Corrective Action Plans

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Identifying Number: 2025-002 - Internal Controls surrounding Special Tests and Provisions compliance requirement Audit Finding: Management of the Organization has not implemented internal controls surrounding the Organization’s compliance with special tests and provisions requirements. Corrective Ac...
Identifying Number: 2025-002 - Internal Controls surrounding Special Tests and Provisions compliance requirement Audit Finding: Management of the Organization has not implemented internal controls surrounding the Organization’s compliance with special tests and provisions requirements. Corrective Action Planned: Management of the Organization has elected not to adopt GAAP accounting requirements for credit loss provisions. The name of the contact person responsible for the corrective action: Lisa Underwood, Executive Director The anticipated completion date: N/A.
Identifying Number: 2025-001 - Internal Controls surrounding Reporting compliance requirement Audit Finding: Management of the Organization has not implemented internal controls surrounding the Organization’s compliance with reporting requirements. Corrective Action Planned: In progress. Management ...
Identifying Number: 2025-001 - Internal Controls surrounding Reporting compliance requirement Audit Finding: Management of the Organization has not implemented internal controls surrounding the Organization’s compliance with reporting requirements. Corrective Action Planned: In progress. Management of the Organization will present compliance reports to the Board of Directors for review and approval prior to submission. The name of the contact person responsible for the corrective action: Lisa Underwood, Executive Director The anticipated completion date: To be completed by July 31, 2026.
Finding 2025-004 – Reporting Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action Plan: The Town will strengthen controls over federal reporting by establishing a formal review and approval process prior to submission of financial and performance reports. Pr...
Finding 2025-004 – Reporting Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action Plan: The Town will strengthen controls over federal reporting by establishing a formal review and approval process prior to submission of financial and performance reports. Procedures will require verification that reported amounts agree to accounting records and that narrative descriptions accurately reflect the use of funds. Evidence of review and approval will be documented and retained. Responsible Official: Clerk/Treasurer Mayor Planned Completion Date: May 2026
Management feels due to the nature of operations that the current system is cost effective for a project of this size; however, they will consider adjusting accounts where possible in the future.
Management feels due to the nature of operations that the current system is cost effective for a project of this size; however, they will consider adjusting accounts where possible in the future.
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268, 84.033, 84.007, and 84.379 Recommendation: We recommend that the College review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagr...
Student Financial Assistance Cluster – Assistance Listing No. 84.063, 84.268, 84.033, 84.007, and 84.379 Recommendation: We recommend that the College review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The colleges IT department is currently working on ensuring the WISP does include all elements that are required. IMplemention and completion will be conducted and completed for FY26. Name(s) of the contact person(s) responsible for corrective action: Mo Darwish Planned completion date for corrective action plan: July 2026
Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.379 Recommendation: We recommend the College reevaluate its procedures, and review policies surrounding controls implemented for COD reporting. Explanation of disagreement with audit finding: There is no disagreement wi...
Student Financial Assistance Cluster – Assistance Listing No. 84.268, 84.063, 84.379 Recommendation: We recommend the College reevaluate its procedures, and review policies surrounding controls implemented for COD reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The College is currently implementing a process in which disbursement dates within the SIS matches all dates within COD’s Award Disbursements Information Disbursement Date. This will be done within the Batch record by utilziing the date the batch was processed as “Funds Deposited” instead of the initial “anticipated” award date. The adjustment will ensure that all dates match as the official date the fund was credited to the student’s account. Review of existing prociedures will be conducted regarding the COD disbursement controls. The importance of accurate documentation and actual disbursement dates within the SIS will be emphasized. All disbursmeent dates will be reviewed and reconcilled by the Director of Financial Aid ensuring timely and accurate reporting. Name(s) of the contact person(s) responsible for corrective action: Walter Thompson Planned completion date for corrective action plan: July 2026
Name of Auditee: Incorporated Village of Island Park, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended May 31, 2025 CAP Prepared by: Nicole Scavone, Treasurer Phone: 516-431-0600 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Audi...
Name of Auditee: Incorporated Village of Island Park, New York Name of Audit Firm: EFPR Group, CPAs, PLLC Period Covered by the Audit: Year ended May 31, 2025 CAP Prepared by: Nicole Scavone, Treasurer Phone: 516-431-0600 (A) Current Findings on the Schedule of Findings and Questioned Costs (3) Audit Finding 2025-003 - Financial Data Collection Form Submission (a) Comments on the finding and recommendation: The Village agrees with the finding. The Village also agrees with the recommendation. See below for actions taken. (b) Actions Taken: Management is now aware of the deadline and is working to get current on audits and submission of the data collection form. (c) Anticipated Completion Date: Management anticipates this finding will be resolved by May 31, 2026.
The Town of Spruce Pine will strengthen internal controls over the identification, tracking, and reporting of federal and state awards. Management will maintain a comprehensive, centralized listing of all known and potential federal and state awards throughout the fiscal year, including assistance l...
The Town of Spruce Pine will strengthen internal controls over the identification, tracking, and reporting of federal and state awards. Management will maintain a comprehensive, centralized listing of all known and potential federal and state awards throughout the fiscal year, including assistance listing numbers, award amounts, and pass‑through information. Grant expenditures and receivables will be reconciled to the general ledger on a monthly basis. Prior to submission to the auditors, the SEFSA be independently reviewed for completeness, accuracy, and compliance with federal and state requirements.
FINDING 2025-001: Head Start Program Control Weakness of Filing the Required Semi-Annual and Annual Reports Response: The District Clerk will contact the Head Start Grant Specialist to ensure the SF424 semi and annual reports are reviewed and approved when submitted. The District Clerk has reached o...
FINDING 2025-001: Head Start Program Control Weakness of Filing the Required Semi-Annual and Annual Reports Response: The District Clerk will contact the Head Start Grant Specialist to ensure the SF424 semi and annual reports are reviewed and approved when submitted. The District Clerk has reached out to the office of Head Start for assistance and has not received assistance needed. The District Clerk will go to fiscal training and continue to be proactive with the office of Head Start fiscal reporting team to ensure this finding is closed out. The District will ensure procedures are in place requiring that all Head Start reports be submitted within 30 days of the reporting period end date. The District Clerk will put an internal control in place with the Head Start Director to make sure all SF424's are submitted on time.
The District's management acknowledges and concurs with the finding regarding the maintenance of documentation for students removed from the graduation cohort. We recognize the importance of strictly adhering to the Elementary and Secondary Education Act (ESEA) requirements to ensure the integrity o...
The District's management acknowledges and concurs with the finding regarding the maintenance of documentation for students removed from the graduation cohort. We recognize the importance of strictly adhering to the Elementary and Secondary Education Act (ESEA) requirements to ensure the integrity of the four-year adjusted cohort graduation rate. Following the audit exit conference, District leadership met with staff from the Information Technology (CALPADS team), Educational Services departments and also site staff to discuss the root causes of the missing documentation. The District is committed to strengthening internal controls and ensuring that every student status change is backed by the specific evidentiary standards required by federal and state regulations.
Finding 1213762 (2025-006)
Material Weakness 2025
Corrective Action: Targeted Staff Training were completed related to recertification processes, including proper handling of COVID-extended cases, accessing and working the Pending Recertification Report, proper verification and documentation of vehicles, obtaining long-term medical needs forms when...
Corrective Action: Targeted Staff Training were completed related to recertification processes, including proper handling of COVID-extended cases, accessing and working the Pending Recertification Report, proper verification and documentation of vehicles, obtaining long-term medical needs forms when required, resource verifications, and all required evidence at application and recertification. Additionally, discussions focused on clear standards for requesting information and required case documentation. A monthly Productivity Report (effective January 1, 2026) will be implemented to track individual worker output, identify backlogs early, and ensure timely completion of reviews and recertifications. Increased supervisory monitoring of worker accuracy, with corrective or disciplinary action for repeated errors. Consistent and documented follow-usp by supervisors on all errors identified to confirm corrections are made and understood. State's operational support will deliver quarterly refresher sessions covering recurring errors, updated policies, and best practices for both Family & Children’s and Adult Medicaid programs. Proposed Completion Date: All Training to be completed by 03/28/2026
Management will include as part of the approval of invoices, a process of follow-up with vendors near the end of the fiscal year to make sure all outstanding invoices or an estimate of costs incurred to date are received. If this is not feasible, management will estimate the unbilled costs at year e...
Management will include as part of the approval of invoices, a process of follow-up with vendors near the end of the fiscal year to make sure all outstanding invoices or an estimate of costs incurred to date are received. If this is not feasible, management will estimate the unbilled costs at year end using vendor information.
April 27, 2026 Person responsible: Teresa Council, Executive Director Fiscal Year Ended June 30, 2025 Section III – Federal Awards Findings and Questioned Costs Item 2025 – 001 Federal Assistance Listing Number: 10.558 – Child and Adult Care Food Program Federal Assistance Listing Number: 93.575 – C...
April 27, 2026 Person responsible: Teresa Council, Executive Director Fiscal Year Ended June 30, 2025 Section III – Federal Awards Findings and Questioned Costs Item 2025 – 001 Federal Assistance Listing Number: 10.558 – Child and Adult Care Food Program Federal Assistance Listing Number: 93.575 – Child Care and Development Block Grant – CCDF Cluster Condition The Organization’s Data Collection Form submission to the Federal Audit Clearinghouse was not filed on time within nine months of the end of its fiscal year. Current Status The delay in submission to the FAC was due to a combination of factors, including the extended time required to prepare the fiscal year 2025 financial statements and compile supporting documentation, as well as delays in the completion of the audit process. To support timely future submissions, the Organization will implement the recommended control procedures and adopt an internal timeline beginning with the fiscal year ending June 30, 2026. In addition, the audit process will be initiated earlier to ensure completion and submission by the established deadline of March 31, 2027.
Finding 1213722 (2025-004)
Material Weakness 2025
Management agrees with the finding and recommendations. The City will begin to implement policies and procedures to assist with monthly reconciliations and review processes to mitigate these errors in the future.
Management agrees with the finding and recommendations. The City will begin to implement policies and procedures to assist with monthly reconciliations and review processes to mitigate these errors in the future.
Finding 1213721 (2025-006)
Material Weakness 2025
Management agrees and acknowledges the delay in issuing the financial statements. Contributing factors included staffing transitions, adjustments to policies and financial software, and the need for additional time to complete year end reconciliations. The City has since implemented process improvem...
Management agrees and acknowledges the delay in issuing the financial statements. Contributing factors included staffing transitions, adjustments to policies and financial software, and the need for additional time to complete year end reconciliations. The City has since implemented process improvements, earlier preparation of key schedules, and expanded cross training among staff. These actions are expected to support timely completion of future financial reports.
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization implement a control process to ensure that it complies with its reporting requirements during the grant period. Explanation of Disagreement With Audit Finding: CLS believes that th...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization implement a control process to ensure that it complies with its reporting requirements during the grant period. Explanation of Disagreement With Audit Finding: CLS believes that this matter would be more appropriately communicated in the management letter rather than presented as part of the overall audit report. Action Taken in Response to Finding: CLS will extend and enforce the verification of these requirements. Name of the Contact Person Responsible for Corrective Action: Silvia Zelaya, Finance Director Planned Completion Date for Corrective Action Plan: July 2026
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization implement a control process to ensure that it obtains signed written simple agreements for all staff members who handle cases or matters or are authorized to make decisions about c...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization implement a control process to ensure that it obtains signed written simple agreements for all staff members who handle cases or matters or are authorized to make decisions about case acceptance where required in accordance with 45 CFR 1620.6. Explanation of Disagreement With Audit Finding: CLS believes that this matter would be more appropriately communicated in the management letter rather than presented as part of the overall audit report. Action Taken in Response to Finding: CLS implemented an onboarding process in 2025 through its HR system, BambooHR, which includes verification of this and other required elements. While this process has been applied to new hires, CLS will extend and enforce the verification of these requirements for employees who joined the organization prior to 2025. Name of the Contact Person Responsible for Corrective Action: Silvia Zelaya, Finance Director Planned Completion Date for Corrective Action Plan: July 2026
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization implement a control process to ensure that it obtains LSC prior written approval where required in accordance with 45 CFR 1630.6(b). Action Taken in Response to Finding: With respe...
Legal Services Corporation Grants – Assistance Listing No. 09.706060 Recommendation: We recommend that the Organization implement a control process to ensure that it obtains LSC prior written approval where required in accordance with 45 CFR 1630.6(b). Action Taken in Response to Finding: With respect to the recommended control process, CLS has an established procedure incorporated within its accounting manual. The organization will reinforce and ensure consistent application of this procedure throughout 2026. Name of the Contact Person Responsible for Corrective Action: Silvia Zelaya, Finance Director Planned Completion Date for Corrective Action Plan: July 2026
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedu...
Management acknowledges the auditors’ review of HUD HOME eligibility testing. We believe our current processes generally comply with HUD requirements; however, we recognize the opportunity to strengthen controls. To address the auditors’ comments, we will enhance our eligibility verification procedures, improve documentation consistency, and provide additional staff training. These corrective actions will help ensure ongoing compliance and accuracy in eligibility determinations. Personnel Responsible for Implementation: Meredith Elguira Position of Responsible Personnel: Community Development Director Expected Date of Implementation: April 30, 2026
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately tracked...
Federal Agency Name: United States Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Federal Assistance Listing #10.766 Finding Summary: The Organization did not have an adequate internal control policy in place to ensure the reserve account was separately tracked and a documented review and approval over the reserve fund occurred. Responsible Individuals: Sharlene Knutson, Administrator Corrective Action Plan: We have adopted a policy to enhance internal control to ensure the reserve fund reconciliation has a secondary review and approval that is documented. Anticipated Completion Date: 6/30/2026
2025-002 Single Audit Submission Planned Corrective Action Plan: The District will ensure all supporting documentation is prepared and ready for Auditors. In addition, audit services will be procured with sufficient time to submit the single audit by the required timeline. Anticipated Completion Dat...
2025-002 Single Audit Submission Planned Corrective Action Plan: The District will ensure all supporting documentation is prepared and ready for Auditors. In addition, audit services will be procured with sufficient time to submit the single audit by the required timeline. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Judy James, Business Manager
Finding 2025-003 – Special Tests and Provisions (Material Weakness in Internal Control Over Compliance) Planned Corrective Action: Seattle Indian Health Board will implement the following actions to ensure accurate application and documentation of the Sliding Fee Discount Program: - EPIC System Upda...
Finding 2025-003 – Special Tests and Provisions (Material Weakness in Internal Control Over Compliance) Planned Corrective Action: Seattle Indian Health Board will implement the following actions to ensure accurate application and documentation of the Sliding Fee Discount Program: - EPIC System Update: Configure EPIC to automatically assign the appropriate sliding fee discount level to patients with zero income to ensure consistent application of the discount schedule. - Required Income Documentation at Intake: Update procedures to require front desk staff to record a patient’s income level at intake for all patients, including a reasonable estimate when documentation in unavailable. This is required for both an accurate sliding fee application and UDS reporting. - Standardized Documentation Requirements: Require retention of supporting documentation for income and family size in the patient record, or documented attestation when estimates are used, in accordance with policy. - Front Desk Training and Accountability: Provide targeted training to front desk and registration staff on sliding fee discount program requirements, with emphasis on proper data entry, documentation standards, and discount application. - Ongoing Monitoring: Implement monthly reviews of a sample of patient accounts to confirm sliding fee discounts are supported, accurately applied, and properly documented. Errors will be corrected and addressed with the staff as needed. Name of Responsible Party: Tempest Dawson, Director of Clinic Operations Anticipated Completion Date: December 31, 2026.
Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requiremen...
Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requirements, specifically related to documentation of Tribal enrollment. While prior corrective actions established foundational training and audit processes, management has identified the need for stronger front-end controls, clearer accountability, and system-based safeguards to prevent recurrence. Seattle Indian Health Board will implement the following actions: 1. Strengthen Front-End Eligibility Controls - Eligibility verification protocols will be updated to require complete Tribal enrollment documentation prior to scheduling non-urgent appointments. - A standardized eligibility checklist will be embedded into intake workflows to ensure all required documentation is identified and collected before services are rendered. 2. System Enhancement and Documentation Tracking - Electronic health record workflows will be enhanced to include required fields and alters for missing eligibility documentation, including Tribal enrollment. - Patients with incomplete eligibility records will be flagged, and services will be limited to allowable scenarios until documentation is obtained. 3. Targeted Training and Competency Validation - All registration and front desk staff will undergo mandatory retraining focused specifically on Tribal enrollment documentation requirements and compliance standards. - Staff competency will be validated through post-training assessments and periodic spot checks. 4. Enhanced Monitoring and Internal Audit - Monthly eligibility audits will be expanded to include a statistically valid sample size and documented review of Tribal enrollment verification. - Audit results will be formally reported to executive leadership, with identified deficiencies tracked through resolution. - Repeat errors or noncompliance will be addressed through corrective coaching and performance management, as appropriate. Management believes these enhanced corrective actions directly address the root cause of the finding by strengthening preventive controls, improving staff competency, and increasing oversight and accountability. Name of Responsible Party: Tempest Dawson, Director of Clinic Operations Anticipated Completion Date: December 31, 2026.
FINDING 2025-018 Name of Responsible Individual: Director of Post Award Compliance and Training Budget Analyst Corrective Action: The University receives advance payments from the sponsor, with the amount determined by the sponsor and adjusted as financial reports are submitted by the University. In...
FINDING 2025-018 Name of Responsible Individual: Director of Post Award Compliance and Training Budget Analyst Corrective Action: The University receives advance payments from the sponsor, with the amount determined by the sponsor and adjusted as financial reports are submitted by the University. In response to the auditor’s recommendation to strengthen internal controls, Howard University will implement procedures to document and reconcile all cash payments received from sponsors on a quarterly basis to actual expenses incurred. This reconciliation process will help ensure that sponsor payments are fully accounted for and appropriately matched to related expenditures, thereby enabling the University to clearly demonstrate which expenses have been reconciled to payments received. Anticipated Completion Date: June 30, 2026
FINDING 2025-017 Name of Responsible Individual: Director of Post Award Compliance and Training Senior Associate Vice President of Financial Strategy Corrective Action: In response to the auditor’s recommendation to strengthen internal controls and ensure timely submission of the Single Audit Report...
FINDING 2025-017 Name of Responsible Individual: Director of Post Award Compliance and Training Senior Associate Vice President of Financial Strategy Corrective Action: In response to the auditor’s recommendation to strengthen internal controls and ensure timely submission of the Single Audit Report to the Federal Audit Clearinghouse, Howard University will enhance cross collaboration across the University to improve audit readiness. During the May 2025 transition from the Grants and Contracts Accounting Office to the Sponsored Awards Office, the University experienced significant staff turnover and a loss of institutional knowledge, which contributed to audit readiness challenges. Since that time, the University has focused on stabilization efforts. The Office of Research Sponsored Programs has been restructured and is now almost fully staffed. The University will be establishing monthly check ins with key stakeholders to ensure adherence to a compliance calendar with clearly defined roles and responsibilities across core compliance areas. Additionally, the University has hired a Director of Post Award Compliance and Training to lead audit readiness efforts, strengthen internal controls, and support ongoing monitoring and compliance throughout the fiscal year. Anticipated Completion Date: March 31, 2027
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