Corrective Action Plans

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HIV Formula Care Grant (AL93.917) - Significant Deficiency 2025-001 Management agrees with the finding and will enhance the current processes. Subsequent to year end, management created a tool to ensure all elements of program income, as well as related expenses incurred, are properly tracked, repor...
HIV Formula Care Grant (AL93.917) - Significant Deficiency 2025-001 Management agrees with the finding and will enhance the current processes. Subsequent to year end, management created a tool to ensure all elements of program income, as well as related expenses incurred, are properly tracked, reported, and utilized in accordance with federal requirements. Additionally, written policies are being drafted to reflect these procedures. Implementation is expected by January 31, 2026.
Corrective Action Plan: To incorporate both the City Finance Department as well as a new Grant Writer position hired earlier this year, the City will update its internal control policy as it pertains to grant reimbursements. The City will define a workflow to allow for opportunities for the Grant Wr...
Corrective Action Plan: To incorporate both the City Finance Department as well as a new Grant Writer position hired earlier this year, the City will update its internal control policy as it pertains to grant reimbursements. The City will define a workflow to allow for opportunities for the Grant Writer and Finance to review draw requests prior to submission for reimbursement, especially for those grants with matching requirements. This workflow will include a checklist of required items, to include an accurate accounting of the required match, as well as signature lines for approval.
staff will work with the auditors to ensure that the single audit report is submitted to the federal clearing house in a timely manner
staff will work with the auditors to ensure that the single audit report is submitted to the federal clearing house in a timely manner
Finding 2025-001: Incorrect Federal Direct Loan Amounts – the auditor tested seventy-one files, sixty-seven of which were Federal Direct Loan recipients, and two students received incorrect loan amounts. It is recommended that the Institution refund $237 to the Department of Education and increase c...
Finding 2025-001: Incorrect Federal Direct Loan Amounts – the auditor tested seventy-one files, sixty-seven of which were Federal Direct Loan recipients, and two students received incorrect loan amounts. It is recommended that the Institution refund $237 to the Department of Education and increase controls over packaging direct loans. There is no action required for the $333 in underawarded subsidized loans, as the student is no longer a current student, so the Institution is unable to reclassify the loans. Comments on Finding and Recommendation(s): This was an oversight on previous FA advisor when prorating loans. Actions Taken or Planned: Employee was removed from role earlier in the year and intense training has been given to the replacement. All debts have been settled with the Department of Education and appropriate student ledgers updated.
Identifying Number: 2025-001 Finding: The Foundation and College did not timely refund a student’s credit balance. Contact person responsible for corrective action: Laura Reagan, Senior Director of Financial Affairs Corrective Actions Taken or Planned: The Student Billing system omitted the student ...
Identifying Number: 2025-001 Finding: The Foundation and College did not timely refund a student’s credit balance. Contact person responsible for corrective action: Laura Reagan, Senior Director of Financial Affairs Corrective Actions Taken or Planned: The Student Billing system omitted the student from the original refund list due to an inactive address in the system. The credit balance was identified on a routine review of the student billing aging report and subsequently processed. It was completed outside of the 14 day requirement. A process will be put in place to increase the frequency of the aging review to ensure any missed credit balances will be processed within the required time frame. Anticipated Completion date: June 30th, 2026
Managemet acknowledges they were not in compliance with the financial covenants ofthe bond. Management has been in contact USDA to keep them informed on thesituation and has put plans into place to improve the financial position of the District.
Managemet acknowledges they were not in compliance with the financial covenants ofthe bond. Management has been in contact USDA to keep them informed on thesituation and has put plans into place to improve the financial position of the District.
The management agent will repay the funds on behalf of the related party housing project until that property has funds available, pending HUD approval.
The management agent will repay the funds on behalf of the related party housing project until that property has funds available, pending HUD approval.
Management agrees and is working to submit a RAD for PRAC application that would include this property and two other properties.
Management agrees and is working to submit a RAD for PRAC application that would include this property and two other properties.
Name of Contact Person – Matt Flett, Chief Financial Officer Corrective Action Plan The District will immediately re-implement monthly personnel activity reports for employees with multiple funding sources and semi-annual certifications for staff 100% funded by a federal grant. Grant program manager...
Name of Contact Person – Matt Flett, Chief Financial Officer Corrective Action Plan The District will immediately re-implement monthly personnel activity reports for employees with multiple funding sources and semi-annual certifications for staff 100% funded by a federal grant. Grant program managers, building administrators, and federally funded staff will receive training to ensure compliance with 2 C.F.R. §200.430. Proposed Completion Date: February 2026
The Non-Profit Affiliate has secured a pre-development loan to reimburse the Authority in FY2026. Additionally, the COCC reimbursed over 50% of the amount due at 06/30/2025 to the Public Housing Programs in July 2025. The remaining funds are being paid down quarterly and will be paid off by end of F...
The Non-Profit Affiliate has secured a pre-development loan to reimburse the Authority in FY2026. Additionally, the COCC reimbursed over 50% of the amount due at 06/30/2025 to the Public Housing Programs in July 2025. The remaining funds are being paid down quarterly and will be paid off by end of FY2026.
FINDING 2025-001 Finding Subject: Annual Report Card, High School Graduation Rate – Special Test and Provisions Contact Person Responsible for Corrective Action: Marilyn Hampton, Supervisor of Student Services Contact Phone Number and Email Address: (219) 933-2461, ext.1048 mehampton@hammond.k12.in....
FINDING 2025-001 Finding Subject: Annual Report Card, High School Graduation Rate – Special Test and Provisions Contact Person Responsible for Corrective Action: Marilyn Hampton, Supervisor of Student Services Contact Phone Number and Email Address: (219) 933-2461, ext.1048 mehampton@hammond.k12.in.us Views of Responsible Officials: We concur with the finding and will implement a corrective action plan. Description of Corrective Action Plan: To ensure compliance with the requirements related to the grant agreement and the Special Test and Provisions Annual Report Card, High School Graduation rate compliance, the School City of Hammond will put into place an effective internal control system. The School City of Hammond will maintain an effective control system for withdrawals from each of the schools within the school system. At the time of withdrawal, a withdrawal form, along with a verified ID will be copied by the school’s registrar or designee. This withdrawal form must include the signatures of a parent and principal. This is the first step in the monitoring process. This system for withdrawals will also include placing a copy of the withdrawal form in the student information system (PowerSchool Attachments). The documentation that needs to be attached to the withdrawal form should include documents that show a Records Request, proof that the student withdrew to attend another school or educational program that results in the awarding of a high school diploma, has immigrated to another country, or is deceased. Upon completion of the withdrawal at the school, a copy of the documentation will be kept at the school, and the original documentation will be placed into the cumulative record. The school will forward a digital copy to Student Services. Upon receipt of the digital copy at Student Services, the administrator will review the file and will sign off to indicate that the record has been reviewed and is complete. To ensure this process is implemented with fidelity, training will take place on a yearly basis with administrators and office staff on the procedures that need to be followed during the withdrawal process. Anticipated Completion Date: 01/31/2026
Recommendation: We recommend that management develop a plan to entice the youth workers to join the program so that they can meet the program compliance requirement. Management Response: Management agrees with the finding. See management’s attached corrective action plan.
Recommendation: We recommend that management develop a plan to entice the youth workers to join the program so that they can meet the program compliance requirement. Management Response: Management agrees with the finding. See management’s attached corrective action plan.
Highway Planning and Construction - Assistance Listing No. 20.205 Recommendation: We recommend that the City evaluate its procedures and implement an additional control to ensure verifications checks are occurring prior to entering into contracts with a vendor. Explanation of disagreement with audit...
Highway Planning and Construction - Assistance Listing No. 20.205 Recommendation: We recommend that the City evaluate its procedures and implement an additional control to ensure verifications checks are occurring prior to entering into contracts with a vendor. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: With the recent filling of open positions and the execution of contracts with engineering firms, additional controls have been implemented to strengthen project review processes. Specifically, the hiring of a City Administrator and an Economic Development Director will enhance controls over new established process. Name(s) of the contact person(s) responsible for corrective action: Kim Barfield Planned completion date for corrective action plan: 12/29/25
The Village has taken steps to ensure that the Village’s Single audit for the year ended April 30, 2025 is filed with the Federal Audit Clearing House in a timely manner. The Village will continue to perform these procedures as part of its annual financial statement preparation process in future yea...
The Village has taken steps to ensure that the Village’s Single audit for the year ended April 30, 2025 is filed with the Federal Audit Clearing House in a timely manner. The Village will continue to perform these procedures as part of its annual financial statement preparation process in future years.
Finding Number: 2025-001: ARP Education Stabilization Fund – Wage Rate Requirements Planned Corrective Action: Summary of corrective action to be taken Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Dave Massa, Treasurer As recommended, the School will perform existing co...
Finding Number: 2025-001: ARP Education Stabilization Fund – Wage Rate Requirements Planned Corrective Action: Summary of corrective action to be taken Anticipated Completion Date: December 31, 2025 Responsible Contact Person: Dave Massa, Treasurer As recommended, the School will perform existing controls and establish new controls to ensure that contractors and subcontractors are in compliance with all labor standards by conducting on-site inspections and collecting the required certified payroll documentation in a timely manner. Specifically, the School will add an Affidavit of Compliance Form to the contracts that will be required to be submitted by the grantee before closing. A project will not be considered closed until the School has received an executed copy of the form. Upon notification of construction commencement, the School will immediately begin monitoring for Wage Rate Requirements in the form of both on-site inspections and review and approval of certified payroll reports.
CORRECTIVE ACTION PLAN Finding 2025-001 – Allowable Costs The District concurs with the finding 2025-001. Corrective Action: The District will implement the following corrective actions to be completed by September 30, 2025: 1.The District will develop and implement new written policies and procedur...
CORRECTIVE ACTION PLAN Finding 2025-001 – Allowable Costs The District concurs with the finding 2025-001. Corrective Action: The District will implement the following corrective actions to be completed by September 30, 2025: 1.The District 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 District will implement a new system to track and certify employee time. Contact Person: Lou D’Ambro, School Business Administrator (315) 822-2826 ldambro@mmcsd.org
Finding 2025-001, Significant Deficiency – Reporting - ERA Corrective Action Plan: Goal: To ensure required reporting to grantors has a defined review process including a preparer, reviewer and an approver to validate accuracy and compliance with data and information submitted to maintain compliance...
Finding 2025-001, Significant Deficiency – Reporting - ERA Corrective Action Plan: Goal: To ensure required reporting to grantors has a defined review process including a preparer, reviewer and an approver to validate accuracy and compliance with data and information submitted to maintain compliance with federal requirements. Plan: Staff is finalizing a formal written review policy which includes compliance components such as timely draft circulation, an independent review, checklists and documented approvals. Once the policy is finalized, training will be provided to staff on the new requirements to ensure consistent application across all grantor reporting cycles. Responsible Party: Housing and Community Development Timeframe: All elements of the Corrective Action Plan will be implemented by March 31, 2026.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.
Views of Responsible Officials and Planned Corrective Actions Clearinghouse reports are from the college’s student information system (SIS). During FY24, the finding stems from a student’s withdrawal, which was promptly processed and entered in the SIS. However, the system categorized the student as...
Views of Responsible Officials and Planned Corrective Actions Clearinghouse reports are from the college’s student information system (SIS). During FY24, the finding stems from a student’s withdrawal, which was promptly processed and entered in the SIS. However, the system categorized the student as "less than half-time” because the student received a passing grade in a course for which the student was exempted after passing a proficiency test. The SIS did not update the student status to 'withdrawn' until the semester ended, which was more than 60 days after the withdrawal date. To remedy this issue, the college’s Business Office now maintains an online spreadsheet listing withdrawn students outside the SIS that is updated whenever a student withdraws from the college. The list has been shared with the personnel responsible for the Clearinghouse reports and the Financial Aid Coordinator. Personnel will monitor the withdrawal listing and verify that all withdrawn students are accurately categorized in the Clearinghouse report from the SIS before completing the submission. After reviewing the FY25 finding, we discovered that the student attended in the spring 2025 semester but withdrew during the college’s drop/add period. By default, the SIS removes students who withdraw during drop/add from the Clearinghouse report.We have confirmed that Welch is unable to modify data or correct errors in the SIS report submitted to the Clearinghouse.Action Taken/Planned To address these problems, which ultimately stemmed from the limitations of Clearinghouse reporting by the college’s SIS, Welch has taken the following steps: 1. Clearinghouse reporting responsibilities have transitioned to a full-time, onsite employee in the Provost’s Office. 2. When preparing Clearinghouse reports and to help with identifying any errors before submitting the report, the employee will continue to monitor the withdrawn students listing maintained by the college’s Business Office, as outlined in the steps taken with the FY24 finding. 3. Welch plans to engage with its SIS and explain the reporting issues and limitations to determine if the SIS can help the college resolve the reporting limitations with its system. 4. To minimize the possibility of students being omitted from any Clearinghouse report, the employee responsible for the Clearinghouse report will submit an initial report to Clearinghouse on the first day of each term (fall, winter, spring, summer), followed by submitting reports on the mandatory reporting dates, as given by Clearinghouse. 5. The employee responsible for Clearinghouse reporting and the college’s Financial Aid Coordinator will collaborate before and after each Clearinghouse submission, and once the submission data is reported to NSLDS by Clearinghouse, the Financial Aid Coordinator will review all withdrawn students to confirm their NSLDS status is correct. If not, she will manually update the student’s NSLDS status to ensure accuracy. Anticipated Completion Date/Date Completed: November 6, 2025
Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the program...
Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the programs in a manner that did not align with the allocation methodology outlined in the 2022–2023 cost allocation plan submitted to MDHHS. Furthermore, the plan lacked explicit certification and contained minor errors and omissions. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Regina Greear Terri Daniels Anticipated completion date: July 2026 Planned Corrective Action: Upon identification, the City worked with the Michigan Department of Health and Human Services (MDHHS) and obtained approval and acceptance of the indirect cost calculation. The City will continue to work with MDHHS to ensure full compliance. The City has initiated a review of its indirect cost allocation methodology to ensure compliance. Management is updating the cost allocation calculation to document the approved allocation method and ensure the method is in accordance with the approved plan. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements.
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Nome: Community Facilities Loans andGrants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the program reserve fund. Corrective Action Plan: Management w...
Federal Agency Name: Department of Agriculture Assistance Listing Number: #10.766 Program Nome: Community Facilities Loans andGrants Finding Summary: There was no formal review separate from the preparer performed over reconciliations of the program reserve fund. Corrective Action Plan: Management will ensure a review separate from the preparer of the reconciliationfor the program's reserve fund is completed with formal documentation notingthe review. The CFO will reconcile the bank statement and will sign off on the bank statement, alongwith the CEO for the reserve accounts. Responsible Individuals: Tammy Larson, CFO Anticipated Completion Date: January 1, 2026
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.
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