Corrective Action Plans

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Management strives to operate within a model of continuous improvement and will review and improve processes appropriately to provide for timely reporting on a go-forward basis.
Management strives to operate within a model of continuous improvement and will review and improve processes appropriately to provide for timely reporting on a go-forward basis.
The Organization will continue to rely on the outside assistance of its auditors for the necessary guidance to adjust the general ledger to accrual and to prepare financial statements and related notes and the schedule of expenditures of federal and state awards in accordance to generally accepted a...
The Organization will continue to rely on the outside assistance of its auditors for the necessary guidance to adjust the general ledger to accrual and to prepare financial statements and related notes and the schedule of expenditures of federal and state awards in accordance to generally accepted accounting principles because it is the most cost effective solution.
Management's Response and Planned Corrective Action: This finding relates primarily to the submission of annual grant reports SF-271 and SF-425, which are required by the FAA to be filed each year. The SF-271 (Outlay Report and Request for Reimbursement) are used to report project expenditures and r...
Management's Response and Planned Corrective Action: This finding relates primarily to the submission of annual grant reports SF-271 and SF-425, which are required by the FAA to be filed each year. The SF-271 (Outlay Report and Request for Reimbursement) are used to report project expenditures and request reimbursement of federal funds. It shows how much of the grant has been spent (outlays) and how much reimbursement is being requested from the funding agency. SF-425 (Federal Financial Report) provides a comprehensive summary of the financial status of a grant, including total expenditures, federal funds used, recipient cost share (if applicable), and remaining balances, to ensure proper accountability and compliance with grant requirements. Although these reports were submitted after the established due dates, management maintained the reporting requirements as an active and ongoing priority. These reports were regularly discussed during monthly coordination meetings involving Airport staff and the FAA Airports District Office (ADO), as well as during weekly internal staff meetings. During these regular discussions with the FAA ADO, the Airport was not advised that it was out of compliance with reporting deadlines. Rather, the FAA consistently indicated that reports should be submitted as soon as practicable. The Airport remained aware of its reporting obligations and their importance, particularly in support of ongoing efforts to secure funding for the terminal expansion project. Notwithstanding the above, management acknowledges that formal tracking mechanisms and documented follow-up procedures can be strengthened to ensure earlier identification and resolution of incomplete or missing grant data. To address this, management will enhance internal controls over grant reporting to ensure timely and complete submissions. Improvements will include implementing calendar-based tracking tools and structured notification procedures, with reminders and follow-up communications beginning at the FAA fiscal year-end (September 30) and continuing through the reporting due date (December 31). Additionally, management will coordinate with the FAA and MDOT to secure reliable access to the FAA’s Delphi System, where the data necessary to complete these reports resides. Communication with both the FAA ADO and MDOT will be further strengthened during the critical period leading up to reporting deadlines to ensure that any missing or incomplete information is promptly identified and addressed. Regular internal discussions regarding grant reporting status will also continue to support timely resolution of outstanding items. Management believes these corrective actions will mitigate the risk of delayed or incomplete reporting and strengthen overall compliance with grant requirements. Responsible Party for Corrective Action: Mark Bishop, Chief Financial Officer Anticipated Completion Date: June 2026.
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code with...
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code within the Union College system specifically related to graduation and withdrawal dates. A report that includes status code changes will be reconciled with student status changes transmitted by the National Student Clearinghouse (NSC) to the National Student Loan Database System (NSLDS), and any necessary corrections will be made in the appropriate time frame. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented at the end of the Spring 2026 term.
The Organization will continue to rely on the outside assistance of its auditors for the necessary guidance to adjust the year end balances to accrual and to prepare financial statements and related notes in accordance to generally accepted accounting principles because it is the most cost effective...
The Organization will continue to rely on the outside assistance of its auditors for the necessary guidance to adjust the year end balances to accrual and to prepare financial statements and related notes in accordance to generally accepted accounting principles because it is the most cost effective solution.
The Organization is aware of the lack of segregation of duties caused by the limited size of its staff. Segregation of duties is enhanced whenever possible, and the Governing Board assumes an active role when possible.
The Organization is aware of the lack of segregation of duties caused by the limited size of its staff. Segregation of duties is enhanced whenever possible, and the Governing Board assumes an active role when possible.
Condition: For the year ended December 31, 2025, the Township submitted reports timely, however, these reports were not reviewed prior to submission. Planned Corrective Action: The Township will implement and document controls to ensure reviews of all required reports are done by an individual indep...
Condition: For the year ended December 31, 2025, the Township submitted reports timely, however, these reports were not reviewed prior to submission. Planned Corrective Action: The Township will implement and document controls to ensure reviews of all required reports are done by an individual independent of the individual preparing the reports. Contact person responsible for corrective action: Barbara Miller, Accounting Mgr. Anticipated Completion Date: 9/30/2026
2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before i...
2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before indirect costs are charged to the grant. A grant expenditure tracking process will be established to monitor direct and indirect costs against the approved budget throughout the grant period. The Chief Financial Officer will review indirect cost calculations and budget-to-actual expenditures monthly to ensure expenditures remain within approved budget limitations and comply with applicable federal regulations and grant requirements. This CMHSP will create grant management policies and procedures, outside of the County of Lapeer’s grant management policy, to include documented reviews of indirect cost calculations, monthly budget monitoring, and supervisory approval of grant expenditures to ensure compliance with federal awards. Responsible Party: Emma McQuillan, Chief Financial Officer Anticipated Completion Date: 09/30/2026
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards...
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Responsible Party: Emma McQuillan, Chief Financial Officer Completion Date: 12/5/2024
Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges...
Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges this finding. City has communicated directly with Housing and Urban Development for clarification on reporting requirements and intends on following the updated guidance they provided. Anticipated Completion Date: July 31, 2026
SEGREGATION OF ACCOUNTING FUNCTIONS Recommendation: The County should be aware of the inherent risks associated with improper segregation of accounting functions. The County should also develop mitigating controls to reduce the risk of errors or fraud associated with improper segregation of accounti...
SEGREGATION OF ACCOUNTING FUNCTIONS Recommendation: The County should be aware of the inherent risks associated with improper segregation of accounting functions. The County should also develop mitigating controls to reduce the risk of errors or fraud associated with improper segregation of accounting functions. Action Taken: The County has assessed the benefits and costs associated with proper segregation of duties for all County departments and offices and has determined that cost would outweigh any benefits received. The County understands the inherent risks associated with improper segregation of accounting functions. Action has been taken to ensure timely deposits to the General Fund from the accounts held by individual departments, and County Management has communicated the need to be transparent regarding the transactions handled within these accounts. The County requires monthly reporting to the Board of Commissioners for various department officials to ensure transactions are recorded, and potential errors and irregularities are identified on a timely basis. The County will continue to review accounting procedures and processes to further mitigate this internal control deficiency whenever possible and feasible.
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compli...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
2025-002 — Filing with the State Auditor and Federal Audit Clearinghouse Finance Department 16 W. 9th St. Shawnee, OK 74801 ShawneeOK.org Condition: The city did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year endingiune 30, 2025....
2025-002 — Filing with the State Auditor and Federal Audit Clearinghouse Finance Department 16 W. 9th St. Shawnee, OK 74801 ShawneeOK.org Condition: The city did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year endingiune 30, 2025. Additionally, the city did not submit its audit report to the FAC within nine months from the year ending June 30, 2025. In conjunction with our FY2025 single audit, please see the City's corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines to remain compliant with requirements. Management will try to correct their timeliness and file within the appropriate deadlines going forward. Expected completion date: FY26 Audit
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the...
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the Town will take the following steps: Before sending any future reports to the federal government, the Finance Department will match the report numbers directly to the Town's official accounting records (the general ledger). A second person in the finance department will review and sign off on the report before it is submitted. We will save copies of the accounting records and the signed approval forms to show future auditors. Planned Implementation Date of Corrective Action: September 1, 2026 Person Responsible for Corrective Action: Town Accountant/ Finance Director
Finding 2025-001 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, net assets, reven...
Finding 2025-001 Financial Close Process Condition: During the audit, it was noted that the Organization lacked a robust financial close and review process. This deficiency resulted in multiple material audit adjustments across key financial statement accounts, including inventory, net assets, revenues, deferred revenue, and related activity accounts. These adjustments were proposed by the auditors and subsequently recorded by management in order to fairly present the financial statements in accordance with generally accepted accounting principles. The extent and materiality of the adjustments indicate that the Organization's existing closing procedures were insufficient to identify and correct errors prior to the audit. Corrective Actions Taken or Planned: A Part-Time Accounting Manager was hired in October 2025 to assist with financial reporting and documentation. The Organization implemented a review and sign-off process for financial reports at board meetings. The Organization will develop a financial close calendar with clear deadlines. We will create a standard operating procedure for account reconciliations, journal entries, and financial reporting with assignments to specific staff.
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.
Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit i...
Finding 2025-003 Inadequate System of Internal Controls over Eligibility Determination Condition: The Organization uses a database to collect and store documentation related to eligibility determinations for program participants. While this tool was used consistently throughout the year, the audit identified a lack of documented review procedures to verify that eligibility criteria were appropriately assessed and that all required documentation was obtained and retained. There is no established process to review or confirm the completeness and accuracy of eligibility documentation within the database. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: In September 2025, the Organization began its transition to Pantry Soft, a new CRM to centralize client records, eligibility documentation and service dates. This went live in December 2025. We included mandatory eligibility fields and document upload requirements before service can begin. We developed SOPs to include a standardized eligibility checklist to be completed for all new and returning participants. Staff were trained on Pantry Soft usage, eligibility requirements and document retention stands. The Executive Team performed spot checks on these records but will begin documenting this procedure.
Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Respon...
Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Responsible Officials: Finance Director, Director of Information Systems and the Municipal Advisor Management's Response & Corrective Action Plan: Concurrence with the Findings: The Management of the Municipality of Corozal concurs with the conditions and recommendations outlined in Findings 2025-001 and 2025-004 We acknowledge that the recent migration of our core accounting system compromised the system's operational and technical capacity to generate balanced trial balances, reconcile subsidiary ledgers, and streamline the automatic production of the Schedule of Expenditures of Federal Awards (SEFA). Corrective Actions to be Implemented: To resolve these deficiencies systematically and ensure full compliance with Government Auditing Standards and the Uniform Guidance (2 CFR 200), the Municipality will execute the following action plan within a strict 120-day timeframe: 1. System Re-alignment & Expert Remediation (Led by: Director of Information Systems and the Municipal Advisor): The Municipality will immediately retain specialized software implementation engineers and municipal accounting consultants to trace the migration mapping errors. This team will re-align the platform's database structure to correct the corrupted historical financial data and prior-period balances. 2. Opening Balance Reconstruction (Led by: Finance Director & Municipal Advisor): A formal data-clearing project will be established to reconstruct, cross-reference, and validate all opening balances transferred from the legacy system against the prior year's audited financial statements to restore data integrity. 3. Interim Manual Tracking for Federal Programs (Led by: Finance Director): To address the risks highlighted in Finding 2025-004 the Finance Department will immediately implement an interim manual spreadsheet tracking matrix. This will ensure all federal expenditures across all active Assistance Listings (ALN) are manually reconciled with federal drawdowns and physical invoices until the core accounting database is completely functional. 4. Closing Controls & Migration Policies (Led by: Joint Committee): We will design and implement rigid monthly closing routines and formal trial balance reviews. Furthermore, we will establish strict IT transition frameworks requiring dual-system running periods and mandatory data-integrity sign-offs before any future application or ledger upgrades are deployed. Should you have any questions or require additional information, please do not hesitate to contact the undersigned at (787) 859-3060, ext. 1703. Sincerely Jose A Rivera Miranda Finance Director
See pdf of corrective action plan
See pdf of corrective action plan
Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended Decem...
Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Summary of finding: Testing of 40 patient encounters identified 2 instances in which the sliding fee discount schedule (SFDS) was not applied in accordance with established requirements. These instances included the incorrect application of the sliding fee scale and the failure to apply the discount when required. As a result, certain patients were undercharged or overcharged for services received. Planned corrective action: CFHC management concurs with the finding. CFHC has policies and procedures in place to ensure compliance. CFHC will provide additional training to the Patient Services Representatives and Billing Clerks to ensure the existing policies and procedures are followed. The CFHC Billing Manager will develop additional reviews to discover, correct, and educate when non-compliance is suspected. CFHC will provide targeted trainings as necessary for site level personnel. Monitoring and review will be an ongoing effort as the positions responsible for real-time compliance tend to be highly transitory. Additional review steps have already been implemented and will become part of the typical workflows to monitor compliance. Anticipated Completion Date: June 1, 2026 Contact Person: Jim Merrill, Chief Financial Officer Email: jmerrill@cfamhc.org Phone: 360-703-6701 Name and Address of Independent Public Accounting Firm: Aprio, LLP 3 Centerpointe Dr, Ste 300 Lake Oswego, OR 97035
Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically tes...
Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026
2025-002 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The disbursement date being reported to COD by the College did not match the disbursement date shown on student account detail reports. Recommendation: Management should review and update internal control proces...
2025-002 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The disbursement date being reported to COD by the College did not match the disbursement date shown on student account detail reports. Recommendation: Management should review and update internal control processes over COD reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This system error has been corrected and additional training offered to bursar’s office. Name(s) of the contact person(s) responsible for corrective action: Wendy Davis Planned completion date for corrective action plan: 06/26/2026
2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The College did not report information to NSLDS in a timely manner, enrollment was not being certified every 60 days, and information being reported was inaccurate. Recommendation: Management should review and u...
2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The College did not report information to NSLDS in a timely manner, enrollment was not being certified every 60 days, and information being reported was inaccurate. Recommendation: Management should review and update internal control processes over NSLDS reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college’s financial aid team has scheduled time for NSLDS reporting until the National Student Clearinghouse reporting has been confirmed by the Department of Education. Name(s) of the contact person(s) responsible for corrective action: Wendy Davis Planned completion date for corrective action plan: 06/26/2026
Identifying Number: 2025-001 Finding: The data collection form for the year ended June 30, 2025, was filed after the March 31, 2026, deadline, making it a late submission. Corrective Actions Taken or Planned: Envision Unlimited will schedule and complete future external audits in a manner that will ...
Identifying Number: 2025-001 Finding: The data collection form for the year ended June 30, 2025, was filed after the March 31, 2026, deadline, making it a late submission. Corrective Actions Taken or Planned: Envision Unlimited will schedule and complete future external audits in a manner that will allow timely reporting of the Single Audit. Contact people responsible for corrective action is Chris Nordloh, CFO and Mary Ann Livovich-Tomondi, Controller. The anticipated completion date is June 30, 2026.
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