Corrective Action Plans

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Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-001 Condition: The University did not have evidence or documentation available to support the control/review process for return of Title IV calculations. Corrective Action Plan : The University will co...
Mount Saint Mary’s University Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-001 Condition: The University did not have evidence or documentation available to support the control/review process for return of Title IV calculations. Corrective Action Plan : The University will continue to review and adhere to our procedures for refunding awards, and the Financial Aid office will formally document the weekly review of the Return of Title IV funds. Name(s) of Contact Person(s) Responsible for Corrective Action: La Royce Housley, Director of Financial Aid Anticipated Completion Date: Immediately Joy E. Brathwaite, MBA MSA Vice President for Finance and Administration Dated: 12/4/2025
2025-005 – Medicaid – Allowable Activities and Costs - The District is aware of the student’s receiving benefits need to have their billed services included in their IEPs. Responsible Official – Austin Moore, Business Manager Anticipated Completion Date – The District will correct this in the subseq...
2025-005 – Medicaid – Allowable Activities and Costs - The District is aware of the student’s receiving benefits need to have their billed services included in their IEPs. Responsible Official – Austin Moore, Business Manager Anticipated Completion Date – The District will correct this in the subsequent fiscal year.
Finding 2025-001 (Material Weakness) AL# 11.307: COVID-19 Economic Adjustment Assistance, Economic Development Cluster, U.S. Department of Commerce, Federal Award # 05-79-06082 - 2021 Condition: The required performance reports ED-916 and ED-917 were not completed or submitted during the fiscal year...
Finding 2025-001 (Material Weakness) AL# 11.307: COVID-19 Economic Adjustment Assistance, Economic Development Cluster, U.S. Department of Commerce, Federal Award # 05-79-06082 - 2021 Condition: The required performance reports ED-916 and ED-917 were not completed or submitted during the fiscal year. Criteria: 2 CFR 200.303(a) states that the Center is required to establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Questioned Costs: None noted. Context: The Center transitioned to the revolving stage of the program and there was a misunderstanding that the ED-916 and ED-917 had to be filed during the revolving stage. The sample size was determined based upon the guidelines provided by the AICPA which is not a statistically valid sample. Cause: The Center misunderstood that the performance reports were applicable during the revolving stage. Effect: Not reporting performance reports may impact the federal agency’s ability to assess the effectiveness of the federal program. Corrective Action Plan: All EDA reporting will be completed and submitted to ensure the Center is up to date on required filings. In addition, the Center will work with the EDA to understand when reporting requirements will change during the revolving process.
Finding 1165234 (2025-004)
Material Weakness 2025
2025-004: Lack of Controls over Reporting Issue: Program reports were submitted without a documented supervisory review to ensure accuracy, completeness, and compliance with reporting requirements. Corrective Actions: 1. Establish a standardized finance report review procedure for all program report...
2025-004: Lack of Controls over Reporting Issue: Program reports were submitted without a documented supervisory review to ensure accuracy, completeness, and compliance with reporting requirements. Corrective Actions: 1. Establish a standardized finance report review procedure for all program reports, including a required supervisory review before submission. 2. Implement a review checklist that includes verification of data sources, accuracy of totals, reconciliation of reported information, and confirmation that all reporting elements required by the funding agency are included. 3. Require documented evidence of review, such as supervisor signatures or electronic approval recorded in the reporting system. 4. Train all reporting and supervisory staff on the new procedures, expectations, and documentation requirements. Responsible Personnel: Grant Accountants, CFO, Program Managers Timeline: Procedures will be finalized within 10 days. Staff training will occur within 30 days. The new review process will be fully implemented by the next reporting cycle for reports due for Q2. Monitoring: Compliance will conduct quarterly spot checks to confirm adherence to the new review procedures and report results to leadership.
Finding 1165233 (2025-003)
Material Weakness 2025
2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Do...
2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Documentation of income verification and classification checks was incomplete or not retained. Corrective Actions: Porter-Leath will strengthen controls over eligibility determination by requiring a complete review of all eligibility documents before system entry. 1. Applications will first be checked by administrative or Family Services staff to verify household size, income documentation, and appropriate eligibility category. 2. Site Managers will review the classification for accuracy and ensure the approved determination is entered consistently into ChildPlus or ProCare. 3. A final review by the Preschool Coordinator will confirm that the eligibility classification on the application matches the classification stored in the system prior to claim submission. 4. A reconciliation step will be built into the monthly workflow so discrepancies between documentation and system data are identified and corrected promptly. Responsible Personnel: Family Services Liaisons, Site Administrative Staff, Site Managers, Preschool Coordinator, CACFP Coordinator Timeline: Revised procedures implemented within 15 days; staff training completed within 30 days. Monitoring: Periodic quarterly reviews of at least 25 percent of eligibility files will be conducted to confirm proper classification and system accuracy, with results reported to management.
The cafeteria manager will reconcile meals served monthly to verify that the numbers match and are verified to actual meals served starting in the 2025-26 School Year.
The cafeteria manager will reconcile meals served monthly to verify that the numbers match and are verified to actual meals served starting in the 2025-26 School Year.
Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action tak...
Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Augustana intends to modify the NSC/NSLDS monthly data file to ensure that campus and program enrollment dates are pulled from the appropriate data fields in the student information system. Additionally, Augustana intends to implement a step in the withdrawal process to ensure the change in status is reported accurately and timely. Name of the contact person responsible for corrective action: John Cage at johncage@augustana.edu Planned completion date for corrective action plan: January 30, 2026
Finding 2025-004 Lack of Internal Controls over Reporting Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Records will be reviewed monthly by two individuals to ensure they are complete. Back up documentation shall be kept in a secure location where at least two oth...
Finding 2025-004 Lack of Internal Controls over Reporting Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Records will be reviewed monthly by two individuals to ensure they are complete. Back up documentation shall be kept in a secure location where at least two other budget supervisors are aware and have access to same. Proposed Completion Date: Fiscal Year 2026
Finding 2025-002 Lack of Internal Control Over Reporting Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all federal reports are properly prepared and values reflect actual values in the accounting software. Proposed Completion Date: December 31, 2025.
Finding 2025-002 Lack of Internal Control Over Reporting Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all federal reports are properly prepared and values reflect actual values in the accounting software. Proposed Completion Date: December 31, 2025.
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 157096-0 Award Year: October 1, 2022 – September 30, ...
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 157096-0 Award Year: October 1, 2022 – September 30, 2025 Compliance Requirement: Reporting Criteria: Per the grant agreements, Maricopa County Community College District Foundation (the “Foundation”) must submit several programmatic reports throughout the grant period with various due dates. Condition: A required programmatic report was submitted 6 days after the due date. Name of Contact Person: Judy Sanchez, Interim CEO Phone Number: 602-402-5062 Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action Plan: The Foundation will design and implement controls regarding the tracking of reporting due dates and retention of concurrent documentation when obtaining extensions or approval for late submissions.
The Business Manager will review all the employee timesheets and contract pay and verify on the gross pay detail reports to authorize payroll prior to finalizing submission of payroll. Intern control procedures will be updated to reflect this process.
The Business Manager will review all the employee timesheets and contract pay and verify on the gross pay detail reports to authorize payroll prior to finalizing submission of payroll. Intern control procedures will be updated to reflect this process.
Strengthening Institutions Program – Department of Education Federal Financial Assistance Listing #84.031 P031A080196 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Section 3 of the Title III Endowment Report for the year ending June 30, 2...
Strengthening Institutions Program – Department of Education Federal Financial Assistance Listing #84.031 P031A080196 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Section 3 of the Title III Endowment Report for the year ending June 30, 2024, was completed materially incorrect for Type of Savings Account Security line items and Total Invested line item. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance Corrective Action Plan: Management will review their current process to ensure reporting requirements are met and amounts are materially correct. Anticipated Completion Date: Already complete – annual report for the year-ending June 30, 2025 has now been submitted with the correct amounts.
Recommendation: It is recommended that the City implement written policies and procedures over significant internal control areas. Action to be taken: We agree with the finding and are in the process of implementing written policies and procedures over significant internal control areas including fe...
Recommendation: It is recommended that the City implement written policies and procedures over significant internal control areas. Action to be taken: We agree with the finding and are in the process of implementing written policies and procedures over significant internal control areas including federal award programs.
Significant Deficiencies: Finding: 2025-002 Segregation of Duties Name of Contact Person: Wendy Duckett, Housing Director Corrective Action: The duties will be separated as much as possible and alternative controls will be used to compensate for lack of separation. The governing board will continue ...
Significant Deficiencies: Finding: 2025-002 Segregation of Duties Name of Contact Person: Wendy Duckett, Housing Director Corrective Action: The duties will be separated as much as possible and alternative controls will be used to compensate for lack of separation. The governing board will continue to approve and sign checks and periodically review the financial statements. Proposed Completion Date: The Board will implement the above procedure immediately. Findings and Questioned Costs - Major Federal Awards Programs Audit Finding: 2025-002 Segregation of Duties Same as above.
Management continues to monitor the situation to determine the cost/benefit to the District. Presently, management believes that the cost outwights the benefit to implement the particular safeguard.
Management continues to monitor the situation to determine the cost/benefit to the District. Presently, management believes that the cost outwights the benefit to implement the particular safeguard.
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. This was an unusual circumstance where a student was withdrawn from the college before they were awarded any federal aid. The director has put in place procedure...
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. This was an unusual circumstance where a student was withdrawn from the college before they were awarded any federal aid. The director has put in place procedures to review the eligibility for federal aid of any student who withdraws to determine whether a post withdrawal disbursement is appropriate. Anticipated Completion Date: January 1, 2026
We are reinforcing our invoice verification procedures which include specific instructions on how to enter invoices including invoices without unique numbers so that the accounting system will flag and prevent any future duplicate payments. The accounts payable staff will also receive a refresher tr...
We are reinforcing our invoice verification procedures which include specific instructions on how to enter invoices including invoices without unique numbers so that the accounting system will flag and prevent any future duplicate payments. The accounts payable staff will also receive a refresher training.
1. Correcting Plan The Council will implement an internal control policy to ensure that all reporting is filed timely. 2. Explanation of Disagreement with the Audit Findings There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Executive Director, Renae ...
1. Correcting Plan The Council will implement an internal control policy to ensure that all reporting is filed timely. 2. Explanation of Disagreement with the Audit Findings There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Executive Director, Renae Donaghue, is responsible for carrying out the corrective action plan. 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Executive Director will monitor completion of the CAP updates to the Board of Education, on an annual basis.
1. Correcting Plan Council will review and update internal control policies and procedures over cash disbursements. 2. Explanation of Disagreement with the Audit Findings There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Executive Director, Renae Don...
1. Correcting Plan Council will review and update internal control policies and procedures over cash disbursements. 2. Explanation of Disagreement with the Audit Findings There is essentially no disagreement with the finding. 3. Official Responsible for Insuring CAP The Executive Director, Renae Donaghue, is responsible for carrying out the corrective action plan. 4. Planned Completion Date for CAP Immediately. 5. Plan to Monitor Completion of CAP The Director will monitor completion of the CAP.
Corrective Action: The Finance Director will establish clear timelines for submitting and processing payment requests to prevent any discrepancies in cash requests or disbursements. Well-defined internal procedures, including submission deadlines and approval workflows, will ensure that funds are re...
Corrective Action: The Finance Director will establish clear timelines for submitting and processing payment requests to prevent any discrepancies in cash requests or disbursements. Well-defined internal procedures, including submission deadlines and approval workflows, will ensure that funds are requested, approved, and drawn down efficiently. Ongoing monitoring of pending requests, coupled with proactive communication among team members, will further support timely financial management and minimize any risks. Responsible Person: Director of Finance
Corrective Action: The Finance Director and Business Office will undergo additional training with Tyler Technologies, Michigan School Business Officials, and others to optimize financial processes and transaction processing. The team will adhere to the state business calendar for timely reconciliati...
Corrective Action: The Finance Director and Business Office will undergo additional training with Tyler Technologies, Michigan School Business Officials, and others to optimize financial processes and transaction processing. The team will adhere to the state business calendar for timely reconciliations, budget amendments, and internal control reviews. Responsible Person: Director of Finance
Corrective Action: The Business Office will implement enhanced internal control procedures to ensure that all expenditures are accurately allocated to the appropriate program account, function, and object code. As part of this process, the Director of Finance will perform regular comparisons of actu...
Corrective Action: The Business Office will implement enhanced internal control procedures to ensure that all expenditures are accurately allocated to the appropriate program account, function, and object code. As part of this process, the Director of Finance will perform regular comparisons of actual expenditures to budgeted amounts. This review will help identify potential misstatements, detect coding errors, and ensure that financial transactions are correctly recorded in accordance with state and district accounting requirements. Responsible Person: Director of Finance and Grant Managers
Action taken: The district is hiring an additional account clerk (N: Tonn) and the deputy treasurer (R. Heimer) will begin working with the treasurer (C. Meher) so that the treasurer can focus more closely on reporting and more of the duties of the business manager. Review of the final cost reports ...
Action taken: The district is hiring an additional account clerk (N: Tonn) and the deputy treasurer (R. Heimer) will begin working with the treasurer (C. Meher) so that the treasurer can focus more closely on reporting and more of the duties of the business manager. Review of the final cost reports is ongoing and the Comptroller's Office and/or Office of Grants Finance will be contacted once the internal audit is complete to make any necessary adjustments. This will be done by the treasurer, C. Meher. Anticipated completion date: will begin January 5, 2026 and continue throughout the school year
In June 2025, once the District became aware that our documentation practices using PowerSchool were not acceptable, the District created a withdrawal guidance document that outlines the proper practice to withdraw a student. The District also created a guardian withdrawal form to accurately capture...
In June 2025, once the District became aware that our documentation practices using PowerSchool were not acceptable, the District created a withdrawal guidance document that outlines the proper practice to withdraw a student. The District also created a guardian withdrawal form to accurately capture the withdrawal request, as well as a staff form to document all steps taken to determine the withdrawal when a guardian cannot be located. The District also runs reports to monitor student withdrawals and documentation to identify students who have not enrolled in another CA school. These corrective actions are managed by the Office Supervisors at the elementary and middle schools and by the Registrar at Arcadia High School.
District staff is aware of the student records requirement and will ensure this is accurate moving forward. In addition, a training has been provided to the staff at the schools to ensure they are also informed of this requirement.
District staff is aware of the student records requirement and will ensure this is accurate moving forward. In addition, a training has been provided to the staff at the schools to ensure they are also informed of this requirement.
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