Corrective Action Plans

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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: A second person will compare the meal counts in the claim to: (1) the daily meal counts prepare...
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: A second person will compare the meal counts in the claim to: (1) the daily meal counts prepared by cafeteria staff and (2) the monthly enrollment reports from the accounting software. The reviewer will then sign and date the supporting documentation before the meal claim is submitted. Anticipated date of completion: December 2025. Name of contact person: Jake Flowers, Superintendent. Management response: The corrective action plan was discussed with the employees responsible for filing the claim and the superintendent. After discussion, the plan was approved by the superintendent and will be adopted.
5. SA-2025-01 a. Deficiency: Employees funded with Title I grant funds should document their time worked for the grant in line with time and effort requirements of the grant. b. Cause: The District did not consistently meet Title I time and effort documentation requirements for certain employees dur...
5. SA-2025-01 a. Deficiency: Employees funded with Title I grant funds should document their time worked for the grant in line with time and effort requirements of the grant. b. Cause: The District did not consistently meet Title I time and effort documentation requirements for certain employees during the audit period. This occurred due to staffing changes and turnover within the federal grant which resulted in retro pay and funding corrections, which resulted in inconsistent time and effort documentation. In addition, there was a lack of centralized oversight to ensure that time and effort records were completed timely and retained in accordance with federal requirements. c. Corrective Action: The District has taken steps to review time and effort allocations, processes and requirements. Training will be provided to applicable employees and supervisors to reinforce federal requirements and expectations.
Department of Education, passed through the State of Montana Office of Public Instruction, Federal Financial Assistance Listing 84.010, federal award numbers S010A240026 and S010240026, grant period 7/1/2024 – 9/30/2026 Title I Grants to Local Education Agencies Special Tests and Provisions Finding ...
Department of Education, passed through the State of Montana Office of Public Instruction, Federal Financial Assistance Listing 84.010, federal award numbers S010A240026 and S010240026, grant period 7/1/2024 – 9/30/2026 Title I Grants to Local Education Agencies Special Tests and Provisions Finding Summary: During the auditor’s federal program testing of Title I, it was noted that several students were removed from the adjusted cohort for unallowable reasons. Corrective Action Plan: The District staff will follow the guidance in ESEA sections 1111(h)(1)(C)(iii)(II) and 8101(23), (25) (20 USC 6311(h)(1)(C)(iii)(II) and 7801(23), (25)), to ensure graduation rate data is reported correctly going forward. Responsible Individual: Laurie Kvamme, Chief Financial Officer Anticipated Completion Date: June 30, 2026
Management’s response/corrective action plan: Management concurs with the audit finding. During fiscal year 2024, the School Unit appropriately recorded the cost of a five-year software agreement as a prepaid expenditure. However, in fiscal year 2025, the entire amount was incorrectly recognized as ...
Management’s response/corrective action plan: Management concurs with the audit finding. During fiscal year 2024, the School Unit appropriately recorded the cost of a five-year software agreement as a prepaid expenditure. However, in fiscal year 2025, the entire amount was incorrectly recognized as a current-year expenditure and included in the calculation of grant reimbursements. To remedy this issue, management will enhance internal controls over prepaid expenditures charged to federal grants. Specifically, finance staff and the business manager, will review all prepaid items at year-end and during grant reimbursement preparation to ensure that expenditures are recognized in the proper fiscal period and in accordance with the underlying contract terms. A reconciliation between prepaid balances, contract terms, and reimbursement requests will be performed prior to federal grant submission. In addition, written procedures will be updated to clearly require verification that only allowable and incurred costs are included in reimbursement claims, and relevant staff will receive additional training on grant compliance requirements related to prepaid expenditures. Management believes these actions will prevent similar issues in the future.
OCCIDENTAL COLLEGE CORRECTIVE ACTION PLAN FINDING 2025-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Explanation of Deficiency: A sample of 20 federal aid recipient students was selected fromsystem generated reports of students ...
OCCIDENTAL COLLEGE CORRECTIVE ACTION PLAN FINDING 2025-001 – Special Tests and Provisions – Enrollment Reporting: Significant Deficiency in Internal Control over Compliance Explanation of Deficiency: A sample of 20 federal aid recipient students was selected fromsystem generated reports of students who graduated, withdrew, or dropped during the 2024-2025 academic year. The enrollment information per the College’s records was compared to the information reported to the National Student Loan Data System (NSLDS) in order to determine if status changes were reported within the required timeframes. All 20 of the students selected as samples were not reported to the NSLDS within the required timeframe. Corrective Action Plan: With the hiring of our Associate Registrar for Systems and Reporting we once again have a staff member specifically responsible for reporting enrollment and degrees to the NSC. That position is backed up by three other staff members who also have access to submit and correct files. This past summer, we adjusted our reporting schedule in a further effort to comply with our reporting requirements. Despite any delays caused by us or by the National Student Clearinghouse, I understand that we are responsible for making sure our data is received and posted according to our obligations. The division of labor that comes with a full staff will allow for data transfers as soon as degrees are posted after the end of a semester. The adjusted timing for enrollment file submissions will also prevent any bottlenecks that might delay our data from being posted. These steps have already been implemented as evidenced by the fact that our degree file for the fall semester just ended was sent before our holiday break. As noted last year, staff have been instructed that the resolution of error files is to be given a high priority. One staff member has priority responsibility for resolving those files backed up by our primary submitter of data to the Clearinghouse. Contact Person Responsible for Corrective Action: James Herr, Occidental College Registrar Anticipated Completion Date: August 1, 2025
Action Taken: The District has updated internal control procedures to add additional segregation of duties and documentation. A standard time sheet has been implemented District wide until the District can purchase and implement the timeclock management system add on to its current employee tracking...
Action Taken: The District has updated internal control procedures to add additional segregation of duties and documentation. A standard time sheet has been implemented District wide until the District can purchase and implement the timeclock management system add on to its current employee tracking software. Timesheets are only allowed to be turned in to the Payroll Clerk by the approving supervisor, and after timesheets are entered by the Payroll Clerk they are scanned to the supervisor to review and make sure they agree to what was turned in. The Chief Operations and Financial Officer, Director of Child Nutrition, and Payroll Clerk have all completed internal control training, and The District is evaluating the Child Nutrition Department’s staffing and job descriptions and looking into adding a clerical position to help with reporting and add to segregation of duties/checks and balances.
Noncompliance with Enrollment Status Change Reporting. Auditor Description of Condition and Effect. Of 18 enrollment status changes tested, we noted 1 change that was not reported to the National Student Loan Data System (NSLDS) within 60 days due to a student being assigned a different coding struc...
Noncompliance with Enrollment Status Change Reporting. Auditor Description of Condition and Effect. Of 18 enrollment status changes tested, we noted 1 change that was not reported to the National Student Loan Data System (NSLDS) within 60 days due to a student being assigned a different coding structure within the College's system which resulted in the student being excluded from the standard status-change reporting process. As a result of university personnel using the incorrect semester start dates. As a result of this condition, the College was temporarily out of compliance with enrollment reporting requirements. Auditor Recommendation. We recommend the College review and update its enrollment reporting processes to ensure that all students-including those with unique or foreign-student coding-are captured in routine status-change monitoring and NSLDS reporting procedures. The College should implement controls to detect nonstandard coding and ensure that all enrollment changes are identified and reported within required federal timelines. Corrective Action. Bay College took swift action after determining some students were being excluded in our enrollment reporting. Our reporting process was excluding students who were noted as being a citizen of a foreign county. We now review these students prior to each reporting cycle to determine if they should be included in the reporting. The Financial Aid team reviews this report to determine if the student is eligible for federal student aid. Students who are eligible are indicated and provided to the Institutional Effectiveness team to include in the enrollment reporting. This process is completed prior to each reporting cycle. For students who were not included in our prior reporting, the Financial Aid team working directly with the Institutional Effectiveness team, determined which should be reported and completed their enrollment reporting directly through NSLDS. Responsible Person. Ruth Carlson, Director of Financial Aid. Anticipated Completion Date. June 30, 2026
Finding 2025-001: Reporting – Significant deficiency in internal controls over compliance. Management Response: The District’s Child Nutrition Assistant Director (AD) prepared the claims data submitted into the Tx-UNPS System to receive Child Nutrition federal funding. The claims data was submitted ...
Finding 2025-001: Reporting – Significant deficiency in internal controls over compliance. Management Response: The District’s Child Nutrition Assistant Director (AD) prepared the claims data submitted into the Tx-UNPS System to receive Child Nutrition federal funding. The claims data was submitted without management approval. The District will implement procedures to ensure that monthly claim reports are reviewed by the Chief Operations Officer (COO) prior to being submitted into Tx-UNPS System. The AD will prepare the claims report documentation, which includes the point of sale and attendance reports. The claims report and supporting documentation will be emailed to the COO. Once the reports are reviewed and determined to be accurate, the COO will email approval. Once the AD receives approval via email from the COO, the email will be printed or digitally saved with the claims reports. The AD will submit claims data into the Tx-UNPS System and print the NSLP Claim for Reimbursement Summary. The Summary will be sent to the COO for confirmation. The new process will begin in October 2025.
Views of Responsible Officials and Corrective Action Plan The Campus Business and Financial Aid Offices reviewed the untimely return of Title IV (R2T4) funds and implemented a revised process to ensure compliance. Weekly R2T4 reviews: Financial Aid specialists now review all accounts requiring R2T4 ...
Views of Responsible Officials and Corrective Action Plan The Campus Business and Financial Aid Offices reviewed the untimely return of Title IV (R2T4) funds and implemented a revised process to ensure compliance. Weekly R2T4 reviews: Financial Aid specialists now review all accounts requiring R2T4 calculations each week. Mid-month reconciliation: Added to the existing end-of-month process to expedite fund returns. Weekly coordination meetings: Financial Aid and Business Services staff review pending cases to ensure all returns meet the 45-day federal deadline. Quarterly compliance checks: Other Financial Aid staff monitor adherence and make recommendations for process improvement. The District will review this process each term and adjust procedures as needed to sustain compliance and efficiency.
This segregation of duties weakness is impratical to totally correct due to the limited resources and staff available to the district. The District will continue to use other controls, where practical, to compensate for this limitation.
This segregation of duties weakness is impratical to totally correct due to the limited resources and staff available to the district. The District will continue to use other controls, where practical, to compensate for this limitation.
Subject: Management response to Fiscal Year 2025 Audit Findings The management of Village Tech Schools acknowledges receipt of the following findings for the FY25 audit and has developed a corrective action plan response to address the findings. Finding 2025-001: Reporting – Significant deficiency i...
Subject: Management response to Fiscal Year 2025 Audit Findings The management of Village Tech Schools acknowledges receipt of the following findings for the FY25 audit and has developed a corrective action plan response to address the findings. Finding 2025-001: Reporting – Significant deficiency in internal controls over compliance. Management Response: The District’s Child Nutrition Supervisor (CNS) prepared the claims data submitted into the Tx-UNPS System to receive Child Nutrition federal funding. The claims data was submitted without management approval. The District will implement procedures to ensure that monthly claim reports are reviewed by the Chief Operations Officer (COO) prior to being submitted into Tx-UNPS System. The CNS will prepare the claims report documentation, which includes the point of sale and attendance reports. The claims report and supporting documentation will be emailed to the COO. Once the reports are reviewed and determined to be accurate, the COO will email approval. Once the CNS receives approval via email from the COO, the email will be printed or digitally saved with the claims reports. The CNS will submit claims data into the Tx-UNPS System and print the NSLP Claim for Reimbursement Summary. The Summary will be sent to the COO for confirmation. The new process will begin in October 2025.
Magnolia Manor Corporation has taken steps to ensure that the Replacement Reserve account will not be underfunded by withdrawing funds to cover the Operating Account. The underfunded amount of $2,688.00 has been deposited on August 20, 2025, and $306.00 has been deposited on September 15, 2025. Magn...
Magnolia Manor Corporation has taken steps to ensure that the Replacement Reserve account will not be underfunded by withdrawing funds to cover the Operating Account. The underfunded amount of $2,688.00 has been deposited on August 20, 2025, and $306.00 has been deposited on September 15, 2025. Magnolia Manor Corporation has reviewed the auditors' recommendation and will ensure that more thorough monthly reviews will be implemented.
Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. Finding 2025-001 – Maintenance of Effort (MOE) Federal Program: Title I, Part A (84.010) Repeat Finding: Yes (Prior Audit Finding 2024-004) Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. acknowledges the Maintenan...
Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. Finding 2025-001 – Maintenance of Effort (MOE) Federal Program: Title I, Part A (84.010) Repeat Finding: Yes (Prior Audit Finding 2024-004) Corrective Action Plan Matchbook Learning Schools of Indiana, Inc. acknowledges the Maintenance of Effort (MOE) finding related to the accuracy of expenditures reported on the Form 9 cash-basis report submitted to the Indiana Department of Education (IDOE). This finding is a repeat finding from the prior audit period. The School recognizes that prior corrective actions were not sufficient to fully address the reliability of Form 9 reporting. As a result, the School has enhanced and formalized internal controls surrounding Form 9 preparation, review, and submission to ensure compliance with IDOE guidelines and to prevent recurrence of this issue. Corrective Actions Implemented 1. Formal Form 9 Reconciliation Process ○ The School has implemented a documented reconciliation process to compare internal cash-basis financial records to the Form 9 prior to submission. ○ This reconciliation ensures that only allowable cash expenditures are reported and that reported totals align with bank activity and supporting documentation. 2. Strengthened Review and Approval Controls ○ Preparation of the Form 9 is now subject to a multi-level review process. ○ The Form 9 will be reviewed by the School’s financial consultant and School leadership to confirm accuracy, compliance with IDOE reporting guidance, and consistency with underlying financial records prior to submission. 3. Written Procedures and Staff Training ○ Written internal procedures have been developed outlining Form 9 preparation requirements, including proper treatment of accruals, timing differences, and non-cash items. ○ Staff involved in financial reporting have received refresher training on IDOE Form 9 reporting requirements and maintenance of effort considerations. 4. Ongoing Monitoring and Communication ○ The School will perform periodic internal monitoring of cash-basis expenditures throughout the fiscal year to identify potential discrepancies prior to year-end reporting. ○ When necessary, the School will proactively communicate with IDOE to clarify reporting requirements before submission. Responsible Officials ● Board of Directors ● School Leadership ● Director of Finance Planned Completion Date ● Immediate and Ongoing These procedures have been implemented and will be applied to the current and all future reporting periods. Expected Results The implementation of these enhanced internal controls will ensure that Form 9 expense reporting is accurate, complete, and prepared in accordance with IDOE guidelines. This will support reliable Maintenance of Effort calculations by IDOE and is expected to prevent recurrence of this finding in future audit periods. Don Stewart COO Matchbook Learning
The board of trustees regularly reviews financial statements, bank reconciliations, and budget vs. actual information to help to mitigate the lack of ideal segregation of duties.
The board of trustees regularly reviews financial statements, bank reconciliations, and budget vs. actual information to help to mitigate the lack of ideal segregation of duties.
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongo...
Corrective Action Planned: Due to the Authority’s size, it is cost-prohibitive and impractical to achieve the ideal level of segregation of duties. The Authority has implemented as many controls and segregation of duties as practically possible for an organization of this size. Completion Date: Ongoing
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar tha...
Management acknowledges the missing internal control over the late submission of the updated financial model/plan for the fiscal year end June 30, 2024. Management has maintained an effective internal control tool for many years in the form of a master spreadsheet called the Annual Task Calendar that the entire Finance staff reviews at every biweekly Finance meeting, but the WIFIA deadlines were errantly not incorporated into that tool until January 2026. While management agrees with the finding, it should be noted that management was not operating without controls. Rather, the deadline being adhered to was just the wrong date. Management submitted updated financial model/plan by January 31, 2025, which was within the month following the close of the calendar year, similarly to the quarterly construction reports that are due 30 days after the end of the preceding quarter. In addition, the data on the annual model reflected current information near the time of release of the report, not June 30, 2024. So, in substance, management provided an even more current, relevant document. Management acknowledges the additional finding language that the June 30, 2025 quarterly construction monitoring report was submitted on day 31 rather than day 30 following the close of the quarter. Finally, management acknowledges that the annual updated financial model/plan for June 30, 2025, will be submitted in January 2026 as the internal control, as mentioned above, was not corrected until January 2026, which will result in the same finding on the Single Audit for June 30, 2026. However, management believes that we have taken the appropriate measures required to avoid ongoing replication. Responsible Official: Matt Zook, Finance Director
Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned: 2025-001: The underfunded replacement reserve deposit will be deposited into t...
Comments on Findings and Recommendations: Management concurs with the findings and auditors’ recommendations to enhance internal controls to ensure compliance with the HUD Regulatory Agreement. Action(s) Taken or Planned: 2025-001: The underfunded replacement reserve deposit will be deposited into the replacement reserve account as cash flow allows during fiscal year 2026. Furthermore, internal controls over replacement reserve funding are being strengthened to prevent future non-compliance.
The Organization has set up a system to review transfers of federal funding by the Senior Asset Manager and Chief Financial Officer prior to the transfer taking place to ensure it is within the compliance requirements of the grant
The Organization has set up a system to review transfers of federal funding by the Senior Asset Manager and Chief Financial Officer prior to the transfer taking place to ensure it is within the compliance requirements of the grant
Bethany College and Affiliate Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025‐001 – Significant Deficiency in Internal Control Over Compliance – Return of Title IV Funds Condition Found: Four students who had withdrawn from the institution did not have Title IV funds returned to...
Bethany College and Affiliate Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025‐001 – Significant Deficiency in Internal Control Over Compliance – Return of Title IV Funds Condition Found: Four students who had withdrawn from the institution did not have Title IV funds returned to the Department of Education within 45 days. Corrective Action Plan: The College will review our workflow and make oversight improvements to prevent future delays, including standardizing withdrawal notification and handoff procedures, initiating R2T4 calculations immediately upon withdrawal determination, confirming that required COD adjustments are submitted without delay and establishing internal tracking to monitor return activity against the 45 day requirement. Responsible Official for Corrective Action Plan: Sarah Sherinian, Vice President for Student Success & Operational Excellence/Chief Financial Aid Officer
Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases, along with adding controls to ensure that the item purchased was r...
Recommendation: CLA recommends the District review its grant disbursement process to ensure that there is adequate segregation of duties in regards to initiating, authorizing, reviewing for grant allowability and approving purchases, along with adding controls to ensure that the item purchased was received by the District. CLA also also recommends the District printout the eligibility reports from Wisegrants and sign and date them to indicate review and approval after meeting with CESA 10 each year. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The District will note the date of the budget meeting with CESA 10. When items are purchased for Title I, approval will be made by either the Elementary Principal or Superintendent before purchases are made. Name(s) of the contact person(s) responsible for corrective action: Brooke Rosemeyer, Adrian Foster, Brandon Baldry Planned completion date for corrective action plan: September 1, 2026.
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District review its internal controls and implement a procedure to ensure all re...
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District review its internal controls and implement a procedure to ensure all reports required under the grant have a designated reviewer that is different from the individual responsible for preparing, even when there are gaps of coverage in preparer and reviewer positions, and that the review and approval happens prior to submitting the reports to the granting agency. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The Food Service Director and the Executive Administrative Assistant will work together to ensure that procedures are in place to review and confirm for accuracy. Name(s) of the contact person(s) responsible for corrective action: Frankie Soto, Dawn Rausch Planned completion date for corrective action plan: September 1, 2026.
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District implement formal procedures to strengthen controls over eligibility det...
Child Nutrition Cluster (School Breakfast Program, National School Lunch Program, and Summer Food Service Program for Children) – Assistance Listing No. 10.553, 10.555, and 10.559 Recommendation: CLA recommends that the District implement formal procedures to strengthen controls over eligibility determinations. These procedures should include ensuring timely updates to eligibility listings when students become ineligible, retaining all required documentation for the applicable retention period, and conducting periodic reviews of benefit issuance listings to confirm accuracy. Additionally, CLA recommends the District implement procedures to ensure staff receive training on proper eligibility determination and recordkeeping requirements. Finally, CLA recommends the District establish monitoring controls to verify that benefits are discontinued promptly for students who no longer qualify. Eligibility determinations should be reviewed and approved by someone other than the person entering the applications and direct certification information into the software. Explanation of disagreement with audit finding: There is no disagreement with this finding. Action planned/taken in response to finding: The Food Service Director, high school secretary and the Executive Administrative Assistant will work together to ensure that procedures are in place to review and confirm for accuracy. Name(s) of the contact person(s) responsible for corrective action: Frankie Soto, Dawn Rausch, Emily Krzyzanowski Planned completion date for corrective action plan: September 1, 2026.
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance – Reporting Finding 2025-010 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of...
U.S. Department of Health and Human Services Program Name: Maternal and Child Health Services Block Grant Federal Assistance Listing Number: 93.994 Significant Deficiency, Nonmaterial Noncompliance – Reporting Finding 2025-010 – Repeat Finding Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Per 2 CFR 200.334 the recipient must retain all federal award records for three years from the date of submission of their final financial report. Condition: During the audit we tested 9 reports and noted the following: a) There was one (1) instance out of (9) nine reports tested where the submitted reports were unable to be provided, including the date of submission for the reports. b) There were four (4) instances out of nine (9) reports tested where the County was unable to provide evidence the report was reviewed prior to submission. c) There were two (2) instances out of nine (9) reports tested where the County was unable to provide the date of submission for the reports. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: By not having the required documentation and underlying support, the County is not able to demonstrate compliance with the applicable requirements. Cause: The County did not have a formal policy to ensure documentation was retained to evidence review and submission of all reports. Recommendation: While the County made updates to policies and procedures surrounding reporting during the current year to address the prior year finding, the County should ensure these policies are adhered to ensure all submitted reports and underlying data are retained in accordance with the Uniform Grant Guidance requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: As of July 2025, The Health Department has created and adopted policy FIS-05 Retention of Reporting Requirement Submissions to ensure that federal award reports and data are retained in accordance with Uniform Guidance. The Health Department will document with screen shots as outlined in the FIS-05 Policy, to address circumstances when the required report consists of answering a NCDHHS survey or form that does not have “save” or “download” capability, to maintain record of documented submissions. In addition, the Health Department has developed a standard operating procedure whereby fiscal compliance Management Analysts, in collaboration with Program Managers, ensure they have reviewed federal award reports prior to submission and file documentation of review and approvals. While review of grant reports is common, the Health Department did not have adequate documentation to demonstrate completion of this step prior to July 2025. An additional training, to be recorded, will be held with program staff Friday December 19th, 2025. Anticipated Completion Date: December 19,, 2025 Responsible Person(s): Autumn Watson, Business Operations Director
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency and Nonmaterial Noncompliance – Child Support Non-Cooperatio...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Significant Deficiency and Nonmaterial Noncompliance – Child Support Non-Cooperation Finding 2025-008 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each sanction for noncooperation. Condition: a) There was one (1) instance out of two (2) sanctions tested where the required form to be sent was dated after the sanction start date. b) There was one (1) instance out of two (2) sanctions tested where the sanction was not properly documented. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: When required sanction notifications are not issued prior to the sanction start date and sanctions are not properly documented, there is an increased risk that clients may not be properly informed of program actions and that the County may not comply with program requirements. Cause: The County did not have adequate procedures in place to ensure that required sanction notifications were issued prior to the sanction start date and that all sanctions were properly documented in accordance with program requirements. Recommendation: The County should implement procedures to ensure all required sanction notifications are issued prior to the sanction start date and that sanctions are properly documented in accordance with program requirements. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this, which is further discussed in the Corrective Action Plan. Corrective Action Plan: Performance Improvement Strategy: Collaborate with Child Support Services to improve understanding of their processes and ensure accurate case handling. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist), Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training and Development Manager), Scott Fritz (Social Services Manager), Program Supervisors Training: Non-Cooperation Sanction Training Anticipated Completion Date: To be completed quarterly. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist). Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training and Development) Anticipated Completion Date: Completed by January 2026.
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Material Weakness and Nonmaterial Noncompliance – Eligibility and Special Tests: In...
U.S. Department of Health and Human Services Pass-through Entity: North Carolina Department of Health and Human Services Program Name: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Material Weakness and Nonmaterial Noncompliance – Eligibility and Special Tests: Income Eligibility and Verification System Finding 2025-007 Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. The County should have adequate documentation for each participant that supports each eligibility determination, and the information entered into NCFAST. We noted several errors related to the following compliance criteria: a) An OVS inquiry must be completed and agreed to information reported in NC FAST. b) For the month of application, Work First cash assistance payments are prorated from the date of application, with the date of application being day one. c) All Work First applicants must provide a Social Security number or apply for a Social Security number if they do not have one. d) Parents and step-parents who apply for children must be included in the case with the child, unless they are otherwise ineligible. Condition: The following are the results of nonmaterial noncompliance noted for each criteria listed above out of the 25 program participants selected for testing a) There were two instances where the OVS query was not run at the time of the determination. b) There was one instance where a hearing extension was incorrectly prorated. c) There was one instance where the social security number was not verified. d) There was one instance where kinship was not documented. Lastly, the following are the results of 60 program participants tested for control testing: a) There were three instances where the County did not remediate the errors identified within their internal review timely. b) There was one instance where a participant received benefits for one month where they should not have. c) There was one instance where incorrect forms were sent to a participant. Questioned Costs: None of the nonmaterial noncompliance items resulted in questioned costs. Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk the County could provide funding to individuals who are not eligible. Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis. Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified and monitored throughout the year for adherence to the policy. Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan. Corrective Action Plan: Performance Improvement Strategy: The Economic Services Division (ESD) Quality and Training Specialist will conduct a 25% sample review of all ongoing cases. Errors identified during these reviews will be documented and communicated to both the Social Services Supervisor and the assigned Eligibility Specialist for correction within a defined timeframe. Failure to comply with correction timelines will result in corrective action. Case Review and Error Notification • ESD Sr. Quality and Training Specialist will review 25% of all ongoing cases. • Errors will be documented on checking sheets and emailed to both the supervisor and the assigned Eligibility Specialist. • Corrections must be completed within 5 business days of notification. Corrective Action • If corrections are not completed within the extended timeframe: o Corrective Action will be initiated in accordance with departmental performance management protocols. Responsible Individuals: Sarah Carter, Tatyenne Rone, Karl Parisien, Denize Cuff (Sr. Quality and Training Specialist), Danisa Concepcion (Quality and Training Supervisor), Staphon Snelling (Training & Development Manager), Scott Fritz (Social Services Manager), Program Supervisors Anticipated Completion Date: To be completed monthly. Training: Training Completion Required for the Following Quality Review Errors: • Ensure the OVS inquiry is completed, and that the information aligns with data reported in NC FAST. • Understand that Work First cash assistance payments are prorated from the application date, which is considered Day One. • Confirm that all Work First applicants must provide a valid Social Security number or apply for one if not already obtained. • Review and apply the rules of kinship, specifically regarding parents and stepparents. Additionally, train supervisors and eligibility specialists on the importance of timely resolution of quality sampling errors and how delays can impact audit outcomes. Responsible Individuals: Sr. Quality & Training Specialists, Quality & Training Supervisor, Training & Development Manager. Anticipated Completion Date: An email will be sent by the Staff Development Unit to the Eligibility Specialist with errors by January 2026, and in-person training will be completed by February 2026.
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