Corrective Action Plans

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Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: The District should design and implement controls to ensure required authorization to bill Medicare (Form M-5) is obtained prior to initial billing. We also recommend the District design and implement controls to ensure a copy of this ...
Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: The District should design and implement controls to ensure required authorization to bill Medicare (Form M-5) is obtained prior to initial billing. We also recommend the District design and implement controls to ensure a copy of this form is retained in accordance with Federal and State requirements and is available for future required reviews. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will strengthen internal controls to ensure all required authorizations are obtained and properly maintained prior to billing. MPS will accomplish this through the execution of the following: • Implementing a pre-billing verification process to confirm a completed Form M-5 is on file before any initial Medicaid billing occurs, • Establishing a standardized documentation procedure to ensure all Forms M-5 are securely retained and readily accessible for review, • Creating a centralized tracking system to monitor the status of required authorizations for all eligible students, • Conducting periodic internal reviews to ensure compliance with authorization and documentation requirements, • Providing training to relevant staff on Medicaid billing requirements and record retention expectations. Name(s) of the contact person(s) responsible for corrective action: Budget Director, Accounting Director (Deputy CFO), Financial Reporting Manager Planned completion date for corrective action plan: Implementation of the new process is currently underway and will be remediated in the coming months of FY26 and into FY27.
Special Education Cluster (IDEA programs) – Assistance Listing No. 84.027, 84.170 Recommendation: The District should implement controls that allow for the identification and proper classification of vendor payments to applicable grant period. Explanation of disagreement with audit finding: There is...
Special Education Cluster (IDEA programs) – Assistance Listing No. 84.027, 84.170 Recommendation: The District should implement controls that allow for the identification and proper classification of vendor payments to applicable grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will strengthen internal controls to ensure that vendor payments are appropriately aligned with the correct grant reporting period. MPS will implement a standardized review process to validate that vendor invoices and related purchase orders are coded to the correct grant period, establish clear procedures for identifying the period of performance for goods and services, enhance coordination between program and finance staff to validate the timing and allowability of expenditures, conduct periodic monitoring of vendor payments to ensure compliance with grant period requirements, and provide training to relevant staff relating to grant period compliance and expenditure classification. Name(s) of the contact person(s) responsible for corrective action: Senior Director of Specialized Services, Accounting Director (Deputy CFO), Financial Reporting Manager Planned completion date for corrective action plan: 6/30/2026
a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, management withdrew $3,169 from the replacement reserve account without HUD approval. b. Action(s) Taken or Planned on the Finding On 03.04.2026, management corrected this issue by depositing $3,169 into the ...
a. Comments on the Finding and Each Recommendation During the year ended December 31, 2025, management withdrew $3,169 from the replacement reserve account without HUD approval. b. Action(s) Taken or Planned on the Finding On 03.04.2026, management corrected this issue by depositing $3,169 into the replacement reserve account. Furthermore, management has implemented a strengthened internal control process requiring a three-level review and approval of all replacement reserve withdrawals. Specifically, the Vice President of Operations, Regional Manager, and Controller must each review and approve the request prior to any transfer of funds to ensure compliance with HUD approved withdrawals.
The District continues to review duties and procedures throughout all fiscal services to improve segregation of duty procedures. We are implementing procedures to ensure additional oversight in areas such as cash handling, recordkeeping and financial reporting. These procedures include ensuring that...
The District continues to review duties and procedures throughout all fiscal services to improve segregation of duty procedures. We are implementing procedures to ensure additional oversight in areas such as cash handling, recordkeeping and financial reporting. These procedures include ensuring that all journal entries, cash receipt entry, check batches, and balancing procedures are reviewed/edited by more than one person at Central Office.
Period of Performance – Assistance Listing No. 93.958 Recommendation: Management should review and revise its process for allocating costs to federal grants to include additional layers of review and so that costs for which some or all are from outside of the period of performance, may be appropriat...
Period of Performance – Assistance Listing No. 93.958 Recommendation: Management should review and revise its process for allocating costs to federal grants to include additional layers of review and so that costs for which some or all are from outside of the period of performance, may be appropriately excluded from the federal grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will revise cost allocation procedures to add program and finance review steps to ensure that only costs incurred within the applicable period of performance are charged to federal grants. Costs identified as outside the allowable period will be excluded or reclassified. Updated procedures will be communicated to relevant staff and monitored for compliance. Name(s) of the contact person(s) responsible for corrective action: George Pepe Planned completion date for corrective action plan: 6/30/2026
Special Tests and Provisions – Assistance Listing No. 14.267 Recommendation: We recommend program managers verify that rent reasonableness checklists and certifications are fully completed by HUD staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...
Special Tests and Provisions – Assistance Listing No. 14.267 Recommendation: We recommend program managers verify that rent reasonableness checklists and certifications are fully completed by HUD staff. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will implement a supervisory review process requiring program managers to review and formally sign off on rent reasonableness checklists and certifications. Staff will receive refresher training on completion requirements, and management will periodically review files to ensure documentation is complete and properly approved. Name(s) of the contact person(s) responsible for corrective action: Jamie Rotter Planned completion date for corrective action plan: 6/30/2026
Suspension and Debarment – Assistance Listing No. 14.267 Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent pra...
Suspension and Debarment – Assistance Listing No. 14.267 Recommendation: We recommend that the organization retain documentation that Sam.gov was used to verify that a vendor was not suspended, debarred, or otherwise excluded from participating in the transaction prior to contract. To the extent practicable, the organization can engage with a third party that will verify any new and existing vendors have not been suspended or debarred on a monthly basis. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will update procurement procedures to require documented SAM.gov verification for all new vendors prior to contract execution and periodically for existing vendors. Evidence of verification (e.g., screenshots or confirmation reports) will be retained in procurement files. Management will also evaluate engaging a third‑party service to perform monthly suspension and debarment screenings. Compliance will be reviewed as part of routine procurement oversight. Name(s) of the contact person(s) responsible for corrective action: Scott Russell Planned completion date for corrective action plan: 6/30/2026
Condition: The CMHSP included all contract costs, including amounts over $25,000 in the modified total direct costs. Corrective Action: Those involved in managing and reporting for the grant will review the approved budget to ensure understanding of what has been approved by SAMHSA. Prior to request...
Condition: The CMHSP included all contract costs, including amounts over $25,000 in the modified total direct costs. Corrective Action: Those involved in managing and reporting for the grant will review the approved budget to ensure understanding of what has been approved by SAMHSA. Prior to requesting funds each month, accounting assistant and chief operating officer will review total costs to date to ensure they are accounted properly in line with modified total direct costs. At year end, a final check will occur to ensure all costs are reported according to modified total direct costs methodology. Staff responsible: Kristyn Kostelec, Grant Manager, Karen Watson, Accounting Assistant, and Kelly Jenkins, Chief Operating Officer Anticipated completion date: 12/30/26
Condition: Expenditures charged to the grant were not authorized in the grant budget. Corrective Action: Each month, the grant manager and accounting assistant will review the items charged to the grant in detail to ensure that all charges are appropriately accounted for according to the grant manag...
Condition: Expenditures charged to the grant were not authorized in the grant budget. Corrective Action: Each month, the grant manager and accounting assistant will review the items charged to the grant in detail to ensure that all charges are appropriately accounted for according to the grant manager's direction and approved grant budget. Staff responsible: Kristyn Kostelec, Grant Manager and Karen Watson, Accounting Assistant Anticipated completion date: 6/30/26
Views of Responsible Officials and Planned Corrective Actions: Management Response: Management concurs with the finding. The hazard insurance policy for the project property was in force; however, due to an administrative oversight during policy renewal, the required standard mortgagee clause identi...
Views of Responsible Officials and Planned Corrective Actions: Management Response: Management concurs with the finding. The hazard insurance policy for the project property was in force; however, due to an administrative oversight during policy renewal, the required standard mortgagee clause identifying the U.S. Department of Housing and Urban Development (HUD) as mortgagee/loss payee was not reflected in the insurance documentation maintained on file. Corrective Action Plan: Management will work with the insurance broker to obtain the required endorsement naming the U.S. Department of Housing and Urban Development (HUD) as mortgagee/loss payee and will implement a review process to ensure required endorsements are verified upon future policy renewals. Responsible Official: Stacey Ninness, President/CEO Anticipated Completion Date: Management anticipates the policy endorsement will be completed within 60 days of the audit report date.
Views of Responsible Officials and Planned Corrective Actions: Management Response: Management concurs with the finding. In prior years, the Single Audit Reporting Package was not submitted to the Federal Audit Clearinghouse due to an internal misunderstanding of management’s responsibility for subm...
Views of Responsible Officials and Planned Corrective Actions: Management Response: Management concurs with the finding. In prior years, the Single Audit Reporting Package was not submitted to the Federal Audit Clearinghouse due to an internal misunderstanding of management’s responsibility for submission. With the engagement of a new audit firm, management has clarified these responsibilities. Corrective Action Plan: Management will formally designate responsibility for the timely submission of the Single Audit Reporting Package to a specific member of the finance department. In addition, management will implement a review process to confirm submission and receipt acknowledgment from the Federal Audit Clearinghouse. Responsible Official: Kimberly Burt, Chief Financial Officer Anticipated Completion Date: Management anticipates the filing will be completed within 30 days of the audit report date.
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Organization should ensure proper review and approval over expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to ...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: The Organization should ensure proper review and approval over expenditures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: YSS engaged a project manager in September 2023 to provide oversight on the two major construction projects taking place, Rooftop Gardens and Ember Campus. The project manager reviews the work being performed to ensure alignment with the progress billing on the monthly AIA pay applications. The project manager submits the invoice for approval to the CFO who, with the CEO, approves payment and the invoice is sent YSS accounts payable to processes payment. Name of the contact person responsible for corrective action: Danielle Fineran Planned completion date for corrective action plan: June 30, 2026
Finding 2025 – 001 Audit Journal Entries Condition: During audit fieldwork, our testing resulted in audit adjustments in order to present materially accurate financial statements on grant activities. Criteria: A good system of internal controls would provide for accurate recording of adjusted grant ...
Finding 2025 – 001 Audit Journal Entries Condition: During audit fieldwork, our testing resulted in audit adjustments in order to present materially accurate financial statements on grant activities. Criteria: A good system of internal controls would provide for accurate recording of adjusted grant receivables and revenues for all Organization grant accounts prior to audit fieldwork. Cause: Year-end entries related to grant receivables and revenues were required in order to accurately present the Organization’s financial statements. Effect: The Organization’s financial statements were not fully adjusted prior to audit fieldwork. Recommendation: A vital process of effective internal controls is the review and subsequent adjustment of all general ledger balances, including grant activity. This review and adjustment will aid in the appropriate budgeting and management of the Organization’s financial activities and resources related to grant programs. Corrective Action Plan: The Fiscal Manager, along with staff, will review year-end adjustments as part of the audit preparation process and work to reduce the number of entries proposed by the auditors and prepare fully adjusted financial statements prior to audit fieldwork.
March 23, 2026 CORRECTIVE ACTION PLAN Cognizant or Oversight Agency for Audit Trinity Academy for the Performing Arts respectfully submits the following corrective action plan for the year ended June 30, 2025 Name and address of independent public accounting firm: AAFCPAs 160 Federal Street, 16th Fl...
March 23, 2026 CORRECTIVE ACTION PLAN Cognizant or Oversight Agency for Audit Trinity Academy for the Performing Arts respectfully submits the following corrective action plan for the year ended June 30, 2025 Name and address of independent public accounting firm: AAFCPAs 160 Federal Street, 16th Floor Boston, MA 02110 Audit period: July 1, 2024, thru June 30, 2025 The findings from June 30, 2025, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS - FINANCIAL STATEMENT AUDIT FINDINGS SIGNIFICANT DEFICIENCY 2025-001 Payroll Recommendation: The School implements a standardized checklist and conducts periodic internal reviews of onboarding documentation to ensure all required forms are properly completed and retained in accordance with Federal Regulations. Action Taken: The School is implementing a standardized onboarding checklist; all personnel folders will now include a printed version to ensure required forms, including Form 1-9 and Form W-4, are completed in full at the time of hire. In addition, periodic internal review of personnel files are completed in full at the time of hire. In addition, periodic internal reviews of personnel files will be conducted to verify ongoing compliance. HR staff will also receive additional training to reinforce proper documentation procedures and retention requirements. We are committed to strengthening internal controls and ensuring full compliance moving forward. If there are any questions regarding this plan, please call Harold Sands at 401-432-7881. Sincerely yours, Harold Sands
March 23, 2026 CORRECTIVE ACTION PLAN Cognizant or Oversight Agency for Audit Trinity Academy for the Performing Arts respectfully submits the following corrective action plan for the year ended June 30, 2025 Name and address of independent public accounting firm: AAFCPAs 160 Federal Street, 16th Fl...
March 23, 2026 CORRECTIVE ACTION PLAN Cognizant or Oversight Agency for Audit Trinity Academy for the Performing Arts respectfully submits the following corrective action plan for the year ended June 30, 2025 Name and address of independent public accounting firm: AAFCPAs 160 Federal Street, 16th Floor Boston, MA 02110 Audit period: July 1, 2024, thru June 30, 2025 The findings from June 30, 2025, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS-FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY Revenue Recognition 2025-002 Elementary and Secondary School Emergency Relief Funds Recommendation: The School develop policies and procedures surrounding revenue recognition. These procedures should also include a reconciliation of expenses incurred versus revenue recognized, ensuring revenue is recognized when services are rendered and the provisions of the grants have been met. Action Taken: Revenue recognition issues that occurred in the fiscal year 2024 audit flowed through to fiscal year 2025 and were not caught in time for the fiscal year 2025 audit. The School continues to adhere to the matching policy. If there are any questions regarding this plan, please call Harold Sands at 401-432-7881. Sincerely yours, Harold Sands
United Way will ensure all disbursements related to major program are allowable.
United Way will ensure all disbursements related to major program are allowable.
2025-004 REPORTING Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material Weakness in Internal Controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context: Documentatio...
2025-004 REPORTING Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Questioned Costs: None Type of Finding: Material Weakness in Internal Controls and Material Noncompliance Compliance Requirement: L. Reporting Condition/Context: Documentation was not provided to support the number of federally connected students reported on the Impact Aid application. Criteria: The District’s policies and procedures should ensure that internal controls over compliance of federal programs are in place and operating effectively. Cause: Management oversight and turnover in the federal grant department. Effect: Internal control weakness and material noncompliance. Recommendation: We recommend the District review its internal control procedures over federal programs to ensure that proper documentation is maintained to support the number of federallyconnected students on the Impact Aid application. Repeat Finding: Yes, similar to prior year finding 2024-005. Views of Responsible Officials: There is no disagreement with this finding. See the corrective action plan. Contact person: Laticia John, Business Coordinator
We agree with the recommendations and will separate duties and obtain training to the extent possible with our available resources. Ther superintendent and board will continue to monitor duties performed by the administrative personnel and contract for professional assistance as necessary.
We agree with the recommendations and will separate duties and obtain training to the extent possible with our available resources. Ther superintendent and board will continue to monitor duties performed by the administrative personnel and contract for professional assistance as necessary.
The District continues to have a limited number of office employees. The District will attempt, with advice from the auditors, to segregate duties as much as reasonably possible with limited office personnel.
The District continues to have a limited number of office employees. The District will attempt, with advice from the auditors, to segregate duties as much as reasonably possible with limited office personnel.
FINDING 2025-005: Private/Home School Communications Response: This issue was an oversight as we transitioned Curriculum Directors. Communications to private/home school students have been completed in FY26 and we will monitor compliance requirements for federal grants in the future to prevent this ...
FINDING 2025-005: Private/Home School Communications Response: This issue was an oversight as we transitioned Curriculum Directors. Communications to private/home school students have been completed in FY26 and we will monitor compliance requirements for federal grants in the future to prevent this from occurring again.
A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on Finding and Each Recommendation Management agrees with the finding and the transition of responsibilities to the new President has been further identified and understood since ste...
A. Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2025-001 a. Comments on Finding and Each Recommendation Management agrees with the finding and the transition of responsibilities to the new President has been further identified and understood since stepping into the role in November 2024. b. Action(s) Taken or Planned on the Finding Identification and understanding of the reporting deadlines, along with the necessary access to facilitate the transmission of data. Going forward the Data Collection Form will be prepared by the management company and reviewed and approved by the President of the Pelham Corporation prior to submission. This action has been completed during 2025. This will allow the timely submission going forward B. Status of Corrective Actions on Findings Reported in the Prior Audit Schedule of Findings, Questions Costs and Recommendations There were no open findings on the prior audit report.
Condition: On May 15, 2025, ISBE communicated to the District that ARP ESSER recipients had until May 24, 2025 to liquidate obligations and that the District needed to submit its expenditure report to ISBE by May 21, 2025 for ISBE to process and submit to the U.S. Department of Education by the new ...
Condition: On May 15, 2025, ISBE communicated to the District that ARP ESSER recipients had until May 24, 2025 to liquidate obligations and that the District needed to submit its expenditure report to ISBE by May 21, 2025 for ISBE to process and submit to the U.S. Department of Education by the new deadline. On May 21, 2025, the District submitted a claim for reimbursement of expenditures totaling $4,343,814. The expenditures comprising this claim by date incurred and liquidated were as follows: $1,668,710 incurred through May 21, 2025 and liquidated as of that date $31,692 incurred through May 21, 2025 but not liquidated as of that date $325,805 incurred from May 21, 2025 through June 30, 2025 and liquidated as of June 30, 2025 $531,321 incurred from May 21, 2025 through June 30, 2025 but not liquidated as of June 30, 2025 $1,786,286 incurred after June 30, 2025 At May 21, 2025 and June 30, 2025, expenditures totaling $2,675,104 and 2,349,299, respectively, out of the $4,343,814 claimed for reimbursement were not incurred, not liquidated or both and, therefore, did not qualify for reimbursement based on the Federal statutes, regulations and the terms and conditions of the Federal award in effect at those dates. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over compliance. Responsible Person: Dr. Maureen M. White, Superintendent Anticipated Completion Date: June 30, 2026
2025-006 – Deficiency in Internal Control over Reporting Corrective Action: The District will establish and implement written policies and procedures for the preparation, review, and submission of required reports for Federal and non-Federal grant awards. The reporting and related review requirement...
2025-006 – Deficiency in Internal Control over Reporting Corrective Action: The District will establish and implement written policies and procedures for the preparation, review, and submission of required reports for Federal and non-Federal grant awards. The reporting and related review requirements will be incorporated into the District’s policies for grant awards, including defined responsibilities and related record retention requirements. Responsible Officials: Fire Chief Gerard Tarleton Anticipated Completion Date: September 2026
2025-005 – Noncompliance and Deficiency in Internal Control over Cash Management Corrective Action: The District will implement a documented review and approval process for each Federal reimbursement request prior to submission, including verification of calculations, agreement to supporting documen...
2025-005 – Noncompliance and Deficiency in Internal Control over Cash Management Corrective Action: The District will implement a documented review and approval process for each Federal reimbursement request prior to submission, including verification of calculations, agreement to supporting documentation, and allowability within the reimbursement period. The reimbursement package, review documentation, and approval will be retained in accordance with the District’s records retention policy for each applicable grant award. Management will not submit reimbursement requests until the documented review is complete and any identified discrepancies are resolved. Responsible Officials: Fire Chief Gerard Tarleton Anticipated Completion Date: September 2026
Management acknowledges the finding related to cash management requirements and the timing of federal fund draws and disbursements. While the University maintains a robust, multi-layered review process, enhancements are necessary to ensure full alignment with federal requirements regarding the minim...
Management acknowledges the finding related to cash management requirements and the timing of federal fund draws and disbursements. While the University maintains a robust, multi-layered review process, enhancements are necessary to ensure full alignment with federal requirements regarding the minimization of time between the receipt and disbursement of funds. The University currently utilizes several internal controls, including: • A two-person pre-draw validation process to ensure draws align with liquidated expenses • Programmatic oversight through detailed fiscal year draw reports and reconciliation to G5 activity • Periodic fiscal year and program year reviews to identify and correct discrepancies These controls enabled the University to identify and correct the instances noted in the audit. However, management recognizes that refinements are needed to further align the timing of draws with actual cash disbursement activity. To address this, the University will implement the following corrective actions: 1. Refinement of Draw Timing – Draw requests will be more closely aligned with immediate cash needs and anticipated disbursement activity. 2. Enhanced Pre-Draw Reconciliation – In addition to existing controls, a real-time reconciliation of outstanding obligations and pending disbursements will be required prior to each draw to ensure alignment with cash needs. 3. Standardized Draw Calendar Adjustments – The University will evaluate and adjust its draw schedule, where necessary, to better align with actual disbursement cycles, including payroll and purchase card activity. 4. Formalized Monitoring and Documentation – Documentation will be maintained to support the relationship between drawdowns and disbursements, and periodic internal reviews will be conducted to ensure ongoing compliance. 5. Training and Communication – Additional guidance will be provided to program and fiscal staff regarding federal cash management requirements and expectations for timing of draws. Management believes these enhancements, in combination with existing internal controls, will ensure compliance with federal cash management requirements and prevent recurrence of this issue. Implementation Date: July 1, 2025 Responsible Party: James Altman (Director of Finance) in coordination with Darla Ellett (Trio Director) and Teriki Barnes (Trio Director)
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