Corrective Action Plans

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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
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards...
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Responsible Party: Emma McQuillan, Chief Financial Officer Completion Date: 12/5/2024
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Correct...
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City concurs with this finding. City has hired additional resources to perform review of subrecipient transactions. On a monthly basis, the new position will review system generated reports to timely capture reportable subrecipient transactions. Additionally, the City has an ongoing quarterly meeting with all grant managers. Training will be provided to grant managers to ensure proper identification of subrecipient contracts and proper entry into the SAM.gov system. Anticipated Completion Date: December 31, 2026
Finding 1223673 (2025-002)
Material Weakness 2025
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 200...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Department of Agriculture, Assistance Listing #: 10.561 – State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP Cluster), Passed through Houston-Galveston Area Council, Contract Number: 20020, Contract Year: 10/01/25 - 09/30/26. Condition and context: During our testing of 40 federal and state payments to childcare providers under the Houston-Galveston Area Council contract, we noted that 1 childcare provider was paid at an incorrect provider rate resulting in an overpayment of $9.10. Recommendation: Re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Corrective action: BakerRipley will re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026
Finding 1223672 (2025-001)
Material Weakness 2025
Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contra...
Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contract Year: 10/01/24 - 09/30/25, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contract Year: 10/01/24 - 09/30/25. Condition and context: During the planning phase of the audit, management disclosed that childcare providers were paid $3.6 million in duplicate childcare assistance payments in July 2025. As of May 15, 2026, $2.5 million of the duplicate payments have been recovered. Recommendation: Implement prevention procedures to identify duplicate payments prior to payment. Corrective action: BakerRipley has reviewed internal processes and procedures to determine the cause and implement prevention procedures related to the duplication of payments prior to payment. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026
Finding 2025-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, for 7 months of the year, it did not maintain sufficient documentation to support the level of effort charged to the ...
Finding 2025-02 Insufficient Documentation of Personnel Expenses Condition: The Organization charges a material amount of payroll-related costs to its major federal program. However, for 7 months of the year, it did not maintain sufficient documentation to support the level of effort charged to the award, as required by federal regulations. While staff members are required to complete timesheets, the format did not capture the level of detail needed to substantiate payroll allocations to federal programs. Additionally, there was no formal process for supervisory review and approval of these timesheets. Although no overcharges or double-dipping were identified, the lack of adequate documentation results in known and likely questioned costs due to noncompliance with documentation requirements. A new system was implemented in August 2025 which improved the deficiencies and compliance matters for the remainder of the year. Corrective Actions Taken or Planned: The Organization started using features within Gusto beginning in August 2025 that capture employee name, pay period, hours worked by funding source, detailed notes (if applicable) and supervisory approval. The Organization trained all staff whose salaries are charged in whole or in part to grants on documentation and time allocation requirements. Monthly timesheets charged to grants are reviewed before submission for reimbursement. All timesheets require approval by a supervisor before payroll is processed and the final payroll requires two approvals by the CEO. Accounting Manager and/or the Development Manager. The Organization will conduct quarterly internal reviews to ensure compliance and adjust as needed.
Program: WaterSMART (Assistance Listing No. 15.507) Compliance Requirement: Matching Corrective Action Planned: The District will establish and maintain a grant monitoring process for all federally funded projects that include matching requirements. Management will maintain a grant tracking workshee...
Program: WaterSMART (Assistance Listing No. 15.507) Compliance Requirement: Matching Corrective Action Planned: The District will establish and maintain a grant monitoring process for all federally funded projects that include matching requirements. Management will maintain a grant tracking worksheet documenting cumulative project expenditures, federal funding received, and non-federal matching contributions. Prior to submitting reimbursement requests or drawing federal funds, management will review the tracking worksheet to verify compliance with applicable cost-sharing requirements. Management will also review grant award documents at the outset of each project and periodically throughout the grant period to ensure all compliance requirements, including matching provisions, are understood and followed. Responsible Official: Board President and District Management Planned Completion Date: Implemented upon issuance of the audit report and applicable to all future federal grant awards.
Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Respon...
Management's Response and Corrective Action Plan Fiscal Year 2025 Single Audit Finding Reference: 2025-001 & 2025-004 o Classification: Material Weakness in Internal Control Over Financial Reporting / Compliance o Target Completion Date: 120 Days (from the issuance of the final audit report o Responsible Officials: Finance Director, Director of Information Systems and the Municipal Advisor Management's Response & Corrective Action Plan: Concurrence with the Findings: The Management of the Municipality of Corozal concurs with the conditions and recommendations outlined in Findings 2025-001 and 2025-004 We acknowledge that the recent migration of our core accounting system compromised the system's operational and technical capacity to generate balanced trial balances, reconcile subsidiary ledgers, and streamline the automatic production of the Schedule of Expenditures of Federal Awards (SEFA). Corrective Actions to be Implemented: To resolve these deficiencies systematically and ensure full compliance with Government Auditing Standards and the Uniform Guidance (2 CFR 200), the Municipality will execute the following action plan within a strict 120-day timeframe: 1. System Re-alignment & Expert Remediation (Led by: Director of Information Systems and the Municipal Advisor): The Municipality will immediately retain specialized software implementation engineers and municipal accounting consultants to trace the migration mapping errors. This team will re-align the platform's database structure to correct the corrupted historical financial data and prior-period balances. 2. Opening Balance Reconstruction (Led by: Finance Director & Municipal Advisor): A formal data-clearing project will be established to reconstruct, cross-reference, and validate all opening balances transferred from the legacy system against the prior year's audited financial statements to restore data integrity. 3. Interim Manual Tracking for Federal Programs (Led by: Finance Director): To address the risks highlighted in Finding 2025-004 the Finance Department will immediately implement an interim manual spreadsheet tracking matrix. This will ensure all federal expenditures across all active Assistance Listings (ALN) are manually reconciled with federal drawdowns and physical invoices until the core accounting database is completely functional. 4. Closing Controls & Migration Policies (Led by: Joint Committee): We will design and implement rigid monthly closing routines and formal trial balance reviews. Furthermore, we will establish strict IT transition frameworks requiring dual-system running periods and mandatory data-integrity sign-offs before any future application or ledger upgrades are deployed. Should you have any questions or require additional information, please do not hesitate to contact the undersigned at (787) 859-3060, ext. 1703. Sincerely Jose A Rivera Miranda Finance Director
2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The College did not report information to NSLDS in a timely manner, enrollment was not being certified every 60 days, and information being reported was inaccurate. Recommendation: Management should review and u...
2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The College did not report information to NSLDS in a timely manner, enrollment was not being certified every 60 days, and information being reported was inaccurate. Recommendation: Management should review and update internal control processes over NSLDS reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The college’s financial aid team has scheduled time for NSLDS reporting until the National Student Clearinghouse reporting has been confirmed by the Department of Education. Name(s) of the contact person(s) responsible for corrective action: Wendy Davis Planned completion date for corrective action plan: 06/26/2026
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