Corrective Action Plans

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The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned costs.
The corrective action plan was documented in our response to the auditor's comment. See the Schedule of Findings and Questioned costs.
The District will ensure that a semi-annual certification is completed at least twice a year and signed by a knowledgeable supervisor or the employee, confirming those employees who worked solely on a single federal program or cost objective.
The District will ensure that a semi-annual certification is completed at least twice a year and signed by a knowledgeable supervisor or the employee, confirming those employees who worked solely on a single federal program or cost objective.
Diabetes, Digestive, and Kidney Diseases Extramural Research (ALN 93.847) Recommendation: We recommend that the Organization reviews the dates of costs incurred before charging costs to their Federal award and that evidence of this review is retained. Explanation of disagreement with audit finding: ...
Diabetes, Digestive, and Kidney Diseases Extramural Research (ALN 93.847) Recommendation: We recommend that the Organization reviews the dates of costs incurred before charging costs to their Federal award and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has implemented procedure enhancements to its review and processing of grant-related costs to better detect and prevent costs being charged outside of the period of performance. Including: the period charged for costs is based on expected receipt date of the goods or services being charged; a threestep/tiered review process of costs to be charged prior to the processing of such costs; a periodic review of the periods in which costs were charged for proper period alignment. Name of the contact person responsible for corrective action: Mahtab Khan Planned completion date for corrective action plan: May 2026
Blood Diseases and Resources Research (ALN 93.839) Recommendation: We recommend that the Organization reviews their calculations around payroll costs before drawdowns and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit...
Blood Diseases and Resources Research (ALN 93.839) Recommendation: We recommend that the Organization reviews their calculations around payroll costs before drawdowns and that evidence of this review is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of implementing an upgraded grants payroll allocation costs software (Paas 2.0) that contains system controls that will detect payroll changes and automatically update, thus preventing such errors in the future. In addition to these automated software controls, management will implement review procedures in parallel as a secondary measure of control to detect and prevent such errors. Management anticipates the implementation and completion of the software project and related procedures in July 2026. Name of the contact person responsible for corrective action: Mahtab Khan Planned completion date for corrective action plan: July 2026
Council and Administration will continue to use supervisory reviews such as monitoring financial statements and budget reports, and segregate duties where costs beneficial to do so.
Council and Administration will continue to use supervisory reviews such as monitoring financial statements and budget reports, and segregate duties where costs beneficial to do so.
Corrective Action Planned: The County relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal and state awards include related note disclosures. The County reviews schedule of expenditures of federal awards and approves all adjustments. The County pl...
Corrective Action Planned: The County relies on the auditor to propose adjustments necessary to prepare the schedule of expenditures of federal and state awards include related note disclosures. The County reviews schedule of expenditures of federal awards and approves all adjustments. The County plans on adopting and implement a Federal Award Compliance Policy. Proposed Completion Date: July 1, 2026 Responsible Party: Anne M. Pruss, County Clerk
MATERIAL WEAKNESS Finding 2025-003 – Allocation and Documentation of Payroll Costs Recommendation: Management should develop a process whereby payroll costs allocated to federal grants; are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, ...
MATERIAL WEAKNESS Finding 2025-003 – Allocation and Documentation of Payroll Costs Recommendation: Management should develop a process whereby payroll costs allocated to federal grants; are supported by a system of internal controls which provides reasonable assurance that the charges are accurate, allowable and properly allocated, reasonably reflect the total activity for which the employee is compensated and support the distribution of the employee’s wages among specific activities or cost objectives if the employee woks on more than one federally funded program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: As corrective action, management implemented a new system to track time and effort effective July 1, 2025, using the Forms Assembly platform for federally funded DHS programs. For other grants, the Agency has continued to maintain supporting time and effort documentation through Excel-based records. Management recognizes that the implementation of the Forms Assembly system has presented operational challenges, particularly due to the need to reconcile information separately with the payroll system. As a result, since October 2025, management has been evaluating and vetting alternative systems that can fully integrate time and effort reporting with payroll processing. Beginning in fiscal year 2027, the Agency plans to implement a new integrated software solution that will record employee time, grant allocations, and payroll information within a single system integrated directly with payroll processing. Management believes this integrated approach will strengthen internal controls, improve the accuracy and timeliness of reporting, reduce manual reconciliation processes, and enhance compliance with federal time and effort requirements. Name of contact person responsible for corrective action: Margarita Rosas, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026
The Prosser School District is in agreement with the finding. We have a new Director, a new fiscal specialist and controls in place to double check allowable expenses. These include following the accounting manual and double checking with the program director, if there is any question whether an exp...
The Prosser School District is in agreement with the finding. We have a new Director, a new fiscal specialist and controls in place to double check allowable expenses. These include following the accounting manual and double checking with the program director, if there is any question whether an expense is allowable or not. In the event that the program director is uncertain they will reach out to ESD123 for additional support.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter and that all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization identified challenges and errors in the prior eligibility workflow after the 2024 audit. Over the course of 2025, the Organization experienced turnover in management and front desk personnel in the dental department. The workflows were modified when the new eligibility manager joined the Organization. Upon hiring a new dental manager and patient access (front desk) manager, workflows and procedures were also modified to ensure the front desk reviews insurance coverage upon check in. The system is set up so the Organization does not need manually adjust all claims, so the claim was auto-posted for the visit identified above. Our corrective action plan is already established, although it was put into place after the date of service of the visit identified above. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Amanda Craig, CFO, at 970-710-5062.
Planned Corrective Action: Management plans to implement the following corrective actions: Responsible party: Kellie Baker, Airport Manager and Shawn Daughtery, Treasurer Corrective action: Management will develop and implement a formal year-end closing and Single Audit preparation calendar. This ca...
Planned Corrective Action: Management plans to implement the following corrective actions: Responsible party: Kellie Baker, Airport Manager and Shawn Daughtery, Treasurer Corrective action: Management will develop and implement a formal year-end closing and Single Audit preparation calendar. This calendar will include clearly defined responsibilities and internal deadlines established in advance of the federal submission due date to ensure adequate time for review and completion. Management will conduct regular status meetings throughout the audit process to monitor progress, promptly address any delays, and ensure timely completion of all required schedules, supporting documentation, and financial statements. Additionally, management will strengthen oversight of external auditors by requiring documented engagement timelines, milestone tracking, and periodic progress updates. Responsibility for submission to the Federal Audit Clearinghouse will be formally assigned, and a secondary review process will be implemented to verify the timely and accurate submission of the reporting package and Data Collection Form. Implementation date: June 30, 2026 27
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to untimely tenant recertifications and missing income documentation. Management reviewed the circumstances that contributed to the delayed comple...
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to untimely tenant recertifications and missing income documentation. Management reviewed the circumstances that contributed to the delayed completion of tenant recertifications and incomplete documentation and determined that existing internal monitoring procedures did not consistently ensure tenant recertifications were completed within required timeframes. To address these issues, management has implemented corrective actions designed to strengthen oversight and improve the timeliness and completeness of tenant recertifications. These actions include reinforcing internal tracking procedures for recertification due dates, enhancing supervisory review of tenant eligibility files, and providing additional training to staff responsible for tenant eligibility determinations and income verification. Management expects these corrective actions to be fully implemented and operating effectively for all tenant recertifications going forward, thereby improving compliance with federal award requirements and reducing the risk of future untimely tenant recertifications or missing documentation. Anticipated Completion Date The corrective action is in the process of being implemented and expected to be completed in fiscal year 2026.
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to the inability to locate certain tenant files. Management acknowledges that one of the eight tenant files selected for audit testing was not ava...
Responsible Official Nichelle Brown, Senior Vice President of Property and Asset Management Plan Detail Management concurs with the audit finding related to the inability to locate certain tenant files. Management acknowledges that one of the eight tenant files selected for audit testing was not available and concurs with the disclosure that nine of the forty tenant files for the program could not currently be located. Management has evaluated the circumstances contributing to the missing files and determined that existing record retention and file management procedures did not sufficiently ensure that all tenant documentation was safeguarded and readily retrievable. Management recognizes that the absence of tenant files limits the ability to demonstrate compliance with federal award requirements and to support costs charged to the program. To address this issue, management has initiated corrective actions to strengthen document retention and file management controls. These actions include implementing enhanced tracking and reconciliation processes for tenant files, improving secure storage and retention practices, and reinforcing staff responsibilities for maintaining complete and accessible tenant records. Management also plans to conduct periodic internal reviews to confirm that tenant files are properly maintained and available for monitoring and audit purposes. Specifically we plan to: 1. All physical resident files are stored in locked cabinets or secured file rooms with access limited to authorized personnel, including Property Managers, Assistant Property Managers, Compliance Specialists, and designated corporate staff. 2. Access to records will be restricted based on job function and necessity 3. There will be a formal file transfer and chain-of-custody process with required signatures 4. File transfers between properties will be by locked file transport boxes marked as confidential. 5. Employees will be required to maintain direct control of files during transport. 6. All files will be maintained during required retention periods. Management believes that these corrective actions will improve compliance with record retention requirements and reduce the risk of missing documentation in the future. Anticipated Completion Date The corrective action is in the process of being implemented and expected to be completed in fiscal year 2026.
Finding 1215371 (2025-001)
Material Weakness 2025
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified and note that correctiv...
A. Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations 1. Finding 2025-001: Lack of Formalized Compliance Monitoring and Documented Management Oversight a. Comments on the Finding and Each Recommendation: We acknowledge the condition identified and note that corrective actions and compliance monitoring enhancements were implemented or initiated prior to report issuance. Historically, certain compliance oversight activities relied heavily on operational knowledge and informal review procedures that were not consistently documented. Following organizational restructuring and personnel transitions, management initiated a broader effort to formalize and strengthen internal compliance monitoring, supervisory review procedures, and documentation practices across our housing portfolio. b. Action(s) Taken or Planned on the Finding: 1. Monthly Compliance and Financial Oversight Meetings: We have implemented recurring monthly oversight meetings involving executive leadership, finance, and housing management personnel to review financial reporting, reserve activity, compliance requirements, tenant-related matters, and operational performance. Meeting documentation and evidence of supervisory review are maintained as part of our compliance monitoring procedures. 2. Expanded Finance and Compliance Oversight Structure: We have strengthened our internal oversight structure through the addition of a Chief Financial Officer with expanded oversight responsibilities for the housing entities and a Director of Housing and Compliance responsible for operational and regulatory compliance oversight. Responsibilities between accounting, compliance, and operational functions have been further segregated to strengthen internal controls and management review procedures. 3. Formalized Compliance Monitoring Procedures: We have implemented standardized compliance monitoring procedures, including monthly reserve deposit tracking, supervisory review checklists, documented financial statement review procedures, reconciliation monitoring, and periodic compliance checklists addressing key HUD program requirements. 4. Ongoing Monitoring and Documentation Retention: We will continue strengthening documentation retention procedures to ensure evidence of compliance monitoring, supervisory review, and reconciliation activities is consistently maintained and available for future audits and regulatory reviews.
Finding 2025-003 Duplicate expenditures charged to same grant Recommendation: We recommend the District establish and maintain proper review procedures for expenditures charged to grants prior to submission for reimbursement. Management’s View: The District will strengthen internal controls over pay...
Finding 2025-003 Duplicate expenditures charged to same grant Recommendation: We recommend the District establish and maintain proper review procedures for expenditures charged to grants prior to submission for reimbursement. Management’s View: The District will strengthen internal controls over payroll expenditures charged to federal grants by implementing a standard operating procedure that will be conducted by the Payroll Specialist of verifying payroll distribution reports, funding codes, and supporting documentation prior to submission for payment. Before each payroll is finalized, the payroll specialist will run a payroll report that will be generated and sorted by employee to verify that no duplicate charges have been applied to the same grant within the same payroll period. This review will ensure that all costs charged to federal grants during the pay period are accurate, allowable, properly coded, and not duplicated. No payroll adjustments will be keyed until timesheets have been verified against previously submitted timesheets and that they are reviewed to confirm that prior entries have not already been charged to the same grant. Additionally, a secondary review by the accountant will be conducted prior to finalizing grant-related payrolls. Effective March 1, 2026, the Payroll Accountant and Chief Financial Officer will review grant-related payroll transactions to ensure accuracy, proper funding allocation, and compliance with applicable federal requirements. Effective Date: March 1, 2026 Contact Person: Sylvia Garza, Chief Financial Officer, Edcouch-Elsa Independent School District
This is the result of procurement transactions fonded with the ARPA Coronavirus State and Local Recovery Funds. The County did not conduct procurement transactions in a manner providing fair and open competition on two constrnction contracts. The comptrollers office will enhance procurement policies...
This is the result of procurement transactions fonded with the ARPA Coronavirus State and Local Recovery Funds. The County did not conduct procurement transactions in a manner providing fair and open competition on two constrnction contracts. The comptrollers office will enhance procurement policies and review of federal grant funded purchases.
Corrective Action: We will continue to have the Board of Directors review the financial activity of the entity. Due to the small size of the organization, it is not economically feasible to achieve a complete segregation of duties. Emily Roark, Executive Director, will be responsible for the correct...
Corrective Action: We will continue to have the Board of Directors review the financial activity of the entity. Due to the small size of the organization, it is not economically feasible to achieve a complete segregation of duties. Emily Roark, Executive Director, will be responsible for the corrective action.
Comments on the Finding and Each Recommendation The auditee did not submit the Single Audit reporting package and data collection form to the Federal Audit Clearinghouse within the required timeframe. We recommend that the auditee implement procedures to monitor reporting deadlines and ensure timely...
Comments on the Finding and Each Recommendation The auditee did not submit the Single Audit reporting package and data collection form to the Federal Audit Clearinghouse within the required timeframe. We recommend that the auditee implement procedures to monitor reporting deadlines and ensure timely submission of the Single Audit reporting package to the FAC. Reporting Views of Responsible Officials Management acknowledges the late submission and has implemented procedures to assign responsibility for FAC submission and track required deadlines. Management believes these actions will prevent recurrence. Auditee concurs with this finding. Auditee agrees with auditor recommendations. Completion Date or Proposed Completion Date: May 31, 2026 by Rebecca Copeland, Controller - Property Accounts Action(s) Taken or Planned on the Finding The electronic submissions will be entered into the online FAC system.
The City acknowledges the finding. The delayed completion of the audit process contributed to the untimely submission of the reporting package and Data Collection Form. Federal reporting deadlines have been incorporated into the City’s annual compliance calendar, and management will continue coordin...
The City acknowledges the finding. The delayed completion of the audit process contributed to the untimely submission of the reporting package and Data Collection Form. Federal reporting deadlines have been incorporated into the City’s annual compliance calendar, and management will continue coordinating earlier completion of audit deliverables and required submissions. Future submissions will be monitored to ensure compliance with the Uniform Guidance deadline requirements.
The City acknowledges the finding. The City will continue developing and maintaining written policies and procedures appropriate to its federal award activity and the terms and conditions of applicable federal awards. Policies and procedures will address internal controls, reporting responsibilities...
The City acknowledges the finding. The City will continue developing and maintaining written policies and procedures appropriate to its federal award activity and the terms and conditions of applicable federal awards. Policies and procedures will address internal controls, reporting responsibilities, record retention, allowable costs, procurement standards, conflictof- interest requirements where applicable, and compliance monitoring procedures consistent with Uniform Guidance requirements.
Finding No. 2025-004 Condition – Claims submitted for reimbursement did not reconcile with the District’s internally prepared monthly claim summary report. Plan – The District will ensure that meal counts are thoroughly reviewed prior to submission. Meal counts are entered into the computer by the F...
Finding No. 2025-004 Condition – Claims submitted for reimbursement did not reconcile with the District’s internally prepared monthly claim summary report. Plan – The District will ensure that meal counts are thoroughly reviewed prior to submission. Meal counts are entered into the computer by the FSMC, and has been a place where errors have occurred. The district secretary is responsible for entering the meal counts into the state system. She is verifying the counts from the FSMC, comparing to attendance and invoices, and ensuring correct data goes into IWAS. This was started last spring, when we became aware of FSMC inconsistencies. The current year, FY26, has been much more accurate. Anticipated Date of Completion: current – 9/1/2026 Name of Contact Person: Matt Stines, Superintendent
Management will implement a monthly reserve funding checklist, automate recurring reserve transfers where feasible, and require Board review of reserve account activity. Reserve deposits will be supported by bank statements and documented through signed monthly checklists, with exceptions documented...
Management will implement a monthly reserve funding checklist, automate recurring reserve transfers where feasible, and require Board review of reserve account activity. Reserve deposits will be supported by bank statements and documented through signed monthly checklists, with exceptions documented and remediated.
2025-004: Subrecipient Monitoring - Contractor vs. Subrecipient Determination (Significant Deficiency in Internal Control) Statement of Condition/Criteria: 2 CFR §200.331 requires pass-through entities to evaluate each subaward to determine whether the recipient is a subrecipient or a contractor. Th...
2025-004: Subrecipient Monitoring - Contractor vs. Subrecipient Determination (Significant Deficiency in Internal Control) Statement of Condition/Criteria: 2 CFR §200.331 requires pass-through entities to evaluate each subaward to determine whether the recipient is a subrecipient or a contractor. This evaluation should be based on the characteristics outlined in 2 CFR §200.331(a) and (b) and documented to support proper classification. Effective internal control over federal awards also requires documentation of compliance-related judgments to ensure consistent application and oversight. During our testing of internal controls over compliance, we noted that the Organization does not maintain formal documentation supporting its evaluation of whether award recipients are classified as contractors or subrecipients in accordance with Uniform Guidance. Planned Corrective Action: The Council will work to implement requirements at the program level to evaluate and document all contracts to properly identify between contract and subaward. Contact person responsible for corrective action plan: Clayton Kincheloe, Executive Director Anticipated Completion Date: September 2026
2025-001: Delinquent Data Collection Form Filing (SF-SAC) (Noncompliance) Statement of Condition/Criteria: Uniform Guidance requires the auditee to submit a reporting package and Data Collection Form to the Federal Audit Clearinghouse within the prescribed timeframe. The auditee must submit the repo...
2025-001: Delinquent Data Collection Form Filing (SF-SAC) (Noncompliance) Statement of Condition/Criteria: Uniform Guidance requires the auditee to submit a reporting package and Data Collection Form to the Federal Audit Clearinghouse within the prescribed timeframe. The auditee must submit the reporting package and DCF within the earlier of 30 calendar days after receipt of the auditor’s reports, or 9 months after the end of the audit period. For the fiscal year ended 9/30/2024, the auditee’s Data Collection Form and reporting package were not submitted timely to the Federal Audit Clearinghouse. Failure to submit the Data Collection Form and reporting package timely may result in delayed federal oversight and monitoring, increased risk of federal agencies deeming the organization noncompliant with Single Audit requirements, or potential sanctions including withholding of federal awards and/or suspension of future funding. Planned Corrective Action: The Council will implement a Single Audit compliance calendar to ensure timely filing. The Executive Director will be responsible for submission of the Data Collection Form and reporting package and will retain confirmation documentation in the finance records. Contact person responsible for corrective action plan: Clayton Kincheloe, Executive Director Anticipated Completion Date: September 2026
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Central Valley School District No. 356 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code...
CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Central Valley School District No. 356 September 1, 2024 through August 31, 2025 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility requirements. Name, address, and telephone of District contact person: Mathew Knott, Director of Business Services 2218 N. Molter Road Liberty Lake, WA 99019 509-558-5437 Corrective action the auditee plans to take in response to the finding: The District does agree that one school with a poverty rate above 75% was not served. However, OSPI reviewed and approved the District’s Title I application, including our proposed ranking and allocation methodology, and no concerns or comments were raised during that review process. Additionally, the District was able to provide alternative snapshot dates demonstrating that no individual school was truly above the 75% threshold. Once the District became aware of the issue, we proactively contacted OSPI to determine whether any corrective action was necessary for the current year. OSPI’s guidance was that no changes or corrections were required for the current year and that adjustments should instead be implemented in the following year if a school exceeded the 75% threshold. Based on that direction from OSPI, the District did not make current-year corrections. Given these circumstances, including OSPI’s prior approval of the application and subsequent guidance that no corrective action was required, the District respectfully disagrees with the State Auditor’s Office conclusion that this matter rises to the level of a Finding rather than being addressed through a Management Letter. We consider this matter to be resolved as no school going into the 2025-2026 fiscal year was above the 75% threshold. Anticipated date to complete the corrective action: 8/31/2025
Continuum of Care Assistance Listing No. 14.267 Payroll Disbursements Recommendation: We recommend that LAHSA implement procedures to ensure that timesheet approval is documented timely. Explanation of disagreement with audit finding: There is no disagreement withthe audit finding. Action taken in r...
Continuum of Care Assistance Listing No. 14.267 Payroll Disbursements Recommendation: We recommend that LAHSA implement procedures to ensure that timesheet approval is documented timely. Explanation of disagreement with audit finding: There is no disagreement withthe audit finding. Action taken in response to finding: LAHSA has enhanced its internal controls over timesheet approvals to ensure timely documentation. Timesheet approval status reports are reviewed on a weekly basis during Chief level meetings to monitor compliance. Timesheets not approved within two days of the established deadline are escalated to the respective Chief and Deputy Chief for immediate follow-up. If timesheets remain unapproved after an additional two days, the matter is further escalated to the CEO, for prompt resolution. These procedures establish clear accountability and escalation protocols to ensure timely approval of timesheets Names of the contact persons responsible for corrective action: Gita O'Neill, Keshia Douglas, Christopher Williams, and Paul Rubenstein. Planned completion date for corrective action plan: Implemented
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