance with federal grant requirements. Responsible Official: Pamela Pokropinski, VP Finance Status of finding: Completion expected June 2025
The City was informed of this finding in December 2023. The City will establish and adopt written policies for federal awards.
The City was informed of this finding in December 2023. The City will establish and adopt written policies for federal awards.
Finding 567012 (2024-002)
Significant Deficiency 2024
ALLOWABLE COSTS AND ALLOWABLE ACTIVITIES – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County has a supervisor review the random moment studies wages in detail to ensure costs are accurate by report line. Explanation of disagreement with audit finding: There ...
ALLOWABLE COSTS AND ALLOWABLE ACTIVITIES – TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Recommendation: It is recommended that the County has a supervisor review the random moment studies wages in detail to ensure costs are accurate by report line. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will implement policies to ensure all expenditures reported are accurate. Name of the contact person responsible for corrective action plan: Kara Terry, Community Services Director Planned completion date for corrective action plan: December 31, 2025
To ensure the new Business Manager has all necessary information to accurately prepare the Schedule of Expenditures of Federal Awards (SEFA), procedures will be implemented to improve communication and documentation. Employees responsible for preparing grant reimbursement claims will maintain organi...
To ensure the new Business Manager has all necessary information to accurately prepare the Schedule of Expenditures of Federal Awards (SEFA), procedures will be implemented to improve communication and documentation. Employees responsible for preparing grant reimbursement claims will maintain organized files with all supporting documentation readily accessible to the Business Manager. Additionally, all department directors and grant writers will be instructed to notify the Business Manager of any grant applications submitted and to keep them informed on the status of each grant. These steps will help ensure the SEFA is complete, accurate, and prepared in a timely manner.
This discrepancy resulted from a lack of understanding by the CFO in processing grant related funding. Grant policies have been updated, and personnel trained to direct and understand the role of independent accounting by funding sources through class codes. Anticipated completion date: 8/31/25. R...
This discrepancy resulted from a lack of understanding by the CFO in processing grant related funding. Grant policies have been updated, and personnel trained to direct and understand the role of independent accounting by funding sources through class codes. Anticipated completion date: 8/31/25. Responsible contact person: John Carroll, CFO
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