Corrective Action Plans

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We will continue to work with the Department for Public Health and will load opening balances of assets, liabilities and fund balances once approved by the Department for Public Health.
We will continue to work with the Department for Public Health and will load opening balances of assets, liabilities and fund balances once approved by the Department for Public Health.
Corrective Action Plan Finding Number: 2025-002 – Return of Title IV Funds Controls Finding: There is no evidence of a control in place by the College to review Return of Title IV Fund calculations. Corrective Action Planned Given the size of the Financial Aid Office, the College will implement comp...
Corrective Action Plan Finding Number: 2025-002 – Return of Title IV Funds Controls Finding: There is no evidence of a control in place by the College to review Return of Title IV Fund calculations. Corrective Action Planned Given the size of the Financial Aid Office, the College will implement compensating internal controls to ensure R2T4 calculations are accurate, timely, and compliant with federal regulations. Effective immediately, the College will implement the following controls: 1. Standardized R2T4 Processing All R2T4 calculations will be performed using the Department of Education Common Origination & Disbursement (COD) system to ensure consistent application of federal formulas. Official withdrawal dates will be confirmed using Registrar records prior to calculation. 2. Independent Post-Calculation Review Each R2T4 calculation will be reviewed by an individual other than the preparer, where feasible, or through supervisory review when staffing is limited. The review will confirm the accuracy of withdrawal dates, days attended, calculation inputs, and Title IV funds included. 3. Coordination and Reconciliation The Office of Financial Aid will coordinate with Student Accounts to ensure R2T4 results are applied correctly to the student account and that returned funds are processed within required timelines. 4. Documentation and Retention Evidence of review, including reviewer initials and date, will be retained for each R2T4 calculation. A simple R2T4 review checklist or log will be maintained. 5. Ongoing Oversight The Director of Financial Aid will conduct periodic spot checks to ensure R2T4 calculations and reviews are completed accurately and timely. Responsible Official: De Rodrick Jonkins, Director of Financial Aid Anticipated Completion Date: Implemented effective August 1, 2025 Additional Context The Director of Financial Aid assumed the role effective April 1, 2025, after prior corrective actions had been identified. While formal independent review controls were not documented during the audit period, there were no identified R2T4 compliance issues, late returns, or calculation errors. The corrective actions above are intended to formalize review processes and further reduce compliance risk.
The Organization will review the processes in place over unpaid invoices to ensure invoices are paid within 30 days of receipt.
The Organization will review the processes in place over unpaid invoices to ensure invoices are paid within 30 days of receipt.
CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a to...
CFDA 10.565 Commodity Supplemental Food Program Name of Contact Person: Shelly Neeley, Program Specialist Corrective Action: Eligibility requirements regarding the Commodity Supplemental Food program (CSFP) are recognized by West Ohio Food Bank (WOFB) and WOFB continues making internal controls a top priority in the program’s operation. There are currently 1,800 applications processed through WOFB and 43 site locations for CSFP. These include those applicants on the active list and the wait list as well as those who may not qualify for the program. During the auditing process, there were 11 participants that did not have a current/updated application on file yet received a distribution. To ensure that all applications are renewed within a twelve-month period, and that the recipients without a valid application on file do not receive distributions until a valid, up-to-date application has been obtained, WOFB has begun to implement and will continue implementing the following internal control procedures. WOFB will continue to update/renew all applications each March to have all expiration dates within the same month each year. The master spreadsheet has also been updated to include parameters that will flag an upcoming expiration date. This will assist the senior sites in knowing more timely who needs a renewal application at their location. In addition, Pantry Trak/Fresh Trak is being updated and revised. I have been working closely with Mid-Ohio in revising the CSFP portion to better meet the needs of the program at WOFB. The ultimate goal is to use the Pantry Trak system to log and track all CSFP information electronically. This too will increase the accuracy of the data. As an additional audit of accuracy WOFB will conduct an internal audit monthly by randomly pulling a sampling of 3 percent (48) of the 1,600 CSFP recipients to verify the accuracy of the applications on file. Proposed Completion Date: The processes implemented will be ongoing. As the Pantry Trak program tool continues to improve its use for tracking and logging, use for CSFP will increase.
Finding 2025-001 Significant Deficiency in Internal Control over Compliance - Reporting AL# 10.553 & 10.555 – Child Nutrition Cluster Corrective Action Plan Employee re-alignment and training was initiated beginning in August 2025, as well as revision to the review process for meal counts to include...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance - Reporting AL# 10.553 & 10.555 – Child Nutrition Cluster Corrective Action Plan Employee re-alignment and training was initiated beginning in August 2025, as well as revision to the review process for meal counts to include a second review prior to submission. In addition, the new system was evaluated for proper configuration to mitigate further issues. Person(s) Responsible M. Thorne, Operations Coordinator Anticipated Completion Date Corrective actions were substantially completed by October 2025.
Monitoring over federal awards – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these ...
Monitoring over federal awards – The District has corrected the reporting error for ESSER fund expenditures and is increasing its monitoring responsibilities to meet the needs of federal programs in the future. The District will be developing controls over reporting of federal funds to ensure these funds reconcile to the general ledger going forward.
Recommendations: The District should put controls in place that require contractors performing contract work valued at more than $2,000 and paid with federal funds to submit the required payroll reports, per the Wage Rate Requirements, throughout the contract work. Action Taken: We agree with the re...
Recommendations: The District should put controls in place that require contractors performing contract work valued at more than $2,000 and paid with federal funds to submit the required payroll reports, per the Wage Rate Requirements, throughout the contract work. Action Taken: We agree with the recommendation. Our targeted implementation date is January 2026
Auditor Description of Condition and Effect: During our audit procedures over the District’s payroll process, we noted that an employee’s wages were allocated to the food service function based on a straight percentage instead actual work performed. As a result of this condition, the District does n...
Auditor Description of Condition and Effect: During our audit procedures over the District’s payroll process, we noted that an employee’s wages were allocated to the food service function based on a straight percentage instead actual work performed. As a result of this condition, the District does not have proper controls in place over its procedures for allocation of wages. Auditor Recommendation: The District should utilize timecards to support the allocation of wages to federal functions. Corrective Action: The District will. Responsible Person: Jamie Johncock, Business Manager Anticipated Completion Date: June 30, 2025
Condition: Three (3) monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, und...
Condition: Three (3) monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, underlying claim support will undergo review before claims are submitted to the ISBE. Responsible Person: Janiesa Owens, Chief School Business Official Anticipated Completion Date: June 30, 2026
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective action will be taken: The University will review and revise policies and procedures related to reviewing and approving Research & Development ...
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective action will be taken: The University will review and revise policies and procedures related to reviewing and approving Research & Development grant scholarships prior to disbursement. The University will do the following:  Implement a review process to verify scholarships are reviewed and approved by Grant Administration prior to disbursement.  Provide training to relevant staff on proper documentation procedures to forward to Grant Administration to enhance compliance and accuracy.
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective actions have been taken: During the 2023-2024 academic year, EngageKY implemented a new process for recordkeeping related to the recruitment a...
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective actions have been taken: During the 2023-2024 academic year, EngageKY implemented a new process for recordkeeping related to the recruitment and selection of Kentucky College Coaches. As part of the implementation, site supervisors and program staff began to use Salesforce to maintain notes from screening interviews and general interviews. The missing documentation referenced in this finding was for individuals hired prior to the new process. EngageKY will continue to use Salesforce to document the recruitment and selection of Kentucky College Coaches.
Finding 1170486 (2025-002)
Material Weakness 2025
Finding 2025-001 Budget Violations Name of contact person: Jen Waterhouse, Chief Financial Officer Corrective Action: Proposed completion date: Finding 2025-002 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date...
Finding 2025-001 Budget Violations Name of contact person: Jen Waterhouse, Chief Financial Officer Corrective Action: Proposed completion date: Finding 2025-002 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: Corrective Actions for Finding 2025-002 also apply to State Award Findings. Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings Training for understanding Subscription Based Information Technology Agreements (SBITA) is a priority and will be conducted immediately. In FY26, SBITA’s will be reviewed and recorded quarterly via a budgeting worksheet to capture payments throughout the year for GASB 96 agreements. In May, the list will be monitored closely, and Finance staff will follow up with departments to confirm anticipated expenditures falling under GASB 96 are taken into consideration. Reports will be reviewed by the Chief Financial Officer for correctness, and the budget amendment will be in place in the first Board of Commissioner’s meeting in June 2026. In addition to the Budget Amendment taking place in early June; staff will also reconcile debt book GASB 96 reports to ensure complete records and agreement with prior year balances are intact. 6/8/2026 Section III - Federal Award Findings and Questioned Costs Training will be conducted with staff specifically concerning the finding areas , ensuring all required request for information and electronic verification sources are used, ensuring all verified information is appropriately updated in NC FAST evidence and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review verify that proper procedures are being followed with regard to these policies. Section IV - State Award Findings and Questioned Costs 12/5/2025 􀀔􀀚􀀕
Lack of Review Documentation (Significant Deficiency) Condition: Four participants were selected for eligibility test work for the Upward Bound Math and Science (UBMS) program. All four of these participants applications did not have any indication that they were reviewed or approved by the appropri...
Lack of Review Documentation (Significant Deficiency) Condition: Four participants were selected for eligibility test work for the Upward Bound Math and Science (UBMS) program. All four of these participants applications did not have any indication that they were reviewed or approved by the appropriate program director before receiving services from the program. Criteria: Based on the clients controls over TRIO eligibility, the program directors obtain various documents from the participant in order to make a determination of eligibility prior to the participant receiving services from the program. It was noted during the testing of the Talent Search – Upward Bound Math and Science program (UBMS) program eligibility that there is no documentation to indicate that applications were formally reviewed or approved by the program director. Cause: Required internal control review procedures were not documented and hence, no evidence was available to support that such review was performed. Effect: Although the students tested appear to be eligible to receive program services, this lack of program director review could’ve led to students that weren’t eligible receiving program services. Identification of repeat finding: No. Recommendation: The University should increase in efforts through training to ensure that all controls related to eligibility for all TRIO programs are properly followed. Views of Responsible Officials: As noted in the audit finding, auditor sample testing disclosed no instances of noncompliance related to participant eligibility to receive program services. While the University’s internal controls over compliance were not fully documented (lack of support proving eligibility review), at a minimum, University staff were aware of program eligibility requirements and first level internal controls functioned properly (no compliance sample errors). Going forward, the University will more stringently adhere to its procedures that include documentation of program eligibility review. Corrective Action: To strengthen internal controls, the TRIO program has implemented a corrective action plan requiring that all application forms be thoroughly reviewed for completion and proper authorization prior to submission. Each form must now include a verified approval signature from the designated supervisor or administrator. Furthermore, all approved TRIO application forms are securely uploaded and stored in the University's OneDrive system, allowing authorized personnel to view, track and confirm approvals in real time. This corrective action ensures documentation integrity, promotes transparency, and supports continuous program readiness for internal and external review. The following documentation protocols will ensure full compliance and transparency for all application forms. *Be thoroughly completed with no missing fields or attachments. *Include a verified approval signature from the designated supervisor or authorized administrator before acceptance. *Be uploaded immediately to the University's secure OneDrive system for real-time viewing, tracking and audit accesss by authorized personnel by the 15th of every month. This process creates a standardized worflow that ensures every TRIO form is accurately documented, authorized, and available for verification at all stages of the review cycle. Responsible Person(s): Stephanie White, AVP/Comptroller swhite@vuu.edu 804 257-5745 Linda Jackson, VP Sponsored Research and Innovation lrjackson@vuu.edu 804 257-5807 Gloria Foote, Grant Accountant gjfoote@vuu.ed 804 257-5781. Planned date of Completion of Corrective Action: December 31, 2025
Segregation of Duties - Auditor’s recommendation: We recognize that the District has attempted to mitigate the lack of segregation of duties by having other individuals perform certain ancillary duties of record-keeping including: opening the mail; signing of checks; distribution of payroll and vend...
Segregation of Duties - Auditor’s recommendation: We recognize that the District has attempted to mitigate the lack of segregation of duties by having other individuals perform certain ancillary duties of record-keeping including: opening the mail; signing of checks; distribution of payroll and vendor checks; and bank reconciliations. The District should continue to obtain involvement from its Board of Education in reviewing monthly financial and expenditure reports. District’s Response: The District understands the importance of having strong segregation of duties and will attempt to separate certain responsibilities as outlined above.
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements - Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting jour...
Adjusting Journal Entries, Required Disclosures and Draft Financial Statements - Auditor’s Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. District’s Response: The District has received, reviewed and accepted all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgments based on these financial statements. Lastly, the District considers such assistance provided by the auditors to be the most cost effective in preparing such information.
FINDING 2025-003 Contact Person Responsible for Corrective Action: Diana Smith Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Along with continuing current control processes, the Registrar will include the Director...
FINDING 2025-003 Contact Person Responsible for Corrective Action: Diana Smith Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Along with continuing current control processes, the Registrar will include the Director of Grants and Assessments in the email to the Data Specialist regarding the withdrawal. A monthly report will be generated by the Data Specialist and given to the Director of Grants and Assessments to verify the withdrawals have been completed appropriately. Anticipated Completion Date: February 2026
FINDING 2025-002 Contact Person Responsible for Corrective Action: Christine Clarahan Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A monthly checklist was created that will be used by those in the Food Services a...
FINDING 2025-002 Contact Person Responsible for Corrective Action: Christine Clarahan Contact Phone Number: 219-663-3371 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: A monthly checklist was created that will be used by those in the Food Services administration team office. The checklist includes the task, line for initials and date that task was completed. Tasks include Direct Certification download, spot checking after the Direct Certification download, verifying Food Service deposits, and other monthly tasks. Anticipated Completion Date: November 18, 2025
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. Th...
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. This error appears to be isolated to January; however, it would likely have been prevented if a review process were in place. Plan: The District will implement a system in which meal count claims will have secondary approval by the CSBO. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: ...
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations and reviews for The Emergency Food Assistance Programs. Responsible Individuals: Kate Molbert, COO David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP programs have proper signatures by necessary parties going forward. An electronic signature process has been implemented to make the dissemination, review and storage of this process easier. Also, additional staffing has been hired to manage this process in the form of a Programs and Operations Compliance Manager with substantial compliance experience. Anticipated Completion Date: Immediate
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses ...
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses attended and fees incurred. Corrective Action: The Financial Aid Department now verifies actual course enrollment prior to disbursement for specialized programs, ensuring accuracy and compliance. Beginning Winter term 2026, mid-term audits for the aviation program have been implemented to strengthen oversight. Additionally, policy updates now require real-time cost of attendance adjustments for all individualized programs to maintain consistency and alignment with federal regulations. Responsible Person: Director of Financial Aid, with support from Aviation Program Director. Anticipated Completion Date: Begin implementation immediately and accomplish full implementation by Spring 2026; ongoing monitoring.
The District will review the work performed by the individual preparing the reports before submission
The District will review the work performed by the individual preparing the reports before submission
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made depos...
Views of Responsible Officials: Management concurs with the recommendations and will provide instruction and policy to all individuals in the reserve for replacement funding activities of the Project. Since it was discovered prior to September 30, 2025, management worked with the bank and made deposits into the reserve for replacement to make up the shortfall. Management will work with the Bank and HUD to ensure the accuracy of the “true-up” payments made.
By requiring Finance Department signatures for all grant applications, a comprehensive list of all potential program awards can be maintained. From this information, potential expenditures can be monitored for the awards inclusion on the SEFA.
By requiring Finance Department signatures for all grant applications, a comprehensive list of all potential program awards can be maintained. From this information, potential expenditures can be monitored for the awards inclusion on the SEFA.
Beginning with the next semi-annual certification period, the Special Education Director will prepare a comprehensive listing of all staff whose salaries and/or benefits are charged in whole or in part to the Special Educaiton program. This listing will be reconciled to payroll records prior to cert...
Beginning with the next semi-annual certification period, the Special Education Director will prepare a comprehensive listing of all staff whose salaries and/or benefits are charged in whole or in part to the Special Educaiton program. This listing will be reconciled to payroll records prior to certification. Once certifications are completed and signed by the Special Education Director, they will be forwarded to the Superintendent's office (or designee) for independent review and approval to verify that every applicable employee has a completed certification on file. Additionally, the District will establish calander reminders and due dates for each semi-annual period to ensure timely completion and submission of certifications. Staff involved in this process will receive refresher training on federal time and effort documentation requirements.
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