Corrective Action Plans

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All grants are to be labeled as federal and non-federal when entered into the Chamber’s general ledger (Emily), and when grant documents are saved internally (Chamber Staff). Expenses associated with federal grants are to be coded and classed to those grants for accurate entry on the SEFA (Emily). T...
All grants are to be labeled as federal and non-federal when entered into the Chamber’s general ledger (Emily), and when grant documents are saved internally (Chamber Staff). Expenses associated with federal grants are to be coded and classed to those grants for accurate entry on the SEFA (Emily). The Executive Director (Tom) will be involved in the preparation of the SEFA to ensure only federal grant expenses are included, and that no expenses are omitted.
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority's size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
The Cutter Morning Star is deeply disappointed by the findings identified through the audit and review involving the former superintendent. The State Board determined that violations occurred involving district, state, and/or federal policies and laws, including failure to honestly report enrollment...
The Cutter Morning Star is deeply disappointed by the findings identified through the audit and review involving the former superintendent. The State Board determined that violations occurred involving district, state, and/or federal policies and laws, including failure to honestly report enrollment, misuse of public funds, and misuse of school property. These actions do not reflect the values, expectations, or standards of the district. The findings exposed the district to unnecessary risk and damaged the trust that the community places in its school leadership. The district remains committed to operating with integrity, transparency, accountability, and full compliance with all applicable laws and policies moving forward.
Finding – 2025-001 Reporting – Material Weakness in Internal controls over compliance, Material Non-Compliance Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: US Department of Treasury Corrective Action: Divi...
Finding – 2025-001 Reporting – Material Weakness in Internal controls over compliance, Material Non-Compliance Federal Program: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Year(s): 2025 Federal Agency: US Department of Treasury Corrective Action: Division will continue to enforce the policy where every grant is sent to the Finance Department for review/approval before the report is submitted to the granting agency(ies). This action will be facilitated and enforced by the Divisional Accounting Manager/Compliance Director. 1. Internal process to be continued throughout FY 2026. 2. The program directors will save a copy of all reporting to the regional internal digital file storage system, as well as send a copy of the finance department for review/approval/storage for audit purposes and the finance department will lastly make sure it is filled out and fulfills the requirement of the contract, as a last line of grant requirement fulfillment. 3. Continued training of field staff and program directors to occur. Anticipated Completion Date: 10/01/2026 Responsible Contact Person: Kendall Phillips, Grants & Contracts Accountant
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Control Procedures • Verify costs fall within grant period prior to posting Review Controls • Require supervisory approval Monitoring • Quarterly compliance testing
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting ...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Cost Allocation Plan • Implement formal allocation plan using drivers such as square footage and headcount Documentation • Maintain invoices, allocation worksheets, and supporting schedules Reconciliation • Perform quarterly true-ups between budget and actual Training • Train staff on allocation methodology and documentation Monitoring • Conduct periodic reviews and report results to management
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitorin...
Camillus House acknowledges the finding and has implemented and is continuing to enhance corrective actions as follows: Documentation • Maintain at least three comparable rent analyses Review • Require supervisory approval prior to lease execution Training • Train staff on HUD requirements Monitoring • Perform quarterly compliance reviews
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we wil...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we will perform a detailed review of all salaries charged to federal grants to ensure there is no salary over the cap. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules and/or enhance monitoring controls where possible. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and proce...
Type of Finding: Significant Deficiency in Internal Control Over Financial Reporting Criteria or Specific Requirement: County management should be aware if the need to have adequate policies and procedures in place for timely reimbursement requests for highway projects. Condition: Policies and procedures in place for timely reimbursement requests will ensure that the County is receiving funds it is owed. In addition, this will ensure there are no cash flow shortages and increase opportunities for investment earnings. Cause: The County had one highway project for which costs were incurred in October and November 2024, and the related reimbursement was submitted and approved in June 2025. Possible Effect: By submitting untimely reimbursement requests, the County is not receiving funds it is owed in a timely manner, which has the potential to cause cash flow shortages. Repeat Finding: No. Recommendation: We recommend County management review internal controls currently in place and design and implement procedures to request reimbursements in a timelier fashion and to submit requests for reimbursements on at least a quarterly basis. Views of Responsible Officials: There is no disagreement with the audit finding. The County will implement procedures to ensure timely submission of reimbursement requests. Anticipated Completion Date: December 31, 2026.
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: ...
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: We intend to include a section in all future agreements with the town to confirm that contractors/vendors acknowledge their suspension and debarment status. These agreements and contracts will be signed and approved by multiple Town officials. Anticipated Completion Date: This adjustment to agreements and contracts will go into effect April 24, 2026.
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with ...
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: Prior to the submission of the P&E report, a copy will be printed and reviewed by another individual from our office (Town Manager or Utility Office Manager), or a member of our Town Council and that individual will initial or sign off on the document after their review. Anticipated Completion Date: This procedure will go into effect on June 1, 2026.
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-03 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will...
Finding Reference Number: 2025-01 View of Responsible Official and Planned Corrective Action Date: Corrective Action: The Finance Director has created additional cost centers for specific federal awards within the financial management system. FY26 YTD expenditures related to the specific grants will be reviewed and re-allocated. All future expenditures for the specific grants will be coded at the time costs are incurred. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-05 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. l. The Organization will update and maintain a fom1al policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented r...
Finding Reference Number: 2025-02 View of Responsible Official and Planned Corrective Action Date: Corrective Action: Management recognizes the importance of maintaining current written policies and procedures, clearly defined job responsibilities, appropriate segregation of duties, and documented review controls over financial reporting. The Organization will take corrective action to strengthen internal control documentation, reduce reliance on informal processes, and ensure that information prepared by third-party service providers is reviewed and approved by management before use in quarterly reporting, annual reporting, the SEFA, and the financial statements. 1. The Organization will update and maintain a formal policies and procedures manual that documents key accounting, grant management, financial reporting, and SEFA preparation processes. The manual will identify responsible positions, required approvals, review procedures, supporting documentation requirements, and backup responsibilities. Management will also evaluate current duties and implement additional segregation of duties where practical. Where staffing limitations prevent full segregation, compensating review controls will be documented and performed by management. 2. Management will document the established review process for all quarterly and annual reports prepared by third-party service providers. This review will include reconciliation to internal accounting records, verification of significant assumptions and supporting schedules, and evidence of management approval prior to submission or inclusion in the financial statements. 3. Finance personnel will be cross-trained on critical accounting, grant reporting, and SEFA responsibilities to ensure continuity of operations if key employees are unavailable or leave the Organization. Name of Contact Person: Susan Phelps, Finance Director Projected Completion Date: September 30, 2026
WE WILL EVALUATE THIS AND ATTEMPT TO SEGRGATE DUTIES AS MUCH AS POSSIBLE.
WE WILL EVALUATE THIS AND ATTEMPT TO SEGRGATE DUTIES AS MUCH AS POSSIBLE.
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to incorrect participant meal coding and reimbursement classifications. Management has implemented the following corrective actions: 2 4 Provide refresher training to all staff responsible for determining and entering participant eligibility classifications. Develop written procedures outlining eligibility determination requirements and reimbursement coding standards. Conduct periodic internal audits of participant eligibility classifications to identify and correct errors timely. Maintain documentation of training attendance and ongoing monitoring activities. Responsible Party Sonja Williams and Site Coordinators Expected Completion Date September 30, 2026
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split betwee...
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split between grant and local projects can record their time to each funding source. This new process will be rolled out starting June 12, 2026.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with t...
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with their contract schedules and they self-report on a schedule-oriented tool. The CFSA team reviews, validates, and approves each and every invoice. The tool tracks invoiced cost for the entire fiscal year such that by year’s end there is a verified, validated catalogue of reported costs that are used to derive the family-based rate that drive the adjustment claims for these special tests and provisions.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Department of Human Services (DHS)/Economic Security Administration (ESA) agree with the auditor’s findings regarding the lack of completion of requests from the Child Support Enforcement (CSE) to the TANF program to impose a child support on parents who have not cooperated with Child Support co...
The Department of Human Services (DHS)/Economic Security Administration (ESA) agree with the auditor’s findings regarding the lack of completion of requests from the Child Support Enforcement (CSE) to the TANF program to impose a child support on parents who have not cooperated with Child Support compliance requirements. The incomplete work was due to staff transitions occurring during the review period which impacted the oversight and productivity of DHS – ESA staff working on the child support sanction process. The following corrective action plan has been developed by DHS/ESA to address the findings. These controls would provide DHS/ESA with the ability to identify discrepancies, promote accountability, and ensure that actions are carried out timely and accurately. The work will be performed by staff working in the Division of Customer, Workforce Employment and Training (DCWET). The DCWET leadership will: • Conduct training sessions for the newly assigned staff to ensure they understand the procedures and expectations to complete the required tasks. The training will also provide clarity about the procedures for imposing a child support sanction and lifting a child support sanction. The lack of clarity was caused by the sanction team’s staff turnover and inability to timely backfill vacancies due to budget constraints. A new staff has been assigned to the team, and OPM has updated the manual that contains the procedures for imposing and lifting child support sanctions. • Implement an internal digital tracking system to ensure completion of all required tasks in a timely and accurate manner. This will include a process to re-assign work when staff are on leave for two or more days. OPM is working with OIS to automate some of the manual processes while retaining the integrity of the process. OPM will collaborate with OIS to automate both the non -cooperation sanction imposition and lifting. OIS will create a digital tracking system that would lead to improvement in the supervision, tracking, and monitoring of staff daily activities and completion of assignments. • Increase supervision and monitoring of employees responsible for completing the requests from the Office of the Attorney General OAG by conducting scheduled follow-up reviews to monitor progress of work and provide guidance to staff, as needed. • Review the procedures document to ensure that the process of calculating sanctions and benefit amounts as well as the content of sanction letters are accurate and timely.
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income su...
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This would be automating the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. DCWET will work with DICM to request that a JIRA ticket be created to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The ESA DPO needs to conduct staff training (re-training) of all SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to providing adequate training to SSRs involved in updating customers’ employment information in DCAS. The DCWET Deputy Administrator will take the lead with the DPO counterpart to implement the necessary training starting before September 30, 2027.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: The Office of Financial Aid is implementing enhanced controls to strengthen the accuracy and timeliness of its Return of Title IV Fund...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. Management action plan includes the following steps: The Office of Financial Aid is implementing enhanced controls to strengthen the accuracy and timeliness of its Return of Title IV Funds (R2T4) processes. Moving forward, all official and unofficial R2T4 calculations will be subject to more comprehensive review, replacing the prior practice of reviewing a limited sample. To further support compliance and coordination, automated email notifications will be issued to designated staff responsible for both loan and Pell Grant reporting whenever an R2T4 is processed. This will ensure timely awareness and appropriate action by all relevant parties. In addition, staff calendars will be updated to include critical regulatory deadlines associated with the return of Title IV funds. These calendar controls are intended to reinforce adherence to federal requirements and promote consistency across all cases. These measures are designed to improve oversight, enhance internal controls, and ensure full compliance with federal Title IV regulations. The Office of Financial Aid acknowledges that elements of these controls had been previously identified and implemented; however, these processes will be further strengthened, formalized, and consistently applied to ensure full compliance with federal Title IV regulations.
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