Corrective Action Plans

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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.
2025-003 – Material Weakness and Material Noncompliance – Cash Management – Cash Request Recommendation We recommend that the organization implement and enforce policies and procedures, to ensure that all federal fund requests are supported by documented, allowable expenditures. Staff responsible fo...
2025-003 – Material Weakness and Material Noncompliance – Cash Management – Cash Request Recommendation We recommend that the organization implement and enforce policies and procedures, to ensure that all federal fund requests are supported by documented, allowable expenditures. Staff responsible for grant management should receive training in federal compliance requirements, and all reimbursement requests should be reviewed and approved by a qualified financial officer prior to submission. Action Taken CHASS management concurs with the audit findings and will put the following corrective action plan in place to mitigate this finding in the future: Implement separation of expenditures that are funded by grants will be recorded only related to that grant. Implementation of separating only revenue and expenditures to draw down grants will be reflected in general ledger for those grants. Implementation of grant 999 to reflect all other expenditures and revenues that are not covered by the grants. Staff will receive training in federal compliance requirements, and all reimbursement. Reconciliation of grants will be done at least once a quarter by grant clerk and will submit documentation of findings to CFO/ designated staff individuals. The CFO will only draw down funds when the general ledger supports the grant expenses. Monthly general ledgers will serve as backup documentation. CEO approval is required before any drawdown is completed. Responsible Parties: Feliz Valbuena, Chief Executive Office and Angela Salgado, Interim Chief Financial Officer
During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have be...
During the 2025 audit, the auditors discovered that a secondary review of eligibility determinations did not occur in a timely manner. The lack of internal control opened the possibility that an individual was incorrectly determined to be eligible to receive benefits and this error would not have been identified or corrected in a timely manner. Federal Regulations establish requirements for internal control over compliance with Federal program requirements. 2 CFR Section 200.303 requires non-Federal entities to establish and maintain effective internal control over Federal awards that provides reasonable assurance the entity is managing the award in compliance with Federal statutes, regulations, and the terms and conditions of the award. These requirements include the design, implementation, and operation of control activities to ensure compliance with applicable compliance requirements, including eligibility. As eligibility is a key compliance requirement identified in the OMB Compliance Supplement, the County is required to implement a review process and system of internal controls that allows management or employees, in the normal course of performing their assigned functions, to prevent, or detect and correct, errors or noncompliance in eligibility determinations on a timely basis. The Department of Human Services (DHS) has implemented a monthly review process to audit a random sample of the IV-E cases. The review includes verification of timely and accurate determinations, client information, supporting documentation, and system entries, with results documented and approved by the reviewer. DHS Division leadership will monitor compliance to ensure the reviews are conducted each month. DHS believes this additional review procedure will provide the needed internal controls over IV-E determination.
Finding #2025-006 14.225 CDBG – Endtitlement Grants Cluster B19ST660001, B20ST660001, B21ST660001, B22ST660001, B23ST660001, B24ST660001 Special Tests and Provisions - Rehabilitation Views of Responsible Officials and Planned Corrective Action Management’s Position: Management partially concurs with...
Finding #2025-006 14.225 CDBG – Endtitlement Grants Cluster B19ST660001, B20ST660001, B21ST660001, B22ST660001, B23ST660001, B24ST660001 Special Tests and Provisions - Rehabilitation Views of Responsible Officials and Planned Corrective Action Management’s Position: Management partially concurs with the finding. Management acknowledges that documentation can be strengthened. However, management does not concur that controls for project documentation and assigned personnel are absent. Explanation of Disagreement: Pre-rehabilitation inspections are conducted by GHURA engineering personnel for all proposed acquisitions. The assessment process requires multiple visits while personnel build the details to develop the scope of the necessary rehab work. These assessments lead to the work writeups to address identified deficiencies (safety, structural, electrical, plumbing, HVAC, lead, radon, etcetera). Senior engineering personnel oversee this process from initial assessment to final writeup. Corrective Actions: Management will reassess current procedures and documentation of pre-rehab condition. This will include inclusion of a periodic review of these procedures. The purpose of this assessment is to augment compliance with rehab requirements and coordination between key divisions responsible for activity completion. The A&E Division will remain responsible for the rehabilitation of CDBG-funded activities and to maintain appropriate documentation. The RPE Division will remain responsible for coordinating and ensuring compliance with CDBG requirements for the rehabilitation of funded activities and to maintain appropriate documentation. Responsible Party: Katherine Taitano, Chief Planner Anticipated Date of Completion: The enhanced documentation procedures will be implemented by or before the beginning of the next program year cycle.
Contact Person: Eric A. Naguski, District Manager. Recommendation: The District should establishe procedures to ensure reports are reviewed and approved prior to submission in the state's GIS system. Action: The Financial Coordinator will prepare the quarterly report and related supporting documenta...
Contact Person: Eric A. Naguski, District Manager. Recommendation: The District should establishe procedures to ensure reports are reviewed and approved prior to submission in the state's GIS system. Action: The Financial Coordinator will prepare the quarterly report and related supporting documentation and enter the data into the state's GIS system. A draft of the quarterly GIS report and supporting documentation will be fowarded to the District Manager for review and approval. The manager approved report will be submitted in the state's GIS system by the Financial Coordinator for final review and approval by the state. Date for Completion: June 16, 2026.
SEE RESPONSE AND CORRECTIVE ACTION PLAN AT 2025-001
SEE RESPONSE AND CORRECTIVE ACTION PLAN AT 2025-001
The County will develop procedures to ensure that required federal reports will be reviewed and approved by an independent person who is knowledgeable about the program. Indpendent review will be documented.
The County will develop procedures to ensure that required federal reports will be reviewed and approved by an independent person who is knowledgeable about the program. Indpendent review will be documented.
The District acknowledges this finding. Due to the limited number of administrative and business office personnel, complete segregation of duties is not always feasible. District administration continually evaluates internal control procedures and has implemented compensating controls to reduce the ...
The District acknowledges this finding. Due to the limited number of administrative and business office personnel, complete segregation of duties is not always feasible. District administration continually evaluates internal control procedures and has implemented compensating controls to reduce the risks associated with limited segregation of duties. As an additional compensating control, the Board of Directors receives and reviews a monthly internal control report that includes receipts, journal entries, manual journal entries, paid claims, and employee absence data. The Board reviews this information and documents its review through a formal sign-off process. In addition, the Board approves claims, reviews monthly financial reports, and monitors budget activity throughout the year. The District will continue to evaluate internal control procedures and implement additional compensating controls when practical to strengthen oversight and reduce the risk of errors or irregularities.
The Organization will review its procedures for preparing and submitting reports under federal loan programs and put proper supervision controls in place.
The Organization will review its procedures for preparing and submitting reports under federal loan programs and put proper supervision controls in place.
Corrective Action Plan The County Board will continue to review all claims provided to them. Anticipated Completion Date The County is not in a financial position to hire additional employees. The increased monitoring will begin December 1, 2025. Responsible Parties Mark Menn, County Board Chairman ...
Corrective Action Plan The County Board will continue to review all claims provided to them. Anticipated Completion Date The County is not in a financial position to hire additional employees. The increased monitoring will begin December 1, 2025. Responsible Parties Mark Menn, County Board Chairman 500 Main Street, P.O. Box 248 Carthage, Illinois 62321 (217) 357-3986 Kris Pilkington, County Treasurer 500 Main Street, P.O. Box 248 Carthage, Illinois 62321 (217) 357-3986 Holly Wilde-Tillman, County Clerk 500 Main Street, P.O. Box 248 Carthage, Illinois 62321 (217) 357-3911
Corrective Action Plan: The Organization concurs with this finding and has implemented enhanced internal controls to ensure all timesheets charged to federal awards are properly reviewed and approved in accordance with policy; specifically, The Organization has established a requirement that all tim...
Corrective Action Plan: The Organization concurs with this finding and has implemented enhanced internal controls to ensure all timesheets charged to federal awards are properly reviewed and approved in accordance with policy; specifically, The Organization has established a requirement that all timecards must be reviewed and approved no later than the fifth day following each pay date, supported by monitoring procedures to track completion and identify any exceptions, and has also implemented a formal delegation protocol requiring supervisors to designate an alternate qualified approver when they are unavailable to ensure approvals occur timely and consistently. Person responsible for corrective action: Tamara Robinson Crayton - Controller Anticipated Completion Date: Initial implementation is in place by June 2026.
FINDING 2025-002 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Gloria Alumbaugh Contact Phone Number and Email Address: 812-591-3500 and townofwestport@comcast.net Views of Responsible Officials: We concur with t...
FINDING 2025-002 Finding Subject: Water and Waste Disposal Systems for Rural Communities - Reporting Contact Person Responsible for Corrective Action: Gloria Alumbaugh Contact Phone Number and Email Address: 812-591-3500 and townofwestport@comcast.net Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Clerk Treasurer will ensure that a review process is in place when completing the RD442-2 (Statement of Budget, Income and Equity) and the RD442-3 (Balance Sheet) for the annual USDA reports. The Clerk Treasurer will complete the RD442-2 and RD442-3 forms with working papers and reports to support the information reported on the forms. Then the Deputy Clerk will review the working papers and reports to verify the same results reported on the forms, before signing off on approval of the form, ensuring two signatures are included on the official forms before submittal to USDA each year. Anticipated Completion Date: The next annual USDA reports will be completed by March 1, 2027. INDIANA STATE
We are aware of the condition and will review procedures to make changes when appropriate and cost effective.
We are aware of the condition and will review procedures to make changes when appropriate and cost effective.
Views of Responsible Officials and Planned Corrective Actions Centre Care acknowledges the 2024 Uniform Guidance Audit report was submitted late to the Federal Audit Clearinghouse. Centre Care was in the process of negotiating with the USDA related to another loan agreement and financial statements ...
Views of Responsible Officials and Planned Corrective Actions Centre Care acknowledges the 2024 Uniform Guidance Audit report was submitted late to the Federal Audit Clearinghouse. Centre Care was in the process of negotiating with the USDA related to another loan agreement and financial statements were reissued to alleviate the going concern impacting the timing of reporting. In addition, our consulting team (CHR) incurred transition within the accounting team and as a result the reporting deadline was not communicated to the new team, and the reporting deadline was missed. Corrective Action Plan: Centre Care already remedied this issue in 2026 by submitting the reporting package and data collection form for the year ended December 31, 2024, and the data collection form process has been started for the December 31, 2025, audit and will be submitted upon finalizing the audit report in accordance with Uniform Guidance requirements.
Management agrees with the finding and acknowledges that documentation of timesheet and payroll reviews was not consistently retained during the audit period. Management notes that this finding relates primarily to the documentation and consistency of review controls rather than an indication that r...
Management agrees with the finding and acknowledges that documentation of timesheet and payroll reviews was not consistently retained during the audit period. Management notes that this finding relates primarily to the documentation and consistency of review controls rather than an indication that reviews were not performed. To address this finding, management has implemented a formal, documented review process for timesheets and payroll prior to disbursement. Timesheets will be reviewed and approved through a centralized system or documented workflow to ensure that evidence of supervisory review is retained. Payroll changes require CEO approval prior to or concurrent with processing and documentation retained. Each payroll is subject to independent review and confirmation. Cumulative payroll and allocation are further subject to independent quarterly review by the CEO with supporting documentation. These procedures will be incorporated into standard operating practices and monitored periodically to ensure consistent application and retention of audit evidence. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026. Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations
Management agrees with the finding and acknowledges that documentation supporting review, approval, and segregation of duties for certain nonpayroll transactions was not consistently maintained during the audit period. To address this finding, management has formalized procedures requiring documente...
Management agrees with the finding and acknowledges that documentation supporting review, approval, and segregation of duties for certain nonpayroll transactions was not consistently maintained during the audit period. To address this finding, management has formalized procedures requiring documented approval of invoices and nonpayroll expenditures prior to payment. These procedures require a clear separation between the individual requesting or managing a transaction and the individual approving the invoice or payment. Management has also implemented standardized approval workflows to strengthen segregation of duties, enforce approval requirements, and maintain a complete audit trail. Management will incorporate these procedures into formal policies and standard operating procedures and will periodically monitor compliance to ensure controls are consistently applied across programs. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026 Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations
Management agrees with the finding and acknowledges that procurement approval documentation was not consistently retained during the audit period. Management notes that the finding primarily relates to documentation and retention of approval evidence, including reliance on verbal approvals and docum...
Management agrees with the finding and acknowledges that procurement approval documentation was not consistently retained during the audit period. Management notes that the finding primarily relates to documentation and retention of approval evidence, including reliance on verbal approvals and documentation gaps associated with system transitions. To address this finding, management has implemented corrective actions requiring documented, written approval for procurements prior to execution. The organization will use standardized approval workflows to ensure procurement approvals are properly evidenced, retained, and available for audit review. Management has also established a centralized repository for procurement records to improve accessibility, consistency, and document retention. In addition, management will enhance data backup and migration procedures to reduce the risk of documentation loss during future system transitions. These procedures will be incorporated into formal policies and standard operating procedures. Management will monitor compliance to ensure procurement documentation and approval controls are consistently followed across federally funded programs. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026. Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations
Finding No. 2025-005 – Late filing of data collection form and reporting package Condition The Authority did not submit the required data collection form and reporting package within the required period by March 31, 2026 (9 months after the end of fiscal year). Views of Responsible Officials and Cor...
Finding No. 2025-005 – Late filing of data collection form and reporting package Condition The Authority did not submit the required data collection form and reporting package within the required period by March 31, 2026 (9 months after the end of fiscal year). Views of Responsible Officials and Corrective Actions The Federal Funds Management Office (FFMO) is aware of the deadlines for filing the data collection form and the reporting package, however, as indicated in previous year’s audits, the completion of the required information continues out of their control. In addition, to having difficulties with its monthly accounting closings due to personnel limitations in the Accounting Office, the implementation of new accounting standards, such as GASBs No. 73, N0. 75, No. 87 and others have been additional obstacles to achieve our objective to file the data collection form and reporting package timely. Accordingly, it has not been possible to complete the audit of the financial statements and the single audits for various fiscal years on time, nor to file the data collection form and the reporting packages. In August 2025 and January 2026, the audited financial statements for 2024 and 2025, respectively were issued. Also, the Authority’s management expects to issue the 2026 financial statements during December 2026. Management will continue emphasizing to the FFMO that reports need to be submi􀄴ed on a timely basis. Management will do its best to procure additional personnel for the Accounting and Federal Funds Management Offices. Once a final catch-up of the timely issuance of the audited financial statements is achieved, the required information will be filed within the timeframe established by federal regulations. Name(s) of the Contact Person(s) Responsible for Corrective Action Romel Pedraza Claudio. P.E. – Assistant Executive Director for Planning & Engineering Luis R. Torres Meléndez – Federal Funds Area Officer José Mojica Bonet – Federal Funds Area Officer Anticipated Completion Date Once the Authority catches up with the financial statements’ issuance, the data collection form and reporting package will be filed timely.
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