Corrective Action Plans

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Betsy Rohde, CEO/Business Manager for the Colome School District, is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the district's business office. The size of the school district and the monetary resourc...
Betsy Rohde, CEO/Business Manager for the Colome School District, is the contact person responsible for the corrective action plan for this finding. This finding is due to the limited number of staff employed in the district's business office. The size of the school district and the monetary resources available prevent the hiring of additional staffing to the business office at the proper levels for internal controls. Planned Corrective Action Plan: The Colome School District has an internal controls policy to identify areas of risk and implements that policy to reduce the risk of any mistakes and inappropriate or illegal activity within the school district. The school board takes an active role in monitoring financials, including reviewing the bank statements, claims, and financial sofware reports each month. They may request any supporting documentation that is not already provided at school board meetings by meeting one on one with the CEO/Business Manager. The principal was added to email alerts of all bank transfers including payroll and ACH payments. This ensures an additional staff member is notified when the CEO/Business Manager makes financial transactions within the school district's bank accounts. The school board will review the policy to identify any areas that still leave a significant risk to ensure all financial activities are monitored by more than one individual. This is an ongoing process.
To enhance compliance and oversight, the Northeastern State University Grant Office has implemented a mandatory dualphase training protocol for all Principal Investigators (PIs). Starting Fiscal Year 2026, all PIs are required to complete an inital compliance training upon award initiation. Furtherm...
To enhance compliance and oversight, the Northeastern State University Grant Office has implemented a mandatory dualphase training protocol for all Principal Investigators (PIs). Starting Fiscal Year 2026, all PIs are required to complete an inital compliance training upon award initiation. Furthermore, to address findings regarding reporting timelines, the university will conduct annual refresher training for all PIs with active awards. This annual session will specifically emphasize regulatory requirements for the timely submission of technical and financial reports.
Corrective Action/Management Response: Ensuring that Adoption records are maintained accurately with all documented requirements. Changing Practice to include putting documents into the document management system (Traverse) in order to have a copy of required documents in the event originals are los...
Corrective Action/Management Response: Ensuring that Adoption records are maintained accurately with all documented requirements. Changing Practice to include putting documents into the document management system (Traverse) in order to have a copy of required documents in the event originals are lost, or documents are damaged due to flooding (which is what occurred in the basement where documents were housed). Cases that are more than 10 years old are typically going to be more difficult to locate needed items, due to records being maintained differently at that time and requirements were different in what the Department was required to maintain in an Adoption file. Proposed Completion Date: June 30, 2026 checking monthly to ensure paper files are scanned into Traverse.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
2025-001 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that required HQS are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
2025-001 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that required HQS are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: See narrative below. SC Housing’s inspection team strives to represent both the organization and HUD at the highest level. The HCV inspections team takes pride in being timely, professional, and thorough, as evidenced by the single finding noted in our most recent audit. SC Housing has taken several corrective steps to mitigate and prevent late inspections. First, we implemented modifications to our organizational structure. Late inspections resulted from the previous structure and business practices, which assigned staff to specific families and required them to oversee all HCV-related tasks for those families, including inspections. While this approach promoted continuity, it created challenges when staff were absent for extended periods, as there was no backup capacity to absorb the workload. As a result, SC Housing reorganized the HCV program to significantly reduce the likelihood of late HQS inspections. Inspections are now centralized as a primary function, and the inspection team has been restructured to be smaller, more flexible, and more responsive. Second, SC Housing has enhanced its monitoring processes. In addition to regularly pulling system-generated reports to identify inspections due, staff are now fully utilizing PIC reports to proactively identify families approaching the maximum 24-month inspection timeframe, thereby reducing the risk of late inspections. Lastly, staff leaves and absences are being managed more effectively to ensure adequate coverage at all times. This approach ensures that sufficient staffing is available to complete all inspection types timely and without delay. Name(s) of the contact person(s) responsible for corrective action: Lisa Wilkerson, Director of Rental Assistance and Compliance Lenzy Morris, HCV Inspections Manager Planned completion date for corrective action plan: Immediately and Ongoing If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Lisa Wilkerson at (803) 896-7030.
2025-002 Finding – Federal Funding Accountability and Transparency Act (FFATA)/Transparency Act Reporting (Timeliness) Federal Agency: U.S. Department of Health and Human Services (HHS) Program: Head Start Cluster – Assistance Listing 93.600 (Head Start) Compliance Requirement: Reporting (L) – FFATA...
2025-002 Finding – Federal Funding Accountability and Transparency Act (FFATA)/Transparency Act Reporting (Timeliness) Federal Agency: U.S. Department of Health and Human Services (HHS) Program: Head Start Cluster – Assistance Listing 93.600 (Head Start) Compliance Requirement: Reporting (L) – FFATA/Transparency Act Special Reporting Type of Finding: Compliance (no internal control deficiency) Finding Summary: Two first-tier subaward actions were submitted in SAM.gov after the required reporting timeframe. Based on the nature of the exceptions and the results of expanded procedures, the late submissions appear to be isolated to the period of the federal FSRS-to-SAM.gov transition rather than indicative of a systemic reporting breakdown. Management attributed the delays to federal system conversion issues, including access/role challenges, delayed training, and data migration/report rejection issues that required resolution with SAM.gov support. Accordingly, the noncompliance is limited to timeliness of transparency reporting (no questioned costs) and does not affect allowability of Head Start expenditures. Corrective Action Plan: Delays were primarily attributable to the federal transition from FSRS to SAM.gov, including access/role configuration challenges and system-related issues encountered during the conversion period. Reasonable and timely steps were taken to submit the required FFATA reports as soon as the federal system issues were resolved and to address any submission rejections or support requests as needed. Now that the filing of back logged reports is complete, we will continue with our existing FFATA reporting procedures. We will track contracts needing FFATA submission with an internal ticketing system to ensure that the filings are on time. We will retain appropriate documentation of submissions and related system communications to support compliance. We will submit said documentation to our business office as a secondary measure to ensure that the filing was done prior to processing said contract. Contact Person responsible for corrective action: Anthony Jordan, Division Director Anticipated completion date of Corrective Action Plan: This item is corrected as of 10/01/2025.
Material Weakness: 2025-001 Incomplete Year-End Closing Procedures: As stated in the findings the District did not complete its year end closing process for the fiscal year. Account reconciliations were incomplete, and financial statement accounts were not properly reconciled to detailed cost report...
Material Weakness: 2025-001 Incomplete Year-End Closing Procedures: As stated in the findings the District did not complete its year end closing process for the fiscal year. Account reconciliations were incomplete, and financial statement accounts were not properly reconciled to detailed cost reports. To rectify the material weakness moving forward, the District is actively advertising for an accountant position as an addition to the Business Department. Interviews are being scheduled, and the most qualified candidate will be recommended for hire by the Board of Directors. The accountant will be performing the reconciliations of all accounts prior to the close-out at year end. A spreadsheet detailing the reconciliations for all accounts will be implemented and utilized moving forward. This will become part of the close-out process prior to beginning the audit.
2025-001 Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing #s 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing we noted one student out of forty was disbursed the incorrect Direct Loan ...
2025-001 Incorrect Direct Loans Disbursement Amount - Student Financial Aid Cluster Assistance Listing #s 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2025 Condition Found During our student file testing we noted one student out of forty was disbursed the incorrect Direct Loan amount. Based on the student’s enrollment status and need this student was eligible for $586 in Subsidized Loans and $2,914 in Unsubsidized Loans; however, the College awarded the student $549 in Subsidized loans and $2,951 in Unsubsidized loans which resulted in an under award of $37 in Subsidized Loans and an over award of $37 in Unsubsidized Loans. We consider this error in awarding to be an instance of noncompliance of the Eligibility Compliance Requirement. Corrective Action Plan Waubonsee will ensure to add the loan fees first to ensure sub-loans are calculated correctly. Responsible Person for Corrective Action Plan Mary Greenwood Implementation Date of Corrective Action Plan 12/9/2025
FINDING SYNOPSIS - During the testing of payroll charged to the Title I program, it was noted that time and effort certifications were not completed or did not contain the proper approvals. ACTION STEPS - The District agrees with the findings and will implement procedures to make sure time and effor...
FINDING SYNOPSIS - During the testing of payroll charged to the Title I program, it was noted that time and effort certifications were not completed or did not contain the proper approvals. ACTION STEPS - The District agrees with the findings and will implement procedures to make sure time and effort documentation is properly documented. CONTACT PERSON - Larry Lovel, Superintendent ANTICIPATED COMPLETION DATE - December 31, 2025
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jessica Johnston, Chief Financial Officer Anticipated Completion Date: August 20, 2025, immediately following the determination that the number o...
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jessica Johnston, Chief Financial Officer Anticipated Completion Date: August 20, 2025, immediately following the determination that the number of meals reported for reimbursement for the January and March claims did not agree to supporting documentation. Planned Corrective Action: The District has modified its internal controls related to child nutrition claims. The revised procedures include a secondary verification of reimbursable meals, which is completed and submitted by personnel independent of the data entry process.
The City will (1) submit the required FFATA subaward reports for the five unreported tier one subawards, (2) implement a formal FFATA compliance checklist to be completed at the time of subaward execution, (3) designate responsible personnel for FSRS reporting with a documented secondary review, and...
The City will (1) submit the required FFATA subaward reports for the five unreported tier one subawards, (2) implement a formal FFATA compliance checklist to be completed at the time of subaward execution, (3) designate responsible personnel for FSRS reporting with a documented secondary review, and (4) provide training to applicable staff on FFATA reporting requirements and deadlines.
1) Draft policy issued to engineers from Deputy Director of Public Works, 2)finalize policy, and 3)follow procedure established to ensure certified payrolls are received and maintained on file.
1) Draft policy issued to engineers from Deputy Director of Public Works, 2)finalize policy, and 3)follow procedure established to ensure certified payrolls are received and maintained on file.
Condition: The County did not perform required on-site inspections of four out of six HOME-assisted properties evaluated during FY 2025, as mandated by 24 CFR §§ 92.209(i), 92.251(f), and 92.504(d). These inspections are required every one to three years, depending on the number of units per project...
Condition: The County did not perform required on-site inspections of four out of six HOME-assisted properties evaluated during FY 2025, as mandated by 24 CFR §§ 92.209(i), 92.251(f), and 92.504(d). These inspections are required every one to three years, depending on the number of units per project. Recommendation: Establish and maintain a formal inspection schedule with assigned accountability to ensure timely completion of all required HOME inspections. Implement tracking tools and cross-training to mitigate delays caused by staff turnover. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Planned in Response to Finding The County agrees with the finding and is implementing the following corrective actions to strengthen internal controls over HOME inspection compliance and ensure inspections are conducted in accordance with federal requirements. 1. Cross-Training of Inspection Staff Housing & Grants staff will conduct formal cross-training with inspectors from Environmental Health and/or the Marin Housing Authority by June 30, 2026. This training will cover HOME inspection requirements, including property standards, documentation expectations, and inspection frequency requirements. Cross-training will ensure sufficient technical expertise and backup coverage to perform and review HOME inspections in compliance with federal regulations and to maintain continuity during staffing changes.2. Implementation of Inspection Tracking Software The Community Development Agency will implement and utilize inspection tracking software by June 30, 2026 to track, schedule, and document HOME program inspections. The system will maintain inspection dates, inspection type (desk audit or physical), findings, corrective actions, and follow-up status. This tool will strengthen monitoring controls, provide management visibility, and help ensure inspections are conducted timely and consistently. 3. Conducting HOME Inspections in Accordance with HOME Regulations Housing & Grants staff will conduct HOME inspections in accordance with HOME program regulations by June 30, 2026, including both desk audits and physical inspections, as follows: • Desk Audits: Staff will review program documentation, tenant eligibility, income certifications, rent limits, and other compliance documentation using standardized desk audit procedures. • Physical Inspections: Physical property inspections will be performed in accordance with HOME property standards to assess health and safety compliance. • Monitoring and Documentation through JotForm Desk Audits: Desk audits will be documented using JotForm inspection and monitoring tools to ensure consistent documentation, clear audit trails, and management oversight of HOME compliance activities. 4. Formal Inspection Schedule and Ongoing Oversight The Community Development Agency has initiated development of a comprehensive HOME on-site inspection schedule that identifies all HOME-assisted properties, applicable inspection frequencies, and assigned staff responsibilities. The schedule will be maintained and reviewed at least quarterly by program management to ensure inspections are completed timely and any overdue inspections are promptly addressed. Responsible Officials • Leelee Thomas, Deputy Director, Community Development Agency Leelee.Thomas@marincounty.gov • Chris Miranda, Senior Program Coordinator, Community Development Agency Chris.Miranda@marincounty.gov Planned Completion Date All corrective actions described above are expected to be fully implemented by June 30, 2026.
NACAA has received and reviewed the draft audit report for fiscal year 2025 conducted November 25, 2025. We have provided our auditors DeLeon & Stang with a Management Response to include with the audit. This document will outline NACAA’s course of corrective action for those findings. Finding 1: Th...
NACAA has received and reviewed the draft audit report for fiscal year 2025 conducted November 25, 2025. We have provided our auditors DeLeon & Stang with a Management Response to include with the audit. This document will outline NACAA’s course of corrective action for those findings. Finding 1: The Organization charged indirect costs to the major federal program in excess of the amount permitted under its approved NICRA for the fiscal year ended September 20, 2020. In addition, amounts reported on the annual Federal Financial Report (FFR) to the federal funder were incorrect, reporting the wrong base and charged amounts. The amounts reported on the FFR did not match the actual indirect cost base and charges for fiscal year 2025. Background As noted in the audit finding, NACAA’s NICRA has historically been based on a salary and fringe benefits allocation base. During fiscal year 2025, NACAA experienced significant turnover of longtenured employees, resulting in a substantial decrease in salaries and wages and, accordingly, a reduction in the approved indirect cost rate. As a result, indirect costs were overcharged to the federal program by $96,196. The annual Federal Financial Report (FFR) submitted on November 6, 2025, was based on internal year-end reports not NACAA’s audited final numbers. The information reported as the indirect cost rates and amounts were taken from the NICRA applications for the FY24 final and FY25 provisional negotiated rates. Remediation In order to address these findings, NACAA has contacted its EPA Project Officer and Grant Specialist to discuss appropriate corrective action. We explained that NACAA is having trouble paying its overhead expenses using the current negotiated indirect cost rate of 16.84% due to the substantial changes in our staff since the rate was negotiated. NACAA’s 2025 provisional indirect costs rate was calculated based on a SWF amount of $1,306,688. At year end because of staff changes, NACAA’s 2025 SWF amount is only $950,264, which makes our base for calculating indirect costs $356,424 less than when the rate was set. The indirect cost limit based on the old SWF was $220,046, while it’s $160,024 based on the new. NACAA’s indirect costs for 2025 were $256,919. After speaking with EPA, NACAA met with its auditors and accountant to discuss corrective action. It was recommended that some of NACAA’s overhead costs that have traditionally been added to the indirect cost pool (professional fees, rent, office insurance, etc.) be charged as direct costs using NACAA’s grant-related salaries and fringe benefits to allocate expenses between direct and indirect costs. To correct the other issue related to the Federal Financial Report (FFR) errors, NACAA will work with its accountant to complete the required FFRs and other grant reports to ensure that all figures being reported at correct. Reclassifying Indirect Charges to Direct Cost Categories NACAA has contacted the EPA Grants Management team to determine if our anticipated corrective course of action would be acceptable to EPA. We have received concurrence by email that the suggestion made by NACAA’s Auditors that pro-rating costs using salary as a basis for allocating overhead charges as direct costs is reasonable. This method should be used to allocate all expenses that are “traditionally” allocated as indirect costs. NACAA is currently drafting a request to re-budget its 2026 expenses, allocating many of the expenses traditionally part of the indirect cost pool as direct expenses, pro-rating costs using salary as a basis for allocating overhead charges as direct costs. NACAA’s Project Officer needs to approve that request so an amendment can be made for the current year of NACAA’s two-year cooperative agreement. Accountability Once NACAA’s re-budgeting request has been approved, NACAA’s Operations Manager and Accountant will be responsible for ensuring that expenses are correctly allocated every month using salary as a basis for allocating overhead charges as direct costs. Please see a description of NACAA’s Time and Attendance System and Method of Fringe Benefit allocation. These will be used to determine the percentage of expenses that will be allocated as direct costs: Salaries and Wages: Time & Attendance System: NACAA’s staff complete detailed timesheets on the 15th and last day of each month. Personnel Time Allocation Policy: Traditionally, activities of the NACAA headquarters office fall into three categories: federal grant-related activities; non-grant related activities; and indirect functions. Fringe benefits are allocated into these three categories based on the number of hours worked in each. Non-grant related activities are funded by the NACAA treasury. A very modest amount of time is allocated as Indirect Salaries, Wages and Fringes. Indirect salaries are included in NACAA’s indirect cost pool. Fringe Benefits: Fringe Benefits for NACAA’s staff members include employer-paid share of payroll taxes, health, life and disability insurance and a retirement plan. NACAA allocates fringe benefits based on a fringe benefit rate and distributes them based on salaries and wages.
SEE REPONSE AND CORRECTIVE ACTION PLAN AT 2025-001.
SEE REPONSE AND CORRECTIVE ACTION PLAN AT 2025-001.
Condition The amount reported in the June 30, 2025 project and expenditure report for total expenditures was not able to be reconciled to the amounts expended in the Town’s general ledger. Corrective Action Plan The Town will implement procedures to ensure reports are based upon the Town’s general l...
Condition The amount reported in the June 30, 2025 project and expenditure report for total expenditures was not able to be reconciled to the amounts expended in the Town’s general ledger. Corrective Action Plan The Town will implement procedures to ensure reports are based upon the Town’s general ledger and properly reconciled and in compliance with U.S. Treasury guidelines. This is expected to be completed by June 30, 2026. The implementation process for the finding will be monitored by the Town’s Finance Director Adam Lawrence.
Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken: Effective February 9,...
Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken: Effective February 9, 2026, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale. -Update the frequency of our sliding fee scale employee training sessions -Implement monthly spot checks to ensure compliance to the sliding fee scale and provide timely feedback
Planned Corrective Action: Our payroll system provider corrected the backend setting to prevent employees from adjusting their timecards after they have been approved and locked. We reviewed and confirmed that the system is now functioning as intended to prevent similar issues in the future. We dedu...
Planned Corrective Action: Our payroll system provider corrected the backend setting to prevent employees from adjusting their timecards after they have been approved and locked. We reviewed and confirmed that the system is now functioning as intended to prevent similar issues in the future. We deducted the overage amount from the November 2025 invoice to reimburse the agency in full. Anticipated Completion Date 11/17/2025 & 12/31/2025. Responsible Contact Person: Katherine Page, Director of Finance
Upon notification of the reporting error, the institution corrected the enrollment status effective date in both the National Student Clearinghouse (NSC) and NSLDS to reflect the student's actual withdrawal date of November 15, 2024. To prevent future reporting errors, the Registrar's Office will im...
Upon notification of the reporting error, the institution corrected the enrollment status effective date in both the National Student Clearinghouse (NSC) and NSLDS to reflect the student's actual withdrawal date of November 15, 2024. To prevent future reporting errors, the Registrar's Office will implement an additional procedural verification step in the enrollment status reporting process. This step will include a review of effective dates prior to submission to NSC and NSLDS. The Registrar will also ensure appropriate staff training and oversight as process documentation is developed and implemented in the new student information system.
Action Taken: Management agrees with the recommendations and will have the business manager compare the support for the amounts reported to the District’s books and records prior to submission. Further, management will implement a review process to confirm the accuracy of the amounts reported, as we...
Action Taken: Management agrees with the recommendations and will have the business manager compare the support for the amounts reported to the District’s books and records prior to submission. Further, management will implement a review process to confirm the accuracy of the amounts reported, as well as maintain the supporting information. Proposed Completion Date: March 31, 2026
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to...
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to work to enhance our grant monitoring, including resuming management team meetings to keep everyone abreast of the status of grants. In addition, we will begin to gradually involve the new business office employee in grant reporting to improve on compliance with grant reporting requirements. Proposed Completion Date: June 30, 2026
Finding 2025-001 Special Tests and Provisions – Participation of Private School Children Finding Summary: The District failed to conduct timely consultations with private school officials regarding the implementation of the Stronger Connections Grant. Responsible Individuals: Dr. Farrah Gomez, Deput...
Finding 2025-001 Special Tests and Provisions – Participation of Private School Children Finding Summary: The District failed to conduct timely consultations with private school officials regarding the implementation of the Stronger Connections Grant. Responsible Individuals: Dr. Farrah Gomez, Deputy Superintendent of Academics and School Leadership Corrective Action Plan: The District will establish and implement written procedures to ensure annual consultation meetings with private school officials for all grants under the Title IV program. Additionally, the District will consult with TEA to determine next steps regarding the Stronger Connections Grant. Anticipated Completion Date: January 2026
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