Corrective Action Plans

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Finding Number: 2025-009 Finding: The Department of Social and Health Services did not have adequate internal controls over financial reporting for the Summer Electronic Benefits Transfer Program for Children. Program: 10.646 – Summer Electronic Benefits Transfer Program for Children Compliance Requ...
Finding Number: 2025-009 Finding: The Department of Social and Health Services did not have adequate internal controls over financial reporting for the Summer Electronic Benefits Transfer Program for Children. Program: 10.646 – Summer Electronic Benefits Transfer Program for Children Compliance Requirement: Reporting Questioned Costs: $0 Status: Corrective action in progress Corrective Action: The Department concurs with the finding. For the two reports that the auditors determined lacked secondary review and approval, the Department maintains that both instances were anomalies that occurred during a staffing transition within the Division of Finance and Financial Resources. The reports were complete, accurate, and submitted timely. To strengthen internal controls over financial reporting, the Department will: • Update federal reporting procedures to designate a backup reviewer and approver. • Communicate the expectations in the updated procedures and provide training to the designated backup reviewer and approver. Prior Findings: None Completion Date: Estimated April 2026 Agency Contact: Richard Meyer External Audit Compliance Manager Richard.Meyer@dshs.wa.gov
During the year a new timesheet template was created. There were a couple of instances during the initial implementation of this new spreadsheet where timesheets did not agree to the template. We believe that this inconsistency has since been addressed.
During the year a new timesheet template was created. There were a couple of instances during the initial implementation of this new spreadsheet where timesheets did not agree to the template. We believe that this inconsistency has since been addressed.
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: In order to rectify the finding related to the reporting of the meal claims, Brown County CUSD ...
Condition: The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan: In order to rectify the finding related to the reporting of the meal claims, Brown County CUSD #1 will provide an independent review of the Accuclaim records and the meal claim with a signature indicating approval. The person best suited to provide an approval signature is the superintendent of the district. Management Response: The superintendent agrees with the finding and will perform and document the review as stated in the corrective action plan.
Management response Finding 2025-001 – Allowability and Period of Performance (Material Weakness) View of Responsible Official: Management concurs with the finding. During the audit period, controls over payroll documentation for FEMA-related labor costs were not sufficiently designed and documented...
Management response Finding 2025-001 – Allowability and Period of Performance (Material Weakness) View of Responsible Official: Management concurs with the finding. During the audit period, controls over payroll documentation for FEMA-related labor costs were not sufficiently designed and documented to demonstrate independent supervisory review and approval of timecards, nor were controls in place to evidence review of wage rates for reasonableness prior to charging labor costs to the award. Management has strengthened its control procedures. Supervisors are required to review and approve employee timecards each pay period in UKG, and compliance with timecard approval is monitored through exception reporting provided to management. In addition, management has implemented a review control over wage rates charged to FEMA claims to verify that rates used are supported and reasonable in accordance with applicable Uniform Guidance requirements and internal policy. These controls will be documented and retained as part of the support for future federal award reporting. Responsible Parties: Payroll Manager, Director of Finance, Vice President of Finance Anticipated Completion Date: Complete
Community Services Block Grant (ALN 93.569) U.S. Department of Health and Human Services State of Vermont Department for Children and Families Finding 2025-002 Compliance Finding - Special Tests and Provisions Corrective Action Plan Board Composition Matrix In response to the audit comment concernin...
Community Services Block Grant (ALN 93.569) U.S. Department of Health and Human Services State of Vermont Department for Children and Families Finding 2025-002 Compliance Finding - Special Tests and Provisions Corrective Action Plan Board Composition Matrix In response to the audit comment concerning the need for a Board Composition Matrix, we reviewed our current Board Roster. This review indicates our Roster meets the requirements listed (sector designation, term start and end dates, public official designation expiration, as applicable, and vacancy status). The board is sent an updated roster upon request. and it is updated each time a board member and/or seat is changed. The Board Development and Governance Committee reviews this most of the months that they meet, especially when discussing board recruitment, which is an ongoing agenda item while a seat is vacant. Current Procedure Currently, the Board Chair (Abby White) and Governance Committee Chair (Karen Lowry Reed) are both regularly consulted about board vacancies by the Executive Director (Alison Calderara), both to commit to outreach, and to review current candidates for the board. The Board Bylaws currently reference that the Board Development & Governance Committee is responsible for "[filling] any vacancies on the Board as soon as reasonably Possible." Additionally, all Board members sign an acknowledgement of the Bylaws annually, which reference the board composition. Recruitment is the responsibility of the Development and Governance Committee. Proposed Update of Procedure With the assistance of associated staff, the Development & Governance Committee will create a procedure to follow when vacancies arise, that covers unforeseen vacancies, as well as planned ones (such as when a board member's term limit is approaching). This will also include reference for different sectors, each of which have slightly different requirements for coming on the board. Capstone will complete this written procedure within 90 days. Current Status The Board seat that resulted in the organizational standard finding was filled November 2025. Three of the four required public sector seats are now filled. Responsible Person: Alison Calderara Date of Completion: June 28, 2026
Weatherization Assistance Program (ALN 81.042) Low-Income Home Energy Assistance (ALN 93.568) U.S. Department of Energy U.S. Department of Health and Human Services State of Vermont Agency of Human Services Finding 2025-001 Compliance Finding - Special Tests and Provisions Material Weakness in Inter...
Weatherization Assistance Program (ALN 81.042) Low-Income Home Energy Assistance (ALN 93.568) U.S. Department of Energy U.S. Department of Health and Human Services State of Vermont Agency of Human Services Finding 2025-001 Compliance Finding - Special Tests and Provisions Material Weakness in Internal Control Over Compliance Views of Responsible Officials Management acknowledges the deficiency identified in the Quality Control Inspection (QCI) process. While questioned costs were not identified, we recognize that the breakdown in controls represents a material weakness requiring immediate and sustained corrective action. Since the Office of Economic Opportunity (OEO) monitoring review, the Organization has undergone structural and cultural changes within the Weatherization Department. Leadership has taken decisive steps to reinforce compliance expectations, supervisory accountability, and documentation integrity. Corrective Action Plan 1. Immediate Structural Oversight Enhancement • Will Eberle (Weatherization Director) is designated as the primary responsible official for QCI program compliance. • Scott Hall (Weatherization Associate Director and Quality Control Lead) is responsible for direct oversight of all QCI staff and inspection standards. • Chris Locarno (Business Manager) will provide executive-level oversight and ensure crossdepartmental accountability and reporting to senior leadership and the Board. Effective immediately: • No weatherization unit may be reported or invoiced until: o QCI documentation is fully complete, o All required test results (blower door, combustion safety, final inspection) are included, o Client signature is present, o Secondary supervisory review is completed. 2. Secondary File Review Control A new Two-Tier Review Process has been implemented: Tier 1 - QCI Review (Performed by Certified BPI QCI) • Full compliance with Vermont Weatherization Program Standards • Documentation of all required final tests • Verification that QCI was not performed by supervising crew members or project participant Tier 2 - Supervisory File Review • Conducted by Scott Hall • Random sampling at minimum 25% of completed units monthly • Monthly summary report submitted to Will Eberle • Quarterly compliance summary reviewed with Chris Locarno No unit will be considered production-complete until Tier 2 review confirms documentation sufficiency. 3. Mandatory QCI Refresher Training • All QC I-certified staff will complete refresher training on: o DOE and HHS requirements o Vermont Weatherization Program Standards o Documentation standards o Independence requirements • Training will occur semi-annually at minimum. • Scott Hall will document attendance and maintain training logs. • Chris Locarno will verify annual compliance training completion as part of management review. Additionally, peer case reviews will be incorporated quarterly to reinforce quality standards. 4. Cultural and Performance Accountability • QCI compliance metrics will be incorporated into staff performance evaluations. • Repeated documentation failures will result in retraining or removal of QCI approval authority. • Monthly compliance meetings led by Scott Hall will include trend review and corrective tracking. 5. Monitoring & Reporting Timeline Action Two-tier review implemented, Will Eberle, Completed Refresher training session, Scott Hall, Within 60 Days Executive compliance review structure , Chris Locarno, Completed Quarterly internal audit sampling, Scott Hall / Will Eberle, Ongoing Responsible Person: Scott Hall Date of Completion: April 1, 2026
The District will add in another level of review to ensure that meals reported to DEW agree to the point-of-sale system CN-6 and CN-7 reports.
The District will add in another level of review to ensure that meals reported to DEW agree to the point-of-sale system CN-6 and CN-7 reports.
The District will ensure that proper semi-annual certifications or other time and effort documentation are prepared timely and properly maintained.
The District will ensure that proper semi-annual certifications or other time and effort documentation are prepared timely and properly maintained.
Elk City Public Schools will ensure that on all future construction contracts that deal with federal awards, requirements of the Davis-Bacon Act will be included. Prevailing wages will be inserted into the language of the contract and shall be signed by contractors and subcontractors. All contracts ...
Elk City Public Schools will ensure that on all future construction contracts that deal with federal awards, requirements of the Davis-Bacon Act will be included. Prevailing wages will be inserted into the language of the contract and shall be signed by contractors and subcontractors. All contracts will also spell out weekly reporting requirements of certified wages paid by contractors and subcontrators. In addition, ECPS will ensure that Davis-Bacon information is posted at all job sites. These policy changes will be implemented immediately and be in place as of October 9, 2025.
The Finance Department has implemented an additional Accounts Payable control requiring departments to verify the invoice date and provide written justification for any invoices submitted to Finance more than ninety days after the invoice date. This additional step strengthens internal controls and ...
The Finance Department has implemented an additional Accounts Payable control requiring departments to verify the invoice date and provide written justification for any invoices submitted to Finance more than ninety days after the invoice date. This additional step strengthens internal controls and helps ensure timely invoice processing and payment.
Management Response and Corrective Action Plan City’s Response: The City concurs with the recommendation. Corrective Action Plan: The City’s finance department has taken over reporting duties and has ensured all reporting related to CSLFRF is done on a timely basis. Planned Implementation Date: Reso...
Management Response and Corrective Action Plan City’s Response: The City concurs with the recommendation. Corrective Action Plan: The City’s finance department has taken over reporting duties and has ensured all reporting related to CSLFRF is done on a timely basis. Planned Implementation Date: Resolved, implemented in December of 2024. Responsible Person: Director of Finance
Responsible Executive: CEO – Carmela Slivinski Implementation Status: Effective Immediately Full Implementation Date: No later than June 30, 2026 Finding — Compliance (Period of Performance) Significant Deficiency Condition: Auditor noted while testing period of performance, 1 of the 10 expenses rec...
Responsible Executive: CEO – Carmela Slivinski Implementation Status: Effective Immediately Full Implementation Date: No later than June 30, 2026 Finding — Compliance (Period of Performance) Significant Deficiency Condition: Auditor noted while testing period of performance, 1 of the 10 expenses recorded in June 2025 pertained to subsequent months outside of the contract period. Effect: One expense was included in the expenditure report under the incorrect grant period ending June 30, 2025. Cause: The Organization noted that this finding came about due to a clerical error. The bookkeeper inadvertently recorded a July invoice on June 30th and this led to an incorrect charge to the grant period ending June 30th. Recommendation: Auditor recommends management continue to perform a second review on the grant submission especially towards the end of the grant period. Management’s Response: Management concurs with the finding regarding deficiencies in grant period-of-performance compliance. Corrective Action Plan - Review existing Accounts Payable and Accounting Controls processes and revise as needed to ensure expenses are recorded as required. - Staff Training and Competency Development conducted annually to review accounting controls and ensure accounting personnel understand period of performance grant compliance requirements. - Ongoing Monitoring and Internal Compliance Review conducted periodically to ensure oversight of financial controls and grant compliance.
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of do...
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of documentation supporting grant deliverables and required progress reports. The procedures will include, at a minimum, the following: • Define required documentation, storage location, staff responsibilities, and retention requirements. • Require all supporting documentation to be maintained in a designated centralized repository and ensure documentation is complete, organized, and readily accessible for review. • Detail the steps during staff transitions that new staff must follow to access, maintain, and update grant-related documentation, ensuring consistency and completeness of records. VPDCP will perform periodic reviews of the centralized repository and formally document and sign-off on the reviews to verify that required documentation is maintained. 3. Anticipated implementation date: June 19, 2026
Identifying Number: 2025-001 Finding: The Coalition erroneously identified certain federal grants as state funded grants on the Schedules. Contact Person Responsible for Corrective Action: Nicole Morella, Co-Executive Director and Adreinne Gantz, Co-Executive Director Corrective Action Planned: The ...
Identifying Number: 2025-001 Finding: The Coalition erroneously identified certain federal grants as state funded grants on the Schedules. Contact Person Responsible for Corrective Action: Nicole Morella, Co-Executive Director and Adreinne Gantz, Co-Executive Director Corrective Action Planned: The Coalition acknowledges past issues with properly separating federal and state grant funds. As of July 1, 2025, the Coalition began fully segregating overlapping grants in its accounting system to ensure accurate allocation and monitoring, including separating FY26 RPE federal and state funds. The Coalition will thoroughly review each award’s conditions and funding streams to ensure all funds are correctly classified in the general ledger and monitored throughout the grant by all staff involved in the implementation, monitoring and reporting on the grant. Before year-end, the Coalition will review all received funds to ensure they are accurately reported in the Schedules. Anticipated Completion Date: June 30, 2026.
Condition: The Organization paid out management fees in excess of allowable amount per the Management Agent’s Certification agreement. Planned Corrective Action: The excess management fees will be reversed out of the Corporation for the year ended December 31, 2026, thus adjusting the fees to the al...
Condition: The Organization paid out management fees in excess of allowable amount per the Management Agent’s Certification agreement. Planned Corrective Action: The excess management fees will be reversed out of the Corporation for the year ended December 31, 2026, thus adjusting the fees to the allowable amount. Management acknowledges noncompliance in the current year and is currently reviewing internal controls related to management fees going forward. Contact person responsible for corrective action: Michael McMillan, Director of Finance / President Anticipated Completion Date: 12/31/2026
Finding 1191734 (2025-003)
Material Weakness 2025
Finding 2025-003 Significant Deficiency Medical Billing Revenue Recognition Internal Controls Finding Summary: Regular reconciliation between the medical billing system and the accounting system was not conducted throughout the year, leading to a significant discrepancy between the end of year trail...
Finding 2025-003 Significant Deficiency Medical Billing Revenue Recognition Internal Controls Finding Summary: Regular reconciliation between the medical billing system and the accounting system was not conducted throughout the year, leading to a significant discrepancy between the end of year trail balance and the billing software report. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We are developing formal procedures to include monthly reconciliation between accounting and billing systems. Anticipated Completion Date: March 31, 2026
Finding 1191716 (2025-002)
Material Weakness 2025
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting ...
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting workpapers. Therefore, the CECL adjustment was not recorded at the beginning of the audit and required multiple attempts before a reasonable estimate was determined and recorded. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We will capture detailed documentation of the CECL calculation process, including training and detailed written procedures. Anticipated Completion Date: January 1, 2026
Finding 1191698 (2025-001)
Material Weakness 2025
Finding 2025-001 Material Weakness Limited Segregation of Duties Over Cash Receipts Finding Summary: The person responsible for opening the mail, preparing the deposit summary, and depositing funds was granted full access to the accounting software, including the ability to enter, modify, and delete...
Finding 2025-001 Material Weakness Limited Segregation of Duties Over Cash Receipts Finding Summary: The person responsible for opening the mail, preparing the deposit summary, and depositing funds was granted full access to the accounting software, including the ability to enter, modify, and delete transactions. While it is not this person’s responsibility to record deposits in the accounting system, they have the ability to do so. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: Our process has been updated to ensure the person opening mail, preparing the deposit summary, and depositing funds do not have access to the accounting software. Anticipated Completion Date: January 1, 2026
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and document...
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and documenting submission. Management expects these procedures to be implemented beginning in the next reporting cycle. Management has subsequently completed and submitted all of the required performance reports to remedy the identified deficiency.
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvement...
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2026
Finding: 2025-001 Reimbursable federal grant revenue Responsible Person: Cecilia Frerotte Title: Contract CFO Phone Number: 617-261-8186 Anticipated Completion Date: June 30, 2026 Corrective Action: Management will enhance grant review and reconciliation procedures to ensure that reimbursable expend...
Finding: 2025-001 Reimbursable federal grant revenue Responsible Person: Cecilia Frerotte Title: Contract CFO Phone Number: 617-261-8186 Anticipated Completion Date: June 30, 2026 Corrective Action: Management will enhance grant review and reconciliation procedures to ensure that reimbursable expenditures incurred under cost-reimbursement grants are properly recognized as contribution revenue and federal expenditures in the appropriate period. These procedures will include a grant-by-grant reconciliation of reimbursement requests, refundable advances, award terms, general ledger balances, amounts reported on the Schedule of Expenditures of Federal Awards (SEFA) and amounts reported in all other grant-related compliance reports, as applicable. Management will also formalize and expand supervisory review and approval controls over all grant compliance reporting and year end financial reporting, including the SEFA. In addition, the Board plans to increase the size of the Audit Committee to include members with substantial experience in auditing and grant program oversight. The Audit Committee will meet regularly with both the external auditors and the outsourced accounting firm to provide enhanced governance and oversight of grant accounting and compliance matters.
Contact Person – Sue Chase, Superintendent Corrective Action Plan – The District should implement policies and procedures to ensure only allowable activities/costs are being charged against grants. Completion Date – March 31, 2026
Contact Person – Sue Chase, Superintendent Corrective Action Plan – The District should implement policies and procedures to ensure only allowable activities/costs are being charged against grants. Completion Date – March 31, 2026
Finding 2025-003: Material Weakness in Internal Control over Compliance and Noncompliance – Eligibility Program: 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: To address the identified material weakness and ensure future compliance with SSG Fox S...
Finding 2025-003: Material Weakness in Internal Control over Compliance and Noncompliance – Eligibility Program: 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: To address the identified material weakness and ensure future compliance with SSG Fox SPGP eligibility and documentation requirements, the organization has implemented the following systemic enhancements: • Standardized Eligibility Controls: The organization has developed and deployed a mandatory Case File Compliance Checklist for all program participants. This control ensures that all federally mandated documentation—including signed program agreements, grievance procedures, religious protections, individualized service plans, and all five required baseline mental health screenings—is present and verified for every file. • Enhanced Management Oversight: To ensure the effectiveness of these controls, the Department Director has implemented a Monthly Quality Assurance (QA) Review. On a monthly basis, the Director will perform a formal audit of active case files to verify compliance. This review will be documented via a formal sign-off, providing a clear audit trail of supervisory oversight. • Records Retention & Security: Management oversight has been expanded to include specific verification of Data Integrity and Retention. Monthly reviews will ensure that all required documentation is maintained in accordance with 2 CFR § 200 standards—ensuring records are secure, unalterable, and readily accessible for future audits. • Continuous Professional Development: The organization has institutionalized a Mandatory Training Curriculum. All relevant staff will undergo initial onboarding and recurring periodic training focused on SSG Fox SPGP compliance standards, participant eligibility, and rigorous documentation procedures. • Personnel Realignment: The organization has undergone a restructuring of the program staff to ensure that all personnel are fully aligned with the agency's internal control environment and commitment to federal compliance. Anticipated completion date: April 30, 2026 Contact Information: Louise Chikigak, Chief Financial Officer, (907) 222-4250
Finding 2025-002: Significant Deficiency in Internal Control over Compliance and Other Matters – Application of Indirect Cost Rates Programs: 93.224 and 93.527 Health Centers Program Cluster 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: See above...
Finding 2025-002: Significant Deficiency in Internal Control over Compliance and Other Matters – Application of Indirect Cost Rates Programs: 93.224 and 93.527 Health Centers Program Cluster 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: See above Anticipated completion date: April 30, 2026 Contact Information: Louise Chikigak, Chief Financial Officer, (907) 222-4250
Management accepts the guidance of the auditors to have an additional quality control step. Development of this is in process. This ongoing monitoring of program compliance is important to the PHA and staff will be trained.
Management accepts the guidance of the auditors to have an additional quality control step. Development of this is in process. This ongoing monitoring of program compliance is important to the PHA and staff will be trained.
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