Corrective Action Plans

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Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will...
Views of Responsible Officials: The District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will prepare the monthly SNP Claim for Reimbursement Summary report and compile all supporting meal count documentation. 2. Prior to submission, the Administrative Assistant to the Director of Food Services or another designated individual independent of the preparation process will: a. Review the claim for mathematical accuracy; b. Verify meal counts against supporting documentation; c. Confirm claims are submitted within required timelines; and 3. Evidence of the review and approval will be documented through: a. Signature or electronic approval on the reimbursement summary report; and b. Retention of supporting documentation in accordance with federal and state record retention requirements. 4. A written standard operating procedure (SOP) outlining these review and approval responsibilities will be developed and communicated to applicable personnel. The Business Manager will periodically monitor compliance with the procedure to ensure controls remain effective.
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient ...
Management concurs with the finding. During the audit period, the Organization maintained payroll records, compensation documentation, and payroll allocation schedules; however, it did not maintain personnel activity reports, periodic certifications, or other after-the-fact documentation sufficient to support compensation costs charged to the Community Development Financial Institutions Program in accordance with 2 CFR § 200.430. The Organization's methodology relied on management-established allocation percentages based on employee responsibilities and anticipated level of effort supporting CDFI Fund activities. While management believes the costs charged to the award were incurred in support of eligible program activities, the Organization recognizes that documentation supporting the allocation methodology did not meet the standards required under Uniform Guidance. Planned Corrective Action: Beginning July 1, 2026, the Organization will implement formal time and effort reporting procedures for all personnel whose compensation is charged, in whole or in part, to federal awards. Specifically, the Organization will: 1.The CFO will establish a cost allocation plan which includes a methodology to support salary, wage, and fringe benefit charges, and other applicable costs, to the federal award and to support allocation among cost objectives. 2. The CFO will implement a documented process for personnel activity reporting and/or periodic certifications (or other equivalent documentation) that reasonably reflects actual work performed and supports the allocation of compensation costs to eligible activities. 3. CFO will reconfigure the current workforce management system to ensure projects, departments, and contextual details are logged at the source. 4. The COO will review existing timesheet submission and review policy to ensure compliance with federal requirements. The policy will require supervisory review and approval of personnel activity documentation/ certifications consistent with the payroll cadence and retain documentation in the grant file and/or payroll file. The CFO will review and enforce compliance with timesheet submission requirements. 5. The CFO will implement a dynamic allocations module within Sage Intacct to facilitate automated allocation of time and fringe benefits to federal and other programs. 6. The CFO will ensure that the systems established perform periodic reconciliation and after-thefact review of payroll and fringe benefit allocations. The CFO will make timely adjustments when actual activity differs from budget estimates or planned allocations. 7. The CFO, COO, and other personnel working on federal programs will receive training on the documentation standards in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 8. The CFO and COO will provide training to program and finance personnel on the documentation standards. in 2 CFR § 200.430 and allowability factors in 2 CFR § 200.403. 9. The CFO will, as part of the monthly close process, review compensation charged to federal awards to ensure all costs are appropriate and supported prior to requesting reimbursement. Management believes these actions will strengthen internal controls over compensation costs charged to federal awards and ensure compliance with Uniform Guidance requirements going forward. Responsible Official: Julia Gazizova, Chief Financial Officer Anticipated Completion Date: September 30, 2026.
The Airport plans to complete a credit memo for all the amounts drawn down on the 2025 grants and reissue a pay request for the remaining federal share on the eligible expenses to be in accordance with the match in the grant agreements.
The Airport plans to complete a credit memo for all the amounts drawn down on the 2025 grants and reissue a pay request for the remaining federal share on the eligible expenses to be in accordance with the match in the grant agreements.
Management Response: Management agrees with the finding. The reporting package and Data Collection Form were not submitted by the required deadline. While the delay was primarily the result of significant staffing shortages within the Finance Department during the reporting period, management recogn...
Management Response: Management agrees with the finding. The reporting package and Data Collection Form were not submitted by the required deadline. While the delay was primarily the result of significant staffing shortages within the Finance Department during the reporting period, management recognizes that it remained the City's responsibility to ensure timely compliance with federal reporting requirements. To address this issue, the City will implement a formal tracking process for all federal reporting requirements, maintain a compliance calendar, clearly assign responsibility for monitoring submission deadlines, and require management review prior to submission. These procedures are expected to strengthen internal controls, improve oversight of compliance deadlines, and ensure timely submission of future reporting packages in accordance with Uniform Guidance requirements. Anticipated Completion Date: 06/30/2026 Responsible Person: Mandy Kellogg, Administrative Services Director
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully t...
Department of Homeland Security - Federal Emergency Management Agency (FEMA) Staffing for Adequate Fire and Emergency Response (SAFER) - CFDA No.97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebecca Holden Planned completion date for corrective action plan: 6/30/2026
Corrective Action Plan: The NCHA has implemented CFP drawdown procedures to ensure that all eLOCCS requests are supported by eligible expenditures, properly documented, and submitted in accordance with applicable federal cash management requirements and HUD Capital Fund Program regulations. Effectiv...
Corrective Action Plan: The NCHA has implemented CFP drawdown procedures to ensure that all eLOCCS requests are supported by eligible expenditures, properly documented, and submitted in accordance with applicable federal cash management requirements and HUD Capital Fund Program regulations. Effective immediately, the Authority has established the following corrective actions:  CFP Drawdown Review and Approval Process  All CFP drawdown requests are now reviewed by Finance staff before submission to verify that requested amounts are supported by eligible CFP expenditures, available obligations, and approved Capital Fund budgets.  A Management approval requirement has been implemented for all eLOCCS draw requests before submission.  Supporting documentation, including invoices, purchase orders, contracts, payroll allocations, and other eligible expenditure support, is maintained with each draw request.  Monthly eLOCCS-to-Expenditure Reconciliation  Finance staff perform a monthly reconciliation of CFP eLOCCS drawdowns to actual expenditures recorded in the accounting system.  The reconciliation process confirms that: o Drawdowns do not exceed eligible costs incurred; o Funds are properly recorded for the appropriate Capital Fund grant year and project; o Outstanding balances and remaining grant funds are accurately monitored; and o Any discrepancies are identified and corrected on time through appropriate accounting adjustments.  Improved Cash Management Controls  NCHA revised its CFP cash management procedures to align drawdown timing with actual cash needs and incurred eligible costs.  Draw requests are limited to amounts necessary to reimburse expenditures and avoid excessive cash balances.  Finance staff have been trained in federal cash management requirements, CFP eligible cost principles, and proper eLOCCS drawdown procedures.  Documentation and Record Retention  NCHA implemented a CFP Drawdown Checklist to document: o Grant availability; o Eligible expenditures supporting the draw; o Required approvals; o Reconciliation completion; and o Supporting documentation retention.  CFP financial records are maintained in accordance with federal record retention requirements and are available for HUD review.  Ongoing Monitoring and Quality Control  The CFO or designee conducts periodic quality control reviews of CFP drawdowns and related reconciliations to ensure continued compliance.  Any identified exceptions are documented, corrected, and incorporated into ongoing staff training and process improvements. Responsible Official: CFO, Sr. Staff Accountant with oversight by Executive Director/CEO Responsible for implementation, monitoring, and continued compliance with CFP drawdown procedures. Expected Completion Date: Implemented July 2026; Ongoing monitoring and monthly reconciliation procedures will continue as part of the Authority’s standard financial management practices
Finding 1224495 (2025-002)
Material Weakness 2025
Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed ...
Medical Assistance - Eligibility Recommendation: We recommend the County strengthen its supervisory review control over Medicaid eligibility casefile reviews by implementing procedures to ensure that identified errors or required corrections are documented, followed up on, and verified as completed in a timely manner. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will ensure that supervisors will properly follow up with staff during casefile review and will retain documentation supporting that evaluation. Name of the contact person responsible for corrective action: Steven Jones Planned completion date for corrective action plan: December 31, 2026
KHDA will hire a CPA to oversee this process.
KHDA will hire a CPA to oversee this process.
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers...
Name of contact person: Melissa Labra, Income Maintenance Administrator II Corrective Action: Caseworkers will receive additional training on inputting the correct evidence into NCFAST. Caseworkers will receive additional training insuring form DSS-8569 is sent to clients at proper time. Caseworkers will receive additional training on obtaining adequate verifications for income. Caseworkers will receive additional training on completing complete and thorough case documentation. Supervisors will conduct second party reviews on applications and recertification’s to determine that the correct procedures are being followed. Supervisors will review cases to verify evidence and supporting documentation match and cases show consistency. Supervisors will review cases to ensure evidence is inputted correctly. Proposed Completion Date: April 30, 2026
Program(s): Supplemental Nutrition Assistance Program (SNAP), Medical Assistance Program; Foster Care Title IV-E Program 10.561 / 93.778 / 93.658 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing of 1,524 and 1,521 random momen...
Program(s): Supplemental Nutrition Assistance Program (SNAP), Medical Assistance Program; Foster Care Title IV-E Program 10.561 / 93.778 / 93.658 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing of 1,524 and 1,521 random moment study participants reported in quarters one and two, respectively, two individuals were reported on the first quarter time study report that were terminated or resigned prior to the start of the respective quarter. Hennepin County’s Corrective Action Planned in Response to Finding: Hennepin County will continue to monitor its procedures for giving timely notice of an individual’s termination or resignation to other departments, as implemented in July 2025. Additionally, the County will ensure departments are reviewing the information provided to granting agencies. Hennepin County Employee Responsible for the CAP: Samantha Braun Planned Completion Date for CAP: 07/31/2026
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files t...
Program(s): Health Center Program Cluster Assistance Listing Number 93.224 / 93.527 Type of Finding: Significant Deficiency in Internal Control over Compliance and Other Matter Condition: During our testing, we noted the following two instances of noncompliance in the sample of forty patient files tested: • In one patient file selected for testing, the sliding fee discount applied was incorrect due to the patient’s income not being entered correctly in Epic, resulting in an inaccurate FPL calculation and associated discount classification. • In one patient file selected for testing, based on support provided and the SFDS, an incorrect discount class was applied, and the County was not able to provide documentation demonstrating how annual income/household size supported the applied discount classification. Hennepin County’s Corrective Action Planned in Response to Finding: Develop a required form for all case aides to use and uniformly determine “annual income”. The EPIC Financial Assistance Module (FAM) recently implemented will maintain record of patient financial calculations / conversations and will include upload of the financial income form. Determination of the proper patient discount is automated in FAM and will reduce chance of incorrect rate setting. Hennepin County Employee Responsible for the CAP: Baye D Diouf, Chief Financial Officer Planned Completion Date for CAP: September 30, 2026
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into inte...
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into interest-bearing accounts. Also, establish a process to track interest earned on Federal advances and remit annually any interest above the $500 de minimis threshold to the federal agency per §200.305(b)(11), retaining records of calculation and remittance.
Corrective Action Plan: THe LFCS program manager updated the Alternatives to Abortion Client Enrollment Requirements document to clarify required case manager documentation for client eligibility and the submission process for entry into the state database. The update was implemented by 06/04/2026. ...
Corrective Action Plan: THe LFCS program manager updated the Alternatives to Abortion Client Enrollment Requirements document to clarify required case manager documentation for client eligibility and the submission process for entry into the state database. The update was implemented by 06/04/2026. The document will be completed, signed and dated by the case manager/social worker. Before the documentation is submitted to the data entry clerk, the case manager/social worker’s supervisor or program manager will verify the needed proofs are uploaded in Apricot along with verifying the funding sources selected in the Program Intake. After the supervisor/program manager verifies that all required proofs are uploaded and the correct funding sources are selected, if there are multiple funders, they will write which ones on the document, initial it and then they will submit the form to the data entry clerk. The data entry clerk will enter the new client into the state database on or before the 15th of the following month.
Corrective Action Plan: THe LFCS program manager updated the Alternatives to Abortion Client Enrollment Requirements document to clarify required case manager documentation for client eligibility and the submission process for entry into the state database. The update was implemented by 06/04/2026.T...
Corrective Action Plan: THe LFCS program manager updated the Alternatives to Abortion Client Enrollment Requirements document to clarify required case manager documentation for client eligibility and the submission process for entry into the state database. The update was implemented by 06/04/2026.The document will be completed, signed and dated by the case manager/social worker. Before the documentation is submitted to the data entry clerk, the case manager/social worker’s supervisor or program manager verifies that all required proofs are uploaded, they will initial the form and then they will submit the form to the data entry clerk. The data entry clerk will enter the new client into the state database on or before the 15th of the following month
Finding Documentation was not retained to evidence management review and approval of PR-29 reports prior to submission. Corrective Action Planned The process was enhanced for 2026 to include documented review and approval of quarterly PR-29 reporting, by the Housing Finance Manager, prior to submiss...
Finding Documentation was not retained to evidence management review and approval of PR-29 reports prior to submission. Corrective Action Planned The process was enhanced for 2026 to include documented review and approval of quarterly PR-29 reporting, by the Housing Finance Manager, prior to submission. Contact Person Nicole Babcock Anticipated Completion Date Implemented June 2026; ongoing monitoring thereafter.
Finding Timesheets charged to federal programs were processed without documented supervisory approval in certain instances. Corrective Action Planned In 2026 and going forward, all staff and Department Director timesheets will be approved by an independent supervisor prior to payroll processing. Con...
Finding Timesheets charged to federal programs were processed without documented supervisory approval in certain instances. Corrective Action Planned In 2026 and going forward, all staff and Department Director timesheets will be approved by an independent supervisor prior to payroll processing. Contact Person Nicole Babcock Anticipated Completion Date Implemented June 2026; ongoing monitoring thereafter.
The Finance Staff will collaborate with Police Department Staff during the budgeting process to ensure that revenue is not inappropriately budgeted. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Finance Staff will collaborate with Police Department Staff during the budgeting process to ensure that revenue is not inappropriately budgeted. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
Finding 2025-002 – Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action: The City is in the process of updating a...
Finding 2025-002 – Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action: The City is in the process of updating and adopting written policies and procedures that are in compliance with Uniform Guidance. Anticipated Completion Date: December 31, 2026 Responsbile Official: John Szymanski, City Manager
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review th...
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review the process to re-establish time-and-effort reporting through the timesheet entry process and the consolidation of time-and-effort information into reporting that can be easily summated by department/project and uploaded to MIP · Determine the allocation and cost distribution methods needed and the resulting detail reporting needed to substantiate the allocation methods used for propriety · Reinstitute the timesheet entry process by project/cost code and train staffing at an upcoming All Staff meeting to reset the view of timesheets and their importance of timesheet tracking to minimize errors for cost allocation purposes · Have staff begin using timesheets in Paylocity (by December 1st) · Complete update of Fiscal Policies Manual (inclusive of Cost Allocation methodology and philosophy) and timely reviews (i.e. at a minimum semiannually or with major program changes/contracts) to ensure no substantive changes needed to policy or actions needed to ensure appropriate accounting updates
Identification: 10.766 United States Department of Agriculture (USDA), Community Facilities Loans and Grants; Noncompliance Finding; Special Tests and Provisions Corrective Action Plan: The Medical Center will take the necessary steps outlined in the bond indenture and retain a financial consultant ...
Identification: 10.766 United States Department of Agriculture (USDA), Community Facilities Loans and Grants; Noncompliance Finding; Special Tests and Provisions Corrective Action Plan: The Medical Center will take the necessary steps outlined in the bond indenture and retain a financial consultant to review operations and make recommendations to restore the days cash on hand ratio above the minimum requirement. Anticipated completion date: The Medical Center has engaged a financial consultant and will work with the consultant during 2026 to improve operations.
Management strives to operate within a model of continuous improvement and will review and improve processes appropriately to provide for timely reporting on a go-forward basis.
Management strives to operate within a model of continuous improvement and will review and improve processes appropriately to provide for timely reporting on a go-forward basis.
Management agrees with the finding above. Management will review the existing accounting policies and procedures and implement additional controls to validate timely submission of reports.
Management agrees with the finding above. Management will review the existing accounting policies and procedures and implement additional controls to validate timely submission of reports.
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code with...
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code within the Union College system specifically related to graduation and withdrawal dates. A report that includes status code changes will be reconciled with student status changes transmitted by the National Student Clearinghouse (NSC) to the National Student Loan Database System (NSLDS), and any necessary corrections will be made in the appropriate time frame. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented at the end of the Spring 2026 term.
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal con...
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal controls over the application of indirect cost rates to federally funded awards. Although corrective actions were initiated following the prior year's finding, the College has identified opportunities to enhance the review and monitoring of indirect cost rate calculations to ensure consistent compliance with Uniform Guidance. Going forward, the accounting group, in collaboration with the Office of Sponsored Programs, will maintain the current federally negotiated indirect cost rates, apply approved rates to applicable awards, and perform periodic reviews to verify that the correct rates are consistently applied. Timeline for Implementation of Corrective Action Plan: The College will finalize written procedures governing the application and review of indirect cost rates, implement a documented review process for indirect cost calculations prior to posting, and provide guidance to employees responsible for grant accounting. These actions will be completed by September 30, 2026. Management will periodically monitor compliance to ensure indirect cost rates are applied accurately and in accordance with federal requirements.
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreeme...
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreement and related funder documentation for indicators of federal funding, including an Assistance Listing Number, a federal award identification number, the originating federal agency, the pass-through entity identifying number, and references to the Uniform Guidance, and should confirm the federal funding status with the pass-through entity when it is not clear. Management will maintain a centralized listing of awards that is reconciled to the general ledger and reviewed for completeness in preparing the schedule of expenditures of federal awards. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Completion Date: July 31,2026
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