Corrective Action Plans

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Significant Deficiency Item 2025-007 - Cash Management - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we...
Significant Deficiency Item 2025-007 - Cash Management - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that there is no evidence of review and approval of drawdowns from the Health Center Program Cluster and the supporting records. Recommendation: We recommend that LBUCC implement a policy that requires all drawdowns and supporting documents to be reviewed and that such review and approval be documented. Action Taken: LBUCC revised the drawdown policy which now includes a review and approval from the CFO and the process is documented. Effectivity Date: Implemented 12/3/2025.
Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During ...
Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC conducted quarterly internal audit reviews of fifty (50) samples self-pay patients to review for sliding fee discount determination. However, we noted that the findings or exceptions identified in the quarterly internal audit review remained uncorrected. Recommendation: We recommend that LBUCC establish a process for communicating, investigating and correcting all internal audit findings or exceptions on a timely manner. Additionally, we recommend that management identify the potential cause of such findings or exceptions and that necessary corrective actions be taken to address such cause. For example, LBUCC may conduct periodic training of all employees involved in the patient intake and screening process. Action Taken: The internal audit process has been redesigned and expanded to include weekly reviews and all exceptions/errors will be corrected and the cause determined. Additional training will be provided with the expectation that the exceptions/errors will reduce going forward. Effectivity Date: This will be fully implemented by 1/31/2026
Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 Dur...
Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC charged salaries to the Section 330 grant based on pre-determined allocations or budget rather than actual hours worked. LBUCC utilized timesheets that reflect the allocations as its time and effort documentation. Recommendation: We recommend that LBUCC implement a time and effort reporting system that tracks actual hours worked on each program or grant. We recommend that they require supervisors to review and approve the actual time spent on grant activities and that such review and approval be documented. Action Taken: LBUCC will implement a time and effort reporting system to include a semi-annual certification for all employees funded by the HRSA 330 grant and a time card reporting system for those funded by multiple grants. Effectivity Date: Time and effort reporting will be implemented in January 2026 and fully in place by 1/31/2026
Name of auditee: Bishop (CSI) Non-Profit Housing Corporation HUD auditee identification number: 044-11134 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 5...
Name of auditee: Bishop (CSI) Non-Profit Housing Corporation HUD auditee identification number: 044-11134 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 586-753-9052 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2025-001: Effective May 1, 2025, the required monthly deposit to the reserve for replacements increased from $12,539 to $63,106 based on the capital needs assessment and replacement reserve analysis. The Corporation did not increase the monthly deposits and as of June 30, 2025, the reserve for replacements account is underfunded by $99,135. Comments on the Finding and Each Recommendation: Management should transfer $99,135 from the operating account in order to bring the reserve for replacements account current. Action(s) taken or planned on the finding: Agreed. On July 1, 2025, management transferred $99,135 to the reserve for replacements account.
Corrective Action Plan 1. Implement Automated Notifications (New and Long-Term Solutions) The institution will establish a two-phase approach to ensure timely and compliant Title IV disbursement notifications. New Process: A weekly report will be generated for Title IV loan disbursements with the co...
Corrective Action Plan 1. Implement Automated Notifications (New and Long-Term Solutions) The institution will establish a two-phase approach to ensure timely and compliant Title IV disbursement notifications. New Process: A weekly report will be generated for Title IV loan disbursements with the corresponding notifications sent to students. Financial aid staff will review the report to confirm that each required notification was issued within the regulatory timeframe. Any missing notifications will be immediately sent and documented. This interim process will remain in effect until full automation is implemented. Long-Term Automated Solution: The student information system will be configured to automatically generate and send Title IV disbursement notifications to students. Each notification will be sent no earlier than 30 days before, and no later than 30 days after, the crediting of Title IV loan funds to the student’s ledger account, as required by 34 CFR §668.165(a)(2). The system will also store a timestamped record of each notification in the student’s electronic file for audit and compliance verification. 2. Develop Written Procedures A formal institutional policy and procedural guide will be developed to define the timing, content, and method of Title IV disbursement notifications. This documentation will explicitly address regulatory requirements under 34 CFR §668.165(a) and outline staff responsibilities for monitoring and documentation. 3. Staff Training Financial Aid staff will receive training on the new automated notification process, including policy updates, system functionality, and documentation requirements. Completion of training will be tracked to ensure all relevant personnel are fully informed and able to implement the new procedures consistently. 4. Periodic Compliance Reviews Quarterly internal audits will be conducted to confirm that required notifications are being issued as scheduled and properly documented in each student’s record. Any discrepancies identified will result in immediate corrective measures and additional staff coaching as needed. Responsible Party Director of Financial Aid Timeline for Completion - New System Implementation: Immediate - Long-Term Solution: Work with software provider and IT for options to implement this process - Policy Documentation & Staff Training: Within 90 days - First Compliance Review: Within 90 days
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: The incorrect withdrawal date was reported to the National Student Loan Database System...
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: The incorrect withdrawal date was reported to the National Student Loan Database System (“NSLDS”) for four of the nine students selected for testing that received Federal Direct Student Loans. Corrective Action Plan: Management agrees with the auditors’ finding and their recommendation. The Financial Aid Director updated the enrollment status for the students in question in December 2025. Procedures will be improved to ensure that a student’s enrollment status is updated timely and with the correct date of the change. Anticipated Completion Date: The corrective action was completed in December 2025. Contact Person: Stephanie Dickerson, Registrar/Financial Aid 910-323-5614
Views of Responsible Officials: The Office of the Registrar has continued to struggle with our reporting using the Ellucian product Power Campus. Since Ellucian is sunsetting this product, there have been significant changes in their support due to changes in their staffing. Ellucian employees with ...
Views of Responsible Officials: The Office of the Registrar has continued to struggle with our reporting using the Ellucian product Power Campus. Since Ellucian is sunsetting this product, there have been significant changes in their support due to changes in their staffing. Ellucian employees with more knowledge in NSC reporting have been transferred to their other products, leaving very little knowledge to support our efforts. We are fortunate to work with our current consultant who does seek resources regarding our inability to have a report that works accurately. She has reviewed and rewritten the report. However, according to her support team, they have now admitted that the report will never run correctly using our current version. They have suggested that we upgrade to a different version with corrections but that is impossible currently. With this knowledge, GCU has purchased a new ERP system, Jenzabar, and has begun the implementation process. We are going into Phase 2 of this implementation and expect to go live in Spring 2027. It is our intention to continue to utilize our current Ellucian consultant until that occurs for us to continue to produce the most accurate reporting we can, given these circumstances.
FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA)-Earmarking Contact Person Responsible for Corrective Action: Chelsea Yon Contact Phone Number and Email Address: 812-354-8731 cyon@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective A...
FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA)-Earmarking Contact Person Responsible for Corrective Action: Chelsea Yon Contact Phone Number and Email Address: 812-354-8731 cyon@pcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Treasurer of Pike County School Corporation will work with Exceptional Children’s Co-op on proportionate share expenditures. PCSC will also track those expenditures in a separate line along with revenue received for the proportionate share. Anticipated Completion Date: This method was implemented in the 2025-2026 school year and will continue with each school year as needed.
The University should take steps to provide loan disbursement notifications to all required students.
The University should take steps to provide loan disbursement notifications to all required students.
The City will ensure financial activity for the funds BOK manages for the City are included in the City general ledger and are reported in the Annual Financial Report in the future.
The City will ensure financial activity for the funds BOK manages for the City are included in the City general ledger and are reported in the Annual Financial Report in the future.
Finding Number Federal Programs Audit: 2025-001; Responsible Person: Rachelle Roby; Management Views: Management agrees with the finding and is in the process of implementing the recommendation.; Corrective Action: The District will collaborate with the Director of Food Service to ensure that, when ...
Finding Number Federal Programs Audit: 2025-001; Responsible Person: Rachelle Roby; Management Views: Management agrees with the finding and is in the process of implementing the recommendation.; Corrective Action: The District will collaborate with the Director of Food Service to ensure that, when a physical count is conducted, the figures are verified by a second staff member for accuracy. Additionally, it will be required that all supporting documentation be submitted to the Chief Financial Officer (CFO) along with the claim figures. The CFO will review and compare the documentation against the data entered into the claiming system prior to the submission of the claim.; Anticipated Completion Date: 08/01/2025
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2025, which resulted in the reserve for replacements account being underfunded by $1,205 as of June 30, 2025. The management agent should t...
Comments on the Finding and Each Recommendation: The Corporation did not make the total required reserve for replacement deposits during the year ended June 30, 2025, which resulted in the reserve for replacements account being underfunded by $1,205 as of June 30, 2025. The management agent should transfer funds of $1,205 from the operating account in order to bring the reserve for replacements account current. Action(s) taken or planned on the finding Management agrees with the recommendation. Management transferred $1,205 from the operating account to the reserve for replacements account on August 26, 2025. No further action is required.
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2025, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical ...
Comments on the Finding and Each Recommendation: The Corporation's Flexible Subsidy Loan was due in full upon maturity of the Corporation's Section 202 mortgage loan, which occurred in March 2017. As of June 30, 2025, the Flexible Subsidy Loan has not been repaid and the Corporation is in technical default on the Flexible Subsidy Loan. Management should continue communicating with HUD in order to obtain approval for the deferment request for the Section 201 Flexible Subsidy Loan. Action(s) taken or planned on the finding Management agrees with the recommendation. Management has submitted a request for deferment of the Flexible Subsidy Loan. Management is awaiting HUD approval of the deferment request.
Management has implemented a year-end reconciliation for all grant funds. Due to the timing of this grant - the District was able to capture the overpayment in the August 2025 expenditure report and therefore, no overpayment was owed. The District does not expect this finding to repeat again.
Management has implemented a year-end reconciliation for all grant funds. Due to the timing of this grant - the District was able to capture the overpayment in the August 2025 expenditure report and therefore, no overpayment was owed. The District does not expect this finding to repeat again.
Auditor Description of Condition and Effect. During our cost of attendance recalculation, we noted that for one student, an additional semester in which the student was not taking any classes was included in their calculation. As a result of this condition, the College overstated the student's finan...
Auditor Description of Condition and Effect. During our cost of attendance recalculation, we noted that for one student, an additional semester in which the student was not taking any classes was included in their calculation. As a result of this condition, the College overstated the student's financial need for the award year. However, no action was required by the College as the corrected cost of attendance still exceeded the student's awards. Auditor Recommendation. We recommend that the College implement a review process to ensure that all manual entries into the cost of attendance system are reviewed and approved by an independent second individual. Auditor Recommendation. We recommend that the College implement a review process to ensure that all manual entries into the cost of attendance system are reviewed and approved by an independent second individual. Corrective Action. Upon discovery of the cost of attendance calculation error, the College went through and determined that this was an isolated incident and had no impact on the amount of aid received by the student. To prevent a similar problem arising in the future, the College will implement a review process to have a second individual review and ensure the cost of attendance is being calculated accurately. Responsible Person. Michelle McNier, Director of Financial Aid. Anticipated Completion Date. June 30, 2026.
Corrective Action Plan: The Authority is now aware of the quarterly reporting requirements. The Authority has developed and implemented procedures to ensure that all future reports will be submitted timely. Anticipated Completion Date: Ongoing Contact Person Responsible: Jennie Weary, Secretary, Bar...
Corrective Action Plan: The Authority is now aware of the quarterly reporting requirements. The Authority has developed and implemented procedures to ensure that all future reports will be submitted timely. Anticipated Completion Date: Ongoing Contact Person Responsible: Jennie Weary, Secretary, Barry Enck, Treasurer
2025 – 003 Suspension and Debarment – Assistance Listing Number 10.553, 10.555, 10.559 Recommendation: CLA recommends the District follow their suspension and debarment policy which includes vendor verification prior to entering into a contract for suspension and debarment for covered transactions. ...
2025 – 003 Suspension and Debarment – Assistance Listing Number 10.553, 10.555, 10.559 Recommendation: CLA recommends the District follow their suspension and debarment policy which includes vendor verification prior to entering into a contract for suspension and debarment for covered transactions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The District will review its policy related to suspension and debarment and is reviewing procedure to ensure requirements are consistently followed. Name(s) of the contact person(s) responsible for corrective action: Kelly Fassbender Planned completion date for corrective action plan: June 30, 2026
FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Jacob Heuchan, Business Manager Contact Phone Number and Email Address: 317-878-2100, jheuchan@nhj.k12.in.us Views of Responsible Officials: We concur with the finding. Descripti...
FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Eligibility Contact Person Responsible for Corrective Action: Jacob Heuchan, Business Manager Contact Phone Number and Email Address: 317-878-2100, jheuchan@nhj.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The Business Manager and Food Service Director will work together to implement a system of controls surrounding eligibility. The Business Manager and Food Service Director will meet on a regular basis to verify eligibility outcomes to ensure accuracy. Anticipated Completion Date: Immediate. INDIANA STATE
Finding 2025-001 – Allowable Costs The BOCES concurs with the finding 2025-001. Corrective Action: The BOCES will implement the following corrective actions to be completed by November 30, 2025: 1. The BOCES will develop and implement new written policies and procedures for time and effort reporting...
Finding 2025-001 – Allowable Costs The BOCES concurs with the finding 2025-001. Corrective Action: The BOCES will implement the following corrective actions to be completed by November 30, 2025: 1. The BOCES will develop and implement new written policies and procedures for time and effort reporting. 2. All grant-funded employees will receive training on the new procedures. 3. The BOCES will implement a new system to track and certify employee time. Contact Person: Daniel Henner, Business Administrator (315) 796-9902 dhenner@herkimer-boces.org
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Special Tests and Provisions Finding Summary: a. One instance was identified where documentation for both the initial home visit and the 30-day follow-up home visit was missing fr...
Federal Agency Name: Department of State Assistance Listing Number: 19.510 Program Name: U.S. Refugee Admissions Program Special Tests and Provisions Finding Summary: a. One instance was identified where documentation for both the initial home visit and the 30-day follow-up home visit was missing from the participant file. No case activity or other documentation was able to be provided to indicate that these visits were conducted in accordance with the federal program. b. One instance was identified where an expense was paid and reimbursed under the grant without evidence of a formal request, invoice support, review, or approval. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on required documentation needed to maintain a complete case file, and that documentation is being completed and retained. Anticipated Completion Date: December 31, 2025
Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: Two instances were identified where the participant was underpaid based upon eligibility for one mont...
Federal Agency Name: Department of Health and Human Services Assistance Listing Number: 93.566 Program Name: Refugee and Entrant Assistance - State Administered Programs Eligibility Finding Summary: Two instances were identified where the participant was underpaid based upon eligibility for one month. Responsible Individuals: Nathan Beyer, Staci Jonson, Dana Boraas Corrective Action Plan: Procedures will be reviewed with staff to ensure staff are fully trained on how to calculate eligibility, and to ensure proper documentation is retained when there are barriers to determining that eligibility. Anticipated Completion Date: December 31, 2025
The Greenwood Housing Authority provided a Corrective Action Plan with the audit packet to REAC indicating the housing will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Jackson Office of Public Housing requires...
The Greenwood Housing Authority provided a Corrective Action Plan with the audit packet to REAC indicating the housing will attain weekly certified payrolls from contractors as applicable for all federally funded contracts subject to the Davis-Bacon Act. The Jackson Office of Public Housing requires evidence of the following compliance efforts listed in the Corrective Action Plan: Contact Person Responsible For Corrective Action: Dr. Earl V. Hall, Executive Director Anticipated Completion Date: Fiscal Year Ending March 31, 2026
FINDING 2025-003 Finding Subject: COVID-19 - Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Todd Nobbe, Corporation Treasurer Contact Phone Number and Email Address: 812-934-2194, tnobbe@batesville.k12.in.us View...
FINDING 2025-003 Finding Subject: COVID-19 - Education Stabilization Fund - Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Todd Nobbe, Corporation Treasurer Contact Phone Number and Email Address: 812-934-2194, tnobbe@batesville.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Management will request and review weekly wage reports for all Davis-Bacon Act projects. Documents will be reviewed and signed off by the Director of Operations and kept for audit. Anticipated Completion Date: Immediately 12/08/2025
FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Internal Controls Contact Person Responsible for Corrective Action: Todd Nobbe, Corporation Treasurer Contact Phone Number and Email Address: 812-934-2194, tnobbe@batesville.k12.in Views of Responsible Officials: We concur with the finding....
FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Internal Controls Contact Person Responsible for Corrective Action: Todd Nobbe, Corporation Treasurer Contact Phone Number and Email Address: 812-934-2194, tnobbe@batesville.k12.in Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The school corporation will establish a proper system for internal controls and develop procedures to ensure free and reduced guidelines are reviewed by the Corporation Treasurer. The school corporation will establish a proper system for internal controls and develop procedures to ensure EFTs are reviewed by the Director of Operations. Anticipated Completion Date: Immediately 12/08/2025
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