Corrective Action Plans

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As of July 2024, DOH revised drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted at certification level of certification. DOH have also incorporated this updated procedure into Federal Gra...
As of July 2024, DOH revised drawdown Standard Operating Procedures (SOPs) to mandate that all supporting documents include a signature or initial to certify that a proper review was conducted at certification level of certification. DOH have also incorporated this updated procedure into Federal Grants update trainings and made it accessible to all staff on Business Process Improvement SharePoint site.
As part of the close-out process, all open purchase orders are now submitted to the Department of Finance for closure. The grant close-out process has been shifted to the OMB to ensure the grant is no longer available for transaction entries or liquidations. Additionally, a dedicated Federal Grants ...
As part of the close-out process, all open purchase orders are now submitted to the Department of Finance for closure. The grant close-out process has been shifted to the OMB to ensure the grant is no longer available for transaction entries or liquidations. Additionally, a dedicated Federal Grants Financial Analyst is being integrated into the workflow to ensure compliance. Additionally, a Director of Federal Grants has been onboarded to add an additional level of oversight.
While the ERP provides a overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. DHS has als...
While the ERP provides a overall expense report, a specific liquidation report has been developed to ensure that matching is completed with each report submission. Additionally, a program specific Federal Grants Financial Analyst with the sole focus on the Supplemental Nutrition Program. DHS has also onboarded a Director of Federal Grants to oversee the financial management of the program. Lastly, a Director of Audit and Compliance has been onboarded. Once the audit team is developed, support and compliance monitoring will be provided to ensure compliance.
2024-010 – EDUCATION STABILIZATION FUND - LACK OF SUPPORT OVER ESSER FUNDS – ALN 84.425 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 was unable to provide supporting documentation for expenses charged to the Education Stabilization Fund. 13 of ...
2024-010 – EDUCATION STABILIZATION FUND - LACK OF SUPPORT OVER ESSER FUNDS – ALN 84.425 - MATERIAL WEAKNESS & MATERIAL NONCOMPLIANCE Condition: Williston Basin Public School District No. 7 was unable to provide supporting documentation for expenses charged to the Education Stabilization Fund. 13 of the 60 we sampled did not have any support, leaving them with known questioned costs of $171,408. Management’s Response: We agree. WBSD#7 created a new Grants Coordinator position in July 2023 with one of the specific responsibilities for that position being oversight of all Federal programs. This oversight responsibility includes monitoring expenditures to ensure all expenditures are allowable within the parameters of each program and also that proper documentation for those expenditures has been maintained. It has taken the district some time to get this area cleaned up. Anticipated Completion Date: FY 2025
FINDING 2024-002 Finding Subject: Airport Improvement Program - Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Judy King, Clerk-Treasurer Contact Phone Number and Email Address: 219-474-5062, jmking1@purdue.edu Views of Responsible Officials: ...
FINDING 2024-002 Finding Subject: Airport Improvement Program - Special Tests and Provisions - Wage Rate Requirements Contact Person Responsible for Corrective Action: Judy King, Clerk-Treasurer Contact Phone Number and Email Address: 219-474-5062, jmking1@purdue.edu Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Still working on solutions but plan to have Airport Manager track payroll claims to make sure all payrolls are obtained and sign off on the payroll claims and make sure the correct wages are being paid. Anticipated Completion Date: Immediately 6/2025
The LEA funding that was budgeted and expended was consistent with expectations, as the required worksheet was completed and submitted to the State for approval of the original allotment. The issue identified in the finding appears to relate specifically to the ARP IDEA funding, which was an additio...
The LEA funding that was budgeted and expended was consistent with expectations, as the required worksheet was completed and submitted to the State for approval of the original allotment. The issue identified in the finding appears to relate specifically to the ARP IDEA funding, which was an additional allocation provided to the district well after the FY23/24 IDEA award was issued. The State did not communicate that revisions to the MOE were required; therefore, a revised version was not initially submitted. The district continued to receive grant approval despite the ARP IDEA allocation not being reflected in the original worksheet. This was not the result of a misunderstanding of MOE reporting requirements, insufficient training, or inadequate review processes to ensure data accuracy. Additionally, the district was not notified that supplemental documentation needed to be submitted. The district has received multiple commendations from the State for its effective management of IDEA funds. After this issue appeared in another district’s single audit, Pembroke revised and submitted the MOE through GMS to ensure all required funding and expenditure areas were accurately captured. Moving forward, the district will revise the MOE whenever additional funding is received to ensure all allocated and expended funds are included, regardless of whether formal notification is provided by the State.
The district continually monitors the food service program’s cash resources. During the fiscal year, a formal written plan was submitted to and approved by NSLP and implemented to reduce cash resources so they would not exceed the three-month average expenditure threshold. Although a plan was in pla...
The district continually monitors the food service program’s cash resources. During the fiscal year, a formal written plan was submitted to and approved by NSLP and implemented to reduce cash resources so they would not exceed the three-month average expenditure threshold. Although a plan was in place, the district was unable to fully implement the plan within the allotted timeframe. Moving forward, the district will ensure that the approved plan is fully executed prior to June 30.
The County will ensure that the Wage Rate Requirements for Federal grants are being used and reported accordingly. A copy of ODOT Quality Assurance Program will be obtained and referenced for all federal projects.
The County will ensure that the Wage Rate Requirements for Federal grants are being used and reported accordingly. A copy of ODOT Quality Assurance Program will be obtained and referenced for all federal projects.
Finding 2024-009: Reporting – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not maintain copies of performance-related reports submitted to the grantor for the Title V program. Corrective Action: Management is implementing a formal process t...
Finding 2024-009: Reporting – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not maintain copies of performance-related reports submitted to the grantor for the Title V program. Corrective Action: Management is implementing a formal process to retain all supporting documentation for performance-related reports submitted to grantors in accordance with Federal requirements. NACA is also hiring and training a Grant Director to strengthen oversight of grant reporting, compliance, and documentation requirements. As part of the monthly and grant reporting process, staff will ensure that copies of all submissions are saved. A review step will also be added to confirm that all required documentation has been retained prior to final submission. Management will continue to evaluate and adjust processes as needed to ensure compliance and completeness. Name of Person Responsible: Walter McCullough, CFO and finance staff Anticipated Date of Completion: May 31, 2026
Finding 2024-008: Cash Management – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not retain copies of cost reimbursement reports submitted to the grantor for the Urban Health Clinic, Substance Abuse Prevention, and Title V programs. Correct...
Finding 2024-008: Cash Management – Material Weakness Condition: As a result of the audit procedures, it was noted that the Organization did not retain copies of cost reimbursement reports submitted to the grantor for the Urban Health Clinic, Substance Abuse Prevention, and Title V programs. Corrective Action: Management is implementing a formal process to retain all cost reimbursement reports submitted to grantors in accordance with Federal record retention requirements. NACA is also hiring and training a Grant Director to strengthen oversight of grant reporting, reimbursement processes, and documentation requirements. This will include establishing a centralized and organized filing system, to ensure all submitted reimbursement reports are maintained and accessible. As part of the monthly reimbursement and grant reporting process, staff will ensure that copies of all submissions are saved and reconciled to the accounting records. A review step will also be added to confirm that all required documentation has been retained and properly organized prior to final submission. Management will continue to evaluate and adjust processes as needed to ensure compliance and completeness. Name of Person Responsible: Walter McCullough, CFO and finance staff Anticipated Date of Completion: May 31, 2026
Finding 1222573 (2024-004)
Material Weakness 2024
Life Academy will work to ensure that internal controls for federal awards are followed. Additionally, Life Academy has crafted a Policy and procedure manual that emphasis roles for various personnel within the district. Anticipated Implementation Date: Before October 1, 2025 Responsible Party: Chie...
Life Academy will work to ensure that internal controls for federal awards are followed. Additionally, Life Academy has crafted a Policy and procedure manual that emphasis roles for various personnel within the district. Anticipated Implementation Date: Before October 1, 2025 Responsible Party: Chief School Financial Officer, Federal Programs Director, Operations, and Superintendent.
Finding 2024-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part ...
Finding 2024-002 Congressionally Mandated Projects / Davis-Bacon Act Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
Finding 2024-001 Congressionally Mandated Projects / Reporting Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the...
Finding 2024-001 Congressionally Mandated Projects / Reporting Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action: Management accepts the recommendation. Management is in the process of developing a template checklist that will be completed as part of the RFP and contract process. Any project that meets additional standards requirements, the checklist will be required and will be maintained for the duration of the project with monthly review at the Executive level to ensure compliance is being met. Responsible Official: Andrew Ferris Chief Financial Officer Kansas City Board of Public Utilities
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a verification framework. We are prioritizing the formalization of inter-agency data sharing agreements, the implementation of standardized income validation protocols, and the execution of a comprehensive training program to ensure a...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to establishing a verification framework. We are prioritizing the formalization of inter-agency data sharing agreements, the implementation of standardized income validation protocols, and the execution of a comprehensive training program to ensure all regional staff adhere to federal IEVS requirements. Action Steps: 1. MOU Formalization – Execute and maintain active Memoranda of Understanding (MOUs) with all relevant agencies to secure legal access to real-time wage, unemployment, and benefit data. 2. Develop and mandate a new "Income Eligibility Validation SOP". This protocol will strictly forbid reliance on sworn statements alone and will require technicians to cross-reference application data against verified external agency sources. 3. Integrated Data Exchange Protocol – Implement a recurring, automated schedule for the ingestion of SWICA, UC, and BENDEX/SSA data into our internal eligibility systems, ensuring data is available to technicians at the point of application and during quarterly reviews. 4. Implement a Training Curriculum – Launch a recurring, mandatory training program for all regional eligibility technicians and supervisors, focusing on federal IEVS requirements, standardized data validation procedures, and the legal consequences of non-compliance. 5. Implement a monthly "Eligibility Quality Assurance" review, where central-level management audits a sample of case files to ensure that income has been verified against external sources as required by the State Plan. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Eddie J. Burgos Auxiliary Administrator for Finance and Budget Carlos Martinez Colón Finance Director Vanessa Ayala Gerena Director of Budget Gerhil Medina Baez Auxiliary Administrator Operational Services
VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family and PR-DDS acknowledge the audit finding regarding the differences identified between the balances reported on Form SSA-4513, the PRIFAS accounting records, and the supporting documentation for unliquidated obligations. To address this issu...
VIEWS OF RESPONSIBLE OFFICIALS The Department of the Family and PR-DDS acknowledge the audit finding regarding the differences identified between the balances reported on Form SSA-4513, the PRIFAS accounting records, and the supporting documentation for unliquidated obligations. To address this issue, the following corrective actions will be implemented: 1. Monthly meetings will be held between the Department of the Family’s Finance staff and PR-DDS administrative and fiscal personnel to review and monitor all outstanding obligations and any differences identified between the PRIFAS records and the reports prepared for the Social Security Administration (SSA). 2. A formal monthly reconciliation will be performed between the balances reported on Form SSA-4513 and the financial records maintained in PRIFAS. Any discrepancies identified will be analyzed, documented, and supported with appropriate evidence. 3. Differences between the PRIFAS records and valid obligations that are not reflected in the system will be explained and documented in the comments section of Form SSA-4513, as applicable. 4. The review process for unliquidated obligations will be strengthened through periodic evaluations to identify obligations that should be modified, liquidated, or canceled in accordance with SSA requirements. 5. Written internal procedures will be developed for the preparation, review, and approval of Form SSA-4513, including the retention of supporting documentation necessary to substantiate the reported balances. Management further notes that certain obligations related to Medical Evidence of Record (MER) and Applicant Travel (AT) are authorized and monitored by PR-DDS before the related disbursements occur. These obligations are not recorded in the PRIFAS accounting system until payment is processed by the Special Payments Office (OPE). As a result, temporary differences may exist between the balances reflected in PRIFAS and the unliquidated obligations reported on Form SSA-4513. To address this situation, PR-DDS and the Department of the Family’s Finance Office have established a monthly reconciliation process to identify, document, and explain all temporary differences between PRIFAS records and the obligations maintained by PR-DDS. In addition, any significant differences will be properly disclosed and explained in the comments section of Form SSA-4513 and supported by the appropriate documentation. IMPLEMENTATION DATE The monthly meetings and formal reconciliation process began during Fiscal Year 2026 and will continue an ongoing basis. Expected Completion Date: September 30, 2026 RESPONSIBLE PERSON Ramón Luis Vargas Escalante Chief Accountant of Finance
VIEWS OF RESPONSIBLE OFFICIALS For the purpose of strengthening compliance with the requirements established under the Federal Funding Accountability and Transparency Act (FFATA) and other applicable federal regulations, ACUDEN developed a Standard Operating Procedure (SOP) that establishes clear an...
VIEWS OF RESPONSIBLE OFFICIALS For the purpose of strengthening compliance with the requirements established under the Federal Funding Accountability and Transparency Act (FFATA) and other applicable federal regulations, ACUDEN developed a Standard Operating Procedure (SOP) that establishes clear and uniform guidelines for the collection, validation, and reporting of information related to federal funds. This procedure defines the responsibilities of the areas involved in the management of federal awards, promotes the timely submission of accurate and complete reports, and ensures that processes related to the identification and reporting of eligible subawards are carried out. IMPLEMENTATION DATE July 15, 2026 RESPONSIBLE PERSON Rafael E. Vargas Ortiz Deputy Administrator
FINDING REFERENCE NUMBER 2024-033 (See Finding Reference Number 2024-012) – continuation VIEWS OF RESPONSIBLE OFFICIALS ADFAN will finalize and implement the revised Finance Procedures Manual, establish monitoring procedures for earmarking compliance, and assess staffing needs within the Finance are...
FINDING REFERENCE NUMBER 2024-033 (See Finding Reference Number 2024-012) – continuation VIEWS OF RESPONSIBLE OFFICIALS ADFAN will finalize and implement the revised Finance Procedures Manual, establish monitoring procedures for earmarking compliance, and assess staffing needs within the Finance area to strengthen oversight and ensure compliance with program requirements. IMPLEMENTATION DATE December 31, 2026 RESPONSIBLE PERSON Yazmín Cruz Colón, Budget Director
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to leveraging the new Government ERP for Matching, LOE, and Earmarking functions, while implementing a tracking system to document the MOE requirement. We will ensure that all data is traceable, accurate, and fully reconcilable to our core financial ...
VIEWS OF RESPONSIBLE OFFICIALS ADSEF is committed to leveraging the new Government ERP for Matching, LOE, and Earmarking functions, while implementing a tracking system to document the MOE requirement. We will ensure that all data is traceable, accurate, and fully reconcilable to our core financial records. Action Steps: 1. Implement an MOE Tracking Tool - To secure, centralized "MOE Compliance Repository". This system will ingest raw expenditure data, map it to TANF-eligible families, and provide an audit-ready trial for the $21.1M requirement. 2. Inter-Agency Data Integration - Establish a formal Data Sharing Agreement and automated interface with ASES (and other contributing agencies) to push expenditure data directly into our MOE repository, eliminating manual reliance on partner reports. 3. Automated Segregation of Duties - Configure the workflow to enforce a mandatory "Preparer-Approver-Certifier" process. The system will prevent report submission unless it has been digitally signed by the designated Finance Officer after reconciliation. 4. Reconciliation Controls - Implement a "Cross-System Reconciliation Control" 5. Appointment of Compliance Official - Designate an MOE Compliance Officer responsible for the continuous, year-round monitoring of expenditure levels and for coordinating inter-agency requests for documentation. IMPLEMENTATION DATE During Fiscal Year 2026-2027 RESPONSIBLE PERSON Waleska Lopez Faria Assistant Secretary for Human Resources Assistant Administrator on Administration – Eddie Burgos Budget Director – Vanessa Ayala Financial Director – Carlos Medina
VIEWS OF RESPONSIBLE OFFICIALS The PRDF Human Resources Department will conduct personal file reviews at the beginning of next fiscal year; to include any missing paperwork and the department will establish as a procedure a periodical review of all files. IMPLEMENTATION DATE First quarter of Fiscal ...
VIEWS OF RESPONSIBLE OFFICIALS The PRDF Human Resources Department will conduct personal file reviews at the beginning of next fiscal year; to include any missing paperwork and the department will establish as a procedure a periodical review of all files. IMPLEMENTATION DATE First quarter of Fiscal Year 2026-2027 RESPONSIBLE PERSON Waleska Lopez Faria Assistant Secretary for Human Resources
Response and Corrective Action Plan: The District will review current processes and determine procedures to implement to ensure proper invoice approval, coding and allowability.
Response and Corrective Action Plan: The District will review current processes and determine procedures to implement to ensure proper invoice approval, coding and allowability.
A process has been put in place where we use bill.com to keep all backup documentation for expenditures. The backup documentation is entered with the invoice for payment.
A process has been put in place where we use bill.com to keep all backup documentation for expenditures. The backup documentation is entered with the invoice for payment.
Finding 1220081 (2024-005)
Material Weakness 2024
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Responsible Officials: We concur wit...
FINDING 2024-005 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Burzynski Thaddeus Contact Phone Number and Email Address: 219-755-3200, burzytx@lakecountyin.org Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: The County will develop and implement a proper system of internal controls and segregation of duties. This will ensure accuracy and correctness of all quarterly P & E Reports in the future. Anticipated Completion Date: December 2026
Recommendations: Management should discontinue charging rent equivalents or mortgage payment amounts to federal programs for owned facilities. Going forward, management should charge allowable facility costs using depreciation, computed in accordance with Uniform Guidance and properly allocated to b...
Recommendations: Management should discontinue charging rent equivalents or mortgage payment amounts to federal programs for owned facilities. Going forward, management should charge allowable facility costs using depreciation, computed in accordance with Uniform Guidance and properly allocated to benefiting programs. Management should also ensure that any interest costs charged to federal awards, if any, are specifically allowable under Uniform Guidance and the terms of the award and are supported by appropriate documentation and approvals. Views of responsible officials and planned corrective actions: Management acknowledged the finding and stated that the occupancy charges were intended to recover facility costs incurred in operating the federal program. Management indicated that policies and procedures will be updated to ensure compliance with Uniform Guidance requirements for charging facility costs to federal awards. Anticipated Completion Date: September 30, 2026
Management has implemented procedures to ensure that prior to the disposition or sale of surplus assets identified as federally funded, the Parish will request disposition instructions from the federal awarding agency as required by 2 CFR 200.313(e).
Management has implemented procedures to ensure that prior to the disposition or sale of surplus assets identified as federally funded, the Parish will request disposition instructions from the federal awarding agency as required by 2 CFR 200.313(e).
Finding 1218367 (2024-003)
Material Weakness 2024
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the Organization develop and implement formal policies and procedures to ensure required performance reports are prepared, reviewed, and submitted in a timely manner. Such procedures should...
Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Recommendation: We recommend the Organization develop and implement formal policies and procedures to ensure required performance reports are prepared, reviewed, and submitted in a timely manner. Such procedures should include clearly defined roles and responsibilities, tracking of reporting deadlines, and documented evidence of supervisory review and approval prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The finding was related to a one-time ARPA grant during a period of staff transition, where performance reports were not consistently documented as reviewed and approved prior to submission. Since then, management has implemented formalized procedures for grant reporting. All performance reports are now prepared by designated program staff, tracked against reporting deadlines, and subject to supervisory review and approval by the Executive Director prior to submission. These procedures establish clear roles and responsibilities and ensure timely, documented review and submission of required reports. Name(s) of the contact person(s) responsible for corrective action: Monique Valenzuela, Executive Director and Theo Everhearts, Senior Director of Finance. Planned completion date for corrective action plan: June 2024
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