Corrective Action Plans

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Condition: The Board could not provide a copy, with supporting documentation, of the annual required information submission to the Alabama Department of Education for the federal program. Planned Corrective Action: The Board will keep a copy of all annual required federal programs submission and sup...
Condition: The Board could not provide a copy, with supporting documentation, of the annual required information submission to the Alabama Department of Education for the federal program. Planned Corrective Action: The Board will keep a copy of all annual required federal programs submission and supporting documentation to the Alabama State Department of Education. Anticipated Completion Date: Effective immediately Point of Contact: Gwendolyn Rogers
Condition: Construction contracts for three federally funded projects did not include the required prevailing wage rate clauses. Monitoring for compliance with the prevailing wage requirements was not performed by the Board. Planned Corrective Action: Going forward, all federally funded construction...
Condition: Construction contracts for three federally funded projects did not include the required prevailing wage rate clauses. Monitoring for compliance with the prevailing wage requirements was not performed by the Board. Planned Corrective Action: Going forward, all federally funded construction projects will include the prevailing wage rate clauses. The Board will monitor for compliance with the prevailing wage requirements. Anticipated Completion Date: Effective immediately Point of Contact: Dr. Timothy Thurman
View Audit 360698 Questioned Costs: $1
Title: Housing Choice Voucher Program Name: Section 8 Housing Choice Vouchers ALN: 14.871 Description: During the audit of the Authority, it was noted that federal funds were inappropriately loaned to affiliated entities without proper authorization or adherence to federal cash management requir...
Title: Housing Choice Voucher Program Name: Section 8 Housing Choice Vouchers ALN: 14.871 Description: During the audit of the Authority, it was noted that federal funds were inappropriately loaned to affiliated entities without proper authorization or adherence to federal cash management requirements. Specifically, the entity disbursed $43,533 in federal funds to the Housing Authority of Florence under the guise of a temporary loan, which was not supported by a formal agreement, lacked board approval, and was not repaid within the fiscal year. Planned Corrective Action: Today’s Marlboro County Housing Authority management concurs with the auditor’s finding that federal funds were disbursed to an affiliated entity without proper authorization, documentation, or compliance with federal cash management requirements. The Authority acknowledges that this disbursement represented a lapse in internal controls and was not consistent with the requirements outlined in 2 CFR §200.305(b). During the fiscal year ended September 30, 2024, the Authority also had a payable to the same affiliate in its Public Housing Program totaling $37,658. During the current 2024-2025 fiscal year, the Authority reimbursed its HCV program the amount loaned from its HCV program by the funds owed to the affiliate in its Public Housing Program. Today’s Marlboro County Housing Authority currently has an amount of $2,015 due to its affiliate as of May 31, 2025.
View Audit 360695 Questioned Costs: $1
Finding 569028 (2024-002)
Significant Deficiency 2024
Condition: The county did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action Plan: The county f ill adopt needed policies per Uniform Guidance Responsible Official: Austin Hazelti,re, County Coordinator Expected Date of Completion: Dec ...
Condition: The county did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action Plan: The county f ill adopt needed policies per Uniform Guidance Responsible Official: Austin Hazelti,re, County Coordinator Expected Date of Completion: Dec mber 31, 2025
Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Offici...
Finding 2024-004 Federal Grantor: United States Department of Health and Human Services Planned Corrective Actions: Management will improve internal controls to include the documentation and retention of approval on all supply expenditures and the annual fringe benefit analysis. Responsible Official – Dawn Ksepka, VP of Finance and System Controller Anticipated completion date –August 2025 Management agrees with the finding. Remediation: The accounting manager reviewed and approved the updated 2025 fringe benefit analysis with 2024 actuals on February 28, 2025. Upon finalization of the 2025 budget, the analysis will be revised and reviewed again. Accounting will collect evidence of review and approval of supply expenditure throughout the year to ensure proper retention of the documentation.
The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expens...
The METRO Vanpool Department, in collaboration with the Grant Programs Administration Division, has initiated actions to strengthen internal controls and improve compliance with federal cost principles. These actions include: • Updating existing policies and procedures related to grant-funded expense transactions; • Developing guidance to ensure transactions are appropriately reviewed for allowability, allocability, and reasonableness; • Enhancing training for relevant personnel to reinforce understanding and application of award-specific terms and conditions; • Ensuring compliance with 2 CFR § 200.403 and § 200.303. These process improvements and control enhancements will be finalized and implemented no later than December 31, 2025, under the direction of the Director, Commuter Services. METRO believes these steps will ensure compliance and mitigate recurrence of similar findings in future audit periods.
View Audit 360643 Questioned Costs: $1
Sliding Fee Application ‑ Background: As sample testing of the program was performed during the 2024 annual financial audit, it was determined that the error rate for retention of applications and accuracy of slide application to charges required additional administrative oversight with attention t...
Sliding Fee Application ‑ Background: As sample testing of the program was performed during the 2024 annual financial audit, it was determined that the error rate for retention of applications and accuracy of slide application to charges required additional administrative oversight with attention to audit standards. Action Plan: Policies and Procedures have been updated and will be presented to the Board of Directors for approval at the April 2025 meeting. The updates include: Inclusion of the application within the policy and procedure document; Review and verification of application by the CFO in addition to the Patient Assistance staff. This will include verification of documentation archival and retention for audit; Daily review of slide applications to charges by AR Staff for accuracy. Responsible Party: Wanda Kimball, Chief Financial Officer.
The Office of Financial Management and Budget (OFMB) has collaborated with County departments and agencies that administer grants to ensure staff are informed of and participate in relevant training opportunities related to State and Federal grants. In addition, OFMB continues to monitor grant activ...
The Office of Financial Management and Budget (OFMB) has collaborated with County departments and agencies that administer grants to ensure staff are informed of and participate in relevant training opportunities related to State and Federal grants. In addition, OFMB continues to monitor grant activity through established agenda review and grant reconciliation processes to identify and address potential errors or omissions and will provide guidance as needed.
Finding 568859 (2024-002)
Significant Deficiency 2024
Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor
Town will no longer be holding invoices until ARPA funding is received but will follow the reimbursement guidelines per the grant agreement. April 30th 2025 anticipated completion date. James A. Sullivan Mayor
Audit Finding: Item 2024-001: Error in Federal Funding Accountability and Transparency Act (FFATA) Reporting Contact Person Responsible for Corrective Action Plan: Justin Johnson, Director, Government Compliance and Internal Controls Email: jbjohnson@rti.org Phone Number: 919-541-6127 Corrective Act...
Audit Finding: Item 2024-001: Error in Federal Funding Accountability and Transparency Act (FFATA) Reporting Contact Person Responsible for Corrective Action Plan: Justin Johnson, Director, Government Compliance and Internal Controls Email: jbjohnson@rti.org Phone Number: 919-541-6127 Corrective Action Plan: Summary of Finding: FFATA requires non-federal entities to report each first-tier subaward action that obligates $30,000 or more to the FFATA Subaward Reporting System (FSRS). Our independent auditor found that a sampled subaward transaction was not reported timely to the FSRS. Corrective Action Implementation: RTI’s Government Compliance and Internal Controls department has taken the following actions to ensure the complete, accurate, and timely FFATA subaward reporting to FSRS: 1. On the automatically generated report of subaward actions to be reported to FSRS, correct the defective date parameters that prevented the subaward action from being reported timely. Completion Date: April 21, 2025. 2. On a semi-annual basis (fiscal year midpoint and fiscal year-end), manually generate the report of subaward actions to be reported to FSRS for the preceding six-month period and perform a secondary check for any actions that have not been reported timely. Completion Date: April 1, 2025.
Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and...
Person(s) responsible for corrective action: Todd Bolster, Director of Administration and Dietrich Schmitt, Grants Program Manager. Management’s Response/Corrective Action Plan: For this tribal pass-through program, narrative, non-financial progress reports are collected from tribes, reviewed and approved by the NWIFC Grants Program Manager and submitted to PSFMC. Effective immediately, the NWIFC grants program manager will increase internal controls by including documentation of internal review and approval prior to progress reports being submitted to PSMFC. Anticipated completion date: July 2025.
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent ...
Expenditures submitted for the Alabama Medicaid Administrative Claiming Program included expenditures suppported by federal funds and undocumented costs. Contact Person: Dr. Brock Nolin, Superintendent Corrective Action: Claims will be adjusted to correct the duplication of federal funds and undocumented costs. Policies and procedures will be implemented according to the recommendations found in the Schedule of Findings and Questioned Costs. Proposed Completion Date: Prior the submission of the July-September 2025 claim.
View Audit 360487 Questioned Costs: $1
Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written ...
Finding 2024-002 Condition: During the auditors’ walkthroughs of the cash draw process, the Organization indicated that there is a lack of evidence supporting preparation and review of federal drawdowns. Corrective action plan: Management agrees with the recommendation and will establish a written policy and implement a documented process for the preparation and review of federal drawdowns, including clear evidence of review such as signoffs or electronic approvals. Responsible Individual: Andres Chavarro, Finance Manager Planned Completion date: 07/01/2025
Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private ...
Re: FY23-24 Federal Single Audit Finding (2024-001) Name(s) of Contact Person(s) Responsible for Corrective Action: Sean Perez, Finance Director; Jeff Gilbreath, Executive Director Hawaiʻi Community Lending (HCL) is diligent and ensures all grant requirements are met for Federal, State, and private funding awards. Due to the transitioning of its Finance Directors upon the start of the FY23-24 audit, the proper procedures to correct the CDFI ERP project account were miscommunicated, and the Schedule of Expenditures for Federal Awards (SEFA) were not reduced to reflect the proper adjustments. The corrective action being taken by HCL leadership is to ensure all loans disbursed and charged to restricted grants are reviewed thoroughly by the Finance Director. The Finance Director will review all eligibility requirements that are met, to include the eligible mapping area, as required and provided by the funder. This thorough review of eligibility will ensure that all loans charged to restricted funding will be properly allocated and charged correctly. In addition to the thorough review mentioned above, HCL will develop procedures to review the SEFA, in detail, which is prepared by a third-party accounting vendor. The procedures will include an extensive review of expenditures by the Finance Director and subsequent review and approval by the Executive Director to ensure all expenses are eligible and allocated properly to our federal grants. Once the SEFA has been fully reviewed and approved by the Finance Director and Executive Director, it will be forwarded to the auditors. Additional staff may be involved in the review and eligibility confirmation process to ensure accuracy. Internal audits of expenditures will also be completed on a quarterly basis. The anticipated completion date of this corrective action plan is June 30, 2025. Mahalo, Jeff Gilbreath Executive Director Hawaiʻi Community Lending
1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Contro...
1) Effective 3/7/25, reports and requests for reimbursements are being reviewed, signed and dated by the Executive Director prior to submission to ensure the reports and requests for reimbursements are not incomplete or inaccurate; and 2) Financial Policy addressing the Deficiency in Internal Controls over Compliance were already in place during the audit period. These policies were reviewed by the Board of Directors on 6/11/25 and found to align with the best practices and compliance requirements. Following the audit, we have also taken steps to reinforce the adherence and ensure consistent implementation across all relevant areas. Responsible Parties: Brandi Senters, Finance Director, will be responsible for implementation, with oversight from Interim Executive Director, Bernie Jackson.
Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during t...
Management acknowledges the importance of maintaining accessible and complete documentation to support all transactions charged to federal grants. The inability to provide the requested approvals for certain transactions was due to the challenging security conditions in some country offices during the audit period. To strengthen documentation access and retention, the Organization has transitioned to NetSuite, where backup documentation for transactions is now stored centrally on the cloud and can be easily accessed by headquarters staff. This change enhances our ability to ensure timely review, approval, and audit readiness, regardless of field conditions. We remain committed to continuous improvement of our internal controls and documentation practices. Responsible Person: Country Finance Directors
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25...
FINDINGS— FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL PROGRAMS DEPARTMENT OF AGRICULTURE 2024 – 002 Community Facilities Loans and Grants Recommendation: Management should continue to focus on making operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25, as required. Action taken in response to finding: The Hospital will continue to make operational improvements to achieve the minimum level of Historical Debt Service Coverage of 1.25 . Name of the contact person responsible for corrective action: Carli Taylor, Chief Financial Officer. Planned completion date for corrective action plan: December 31, 2025 If the Department of Health and Human Services has questions regarding this plan, please call Carli Taylor, Chief Financial Officer at 660.385.8716 .
Corrective Actions Taken or Planned: Create procedures by the type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required re...
Corrective Actions Taken or Planned: Create procedures by the type of required reporting by grantor, as necessary. The procedure will include what and how the required report will be completed, who will and/or should review the required report, including signature for proof, and when the required report should be completed. Procedures will be added to the accounting department procedures and shared with staff as necessary. This is a work in progress and will continue to be adjusted as necessary. Contact person(s) responsible for corrective action: Gina Brown, CFO Anticipated Completion Date: September 2025
Finding No. 2024-004: Financial Statement Preparation Responsible Individuals: Ona Arnold, Director of Operations and Finance Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2025
Finding No. 2024-004: Financial Statement Preparation Responsible Individuals: Ona Arnold, Director of Operations and Finance Corrective Action Plan: The Organization will establish and maintain documentation to support in-kind/matching balances. Anticipated Completion Date: September 30, 2025
Finding 567892 (2024-004)
Significant Deficiency 2024
Hips
DC
Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, emp...
Views of Responsible Officials: This deficiency was noted internally even before the auditors flagged it in April 2024. Effective April 2024, the allocation of salaries and wages to different grants was transferred back to the Finance Manager who has more information regarding the grants timing, employees involved, % of time spent et al. In addition, the salaries and wages allocation is now a prerequisite for the invoicing process every month. HIPS have already seen significant improvements in both accuracy in seeking salaries and wages reimbursement as well as in wages reconciliations against paychex reports. COLA adjustments will be recorded more accurately and approval documented. As of 2024, HIPS has also updated our HR policy to provide written documentation by the Operations Manager of COLA increases to each staff member when they are implemented.
Finding 567837 (2024-046)
Significant Deficiency 2024
Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the bi...
Finding 2024-046 Temporary Assistance for Needy Families, ALN 93.558 - Inappropriate TANF- Funded Emergency Foster Care Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS redetermined the Foster Care Title IV-E (Title IV-E) program eligibility after the birth certificate was identified and the youth was determined to be Title IV-E eligible. MDHHS will reclassify the funds to the appropriate funding source, allowing the department to claim Title IV-E for the eligible placement. For those cases in which Title IV-E funding is denied initially based on lack of a birth certificate or other documentation of citizenship, the Child Welfare Funding Specialists will continue to monitor the case for updated documentation in order to complete a redetermination of funding. Child Welfare Funding Specialists will be reminded to monitor cases for updated documentation during a Child Welfare Funding conference call in June 2025. Anticipated Completion Date June 30, 2025 Responsible Individual(s) Nancy Berger, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567769 (2024-043)
Significant Deficiency 2024
Finding 2024-043 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroact...
Finding 2024-043 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Practitioner Reimbursement Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has determined the primary remaining source for overlaps between fee-for-service and capitation payments is due to retroactive removal of Medicaid eligibility within Bridges. An upgraded interface fix was implemented during March 2025 to address several issues. This upgraded interface removed the existing limitations to mitigate the occurrence of retroactive disenrollment. Anticipated Completion Date Completed Responsible Individual(s) Latina McCausey, MDHHS Alexis Bond, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567768 (2024-042)
Significant Deficiency 2024
Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notificatio...
Finding 2024-042 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible Home Help Assistance Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS added the Electronic Document Management system (EDM) to MiAIMS in March 2023 and issued an Adult Services Notification to adult services staff, communicating that medical needs forms should be uploaded into EDM. MDHHS issued an Adult Services Notification to adult services staff during May 2025 to communicate the exceptions identified and remind them of the medical needs form requirements. MDHHS will develop a procedure to monitor the expiration of medical needs forms using the MiAIMS Plan of Care by August 2025. In addition, MDHHS will research potential options to automate monitoring of the medical needs forms in MiAIMS and determine if any necessary system changes are needed by December 2026. Anticipated Completion Date December 2026 Responsible Individual(s) Elaina Brown, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567767 (2024-041)
Significant Deficiency 2024
Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review proce...
Finding 2024-041 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS generates a monthly hospitalization report and distributes to adult services workers as part of the post-payment review process. MDHHS enhanced the report query to improve the data used to identify overlaps in services and timely recover payments. MDHHS implemented the updated query during June 2025. Also, MDHHS issued an Adult Services Notification to managers and directors during February 2025, informing them of the audit finding and reminding local office management of the expectation to thoroughly monitor and review the hospitalization reports to ensure timely and accurate action is taken by adult services workers. In addition, MDHHS reissued the Home Help Recoupment Process training and procedural resources during February 2025 to adult services workers who manage Home Help cases to ensure process steps are consistently followed. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown, MDHHS Michelle Martin, MDHHS
View Audit 360209 Questioned Costs: $1
Finding 567766 (2024-040)
Significant Deficiency 2024
Finding 2024-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, as we...
Finding 2024-040 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to work with DTMB on the underlying issues in Bridges causing these overpayment issues, as well as developing mitigation strategies to temporarily address the overpayment concerns while the more permanent system solutions are developed. MDHHS expects all remaining synchronization issues to be resolved once the remaining larger system changes are implemented in December 2025. Anticipated Completion Date December 31, 2025 Responsible Individual(s) Jamy Hengesbach, MDHHS
View Audit 360209 Questioned Costs: $1
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