Corrective Action Plans

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2025-002 US Department of Education Material Weakness in Internal Control over Compliance Material Noncompliance Procurement Auditor's Recommendation: We recommend that the Organization maintain effective internal controls over procurement requirements. Corrective Action: One City adopted a new proc...
2025-002 US Department of Education Material Weakness in Internal Control over Compliance Material Noncompliance Procurement Auditor's Recommendation: We recommend that the Organization maintain effective internal controls over procurement requirements. Corrective Action: One City adopted a new procurement policy and while it was implemented, documentation that the procedures were performed were lacking. In addition, One City has developed a training tool so that all staff who have purchasing authority must participate in the training. The new Chief Financial Officer will monitor compliance with the policy and ensure proper documentation exists Responsible for Corrective Action: Scott R Haumersen CPA, CGMA Shaumersen@onecityschools.org 608-575-4950 Anticipated Completion Date: June 30th, 2026
Finding Number: 2025-040 Planned Corrective Action: Risk-Based Screenings – Death Master File (DMF): The Agency continues to make incremental improvements in its use of the SSA DMF during provider enrollment and re-enrollment. To achieve further progress and resolve this finding, the Agency is evalu...
Finding Number: 2025-040 Planned Corrective Action: Risk-Based Screenings – Death Master File (DMF): The Agency continues to make incremental improvements in its use of the SSA DMF during provider enrollment and re-enrollment. To achieve further progress and resolve this finding, the Agency is evaluating additional opportunities and taking steps to leverage the Enterprise Data Warehouse and other Medicaid infrastructure tools during these processes. The Agency will also explore the use of these tools to support realtime checks related to Risk-Based Screenings – NPPES and to enhance the review and resolution of LEIE and SAM matches. Anticipated Completion Date: June 2027 Responsible Contact Person: Nancy Massey
Finding Number: 2025-039 Planned Corrective Action: To proactively address these issues, FAHCA has taken several steps to improve efficiency and survey scheduling accuracy. The Quality Assurance and Performance Improvement Protocol, revised in 2024, has enhanced tracking measures to better identify ...
Finding Number: 2025-039 Planned Corrective Action: To proactively address these issues, FAHCA has taken several steps to improve efficiency and survey scheduling accuracy. The Quality Assurance and Performance Improvement Protocol, revised in 2024, has enhanced tracking measures to better identify and prioritize surveys requiring scheduling. Both management and schedulers participated in targeted training sessions held in August 2024 and December 2024. In addition, Monthly Scheduler calls are conducted to provide ongoing guidance and support to field offices regarding scheduling needs and best practices. Furthermore, scheduling workload updates are reviewed every two weeks during Bureau Call Meetings with schedulers and managers to ensure continual monitoring of survey scheduling needs and progress. This improvement reflects the commitment of staff and leadership to proactively respond to challenges and implement strategies that advance the agency’s overall performance. Anticipated Completion Date: September 15, 2026 Responsible Contact Person: Mary Maloney
Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Directo...
Finding Number: 2025-038 Planned Corrective Action: FDCF will evaluate its manual closure process and if necessary, make adjustments to ensure appropriate action is taken when a manual review is required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Tera Bivens, Director of Programs & Policy Julie Reed, Chief of Policy
Finding Number: 2025-035 Planned Corrective Action: FAHCA management will enhance reporting controls to ensure that all applicable CHIP subaward action information is timely reported in accordance with FFATA. Anticipated Completion Date: Completed Responsible Contact Person: Kimberly Jordan
Finding Number: 2025-035 Planned Corrective Action: FAHCA management will enhance reporting controls to ensure that all applicable CHIP subaward action information is timely reported in accordance with FFATA. Anticipated Completion Date: Completed Responsible Contact Person: Kimberly Jordan
Finding Number: 2025-027 Planned Corrective Action: FDCF continues the phased approach of modernizing its eligibility (ACCESS) system. The modernization of the FLORIDA legacy eligibility system started development in State Fiscal Year 2025-2026 and includes the operational analysis of the state’s da...
Finding Number: 2025-027 Planned Corrective Action: FDCF continues the phased approach of modernizing its eligibility (ACCESS) system. The modernization of the FLORIDA legacy eligibility system started development in State Fiscal Year 2025-2026 and includes the operational analysis of the state’s data exchange processes. Anticipated Completion Date: June 30, 2027 Responsible Contact Person: Chris Presnell, Director of Data and Information Technology
Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persiste...
Finding Number: 2025-010 Planned Corrective Action: FCOM worked with its Employ Florida vendor and deployed a fix for the connectivity issue between Reconnect and Employ Florida in January 2025. A follow up meeting in April of 2025 where the issue was discussed did not reveal that the issue persisted. In February 2026, the Auditor General notified FCOM that the fiscal year 2024/2025 audit revealed that the connectivity issue raised previously may still persist. FCOM is currently conducting an evaluation of the Auditor General’s sample and its larger datasets to isolate the variables causing these inconsistencies to determine if the issue has been resolved or if there is potentially a new connectivity issue to be resolved. The updated resolution will be completed by December 31, 2026. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Roosevelt Petithomme/Wendy Castle
Item: 2025-002 Assistance Listing Number: 93.224 Programs: Health Center Program Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: N/A Contract Number: 24H80CS28365; H8JCS54690; 21H8HCS44987 Award Year: June 1, 2024 to May 31, 2025; December 1, 2024 to November 30, 20...
Item: 2025-002 Assistance Listing Number: 93.224 Programs: Health Center Program Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: N/A Contract Number: 24H80CS28365; H8JCS54690; 21H8HCS44987 Award Year: June 1, 2024 to May 31, 2025; December 1, 2024 to November 30, 2025; September 1, 2023 to August 31, 2025 Compliance Requirement: Special Tests and Provisions Criteria: Health Centers must prepare and apply a sliding fee discount schedule so that the amounts owed for health center services by eligible patients are adjusted (discounted) based on the patient’s ability to pay. Condition: For five claims tested, the discount for eligible patients was inaccurately calculated and billed. Name of Contact Person: Michele Grebisz, CFO Phone Number: (602)776-0776 Anticipated Completion Date: March 31, 2026 Views of Responsible Officials and Corrective Actions: Management agrees with the finding and will implement additional controls to ensure sliding fee discounts applied are reviewed and approved before patients are billed. Management will ensure this additional process includes clearly documenting the review and approval.
Coronavirus State and Local Fiscal Recovery Funds 21.027 Recommendation: CLA recommends that management compose a procurement policy with the criteria as set out in 2 CFR sections 200.318 and 200.326. and review the conflict of interest policy and make necessary changes to comply with the criteria a...
Coronavirus State and Local Fiscal Recovery Funds 21.027 Recommendation: CLA recommends that management compose a procurement policy with the criteria as set out in 2 CFR sections 200.318 and 200.326. and review the conflict of interest policy and make necessary changes to comply with the criteria as set out in 2 CFR section 200.318. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: Management will compose a procurement policy in line with compliance requirements and review and edit the conflict of interest policy to be in compliance. Name of the contact person responsible for corrective action: Maria Giaimo, CFO Planned completion date for corrective action plan: June 30, 2026
Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. ...
Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. Additionally, ongoing training should be provided to financial aid staff on the importance of internal controls and compliance with Title IV regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review its staffing and the need for separation of duties as part of an effective internal control system and take appropriate actions.. Name(s) of the contact person(s) responsible for corrective action: Vice President for Enrollment Management Damon Wade, Director of Financial Aid Deniesha Newby, and Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026
Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the Cou...
Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the County will strengthen internal controls related to eligibility determinations by implementing a comprehensive, county-wide corrective action strategy focused on staff competency, supervisory oversight, and process standardization. First, the County will enhance training for all staff involved in Medicaid eligibility determinations. This training will reinforce program requirements and applicable State Medicaid manuals, with specific emphasis on income and resource verification, household composition, timely requests for information, redetermination timeframes, and proper handling of SSI terminations. Refresher trainings will be conducted regularly, and training materials will be updated to reflect current policy and procedural changes. Second, the County will formalize and strengthen its internal case review and quality assurance processes. Supervisory reviews will be conducted routinely to ensure eligibility determinations are accurate, complete, and compliant with federal and state guidelines. Identified errors will be documented, corrected timely, and used as coaching opportunities to prevent recurrence. Management will monitor trends in errors to assess effectiveness of corrective actions and adjust oversight efforts as needed. Anetre Vaughan, Adult Medicaid Supervisor and Jacqueline Boyd, Family and Children's Medicaid Supervisor Section III - Federal Award Findings and Question Costs BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 116
Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weaknes...
Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Instance of Noncompliance Criteria: CFR Appendix A to Part 170I(a)(2), Reporting Requirements, states the recipient must report each subaward to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was issued. Condition: During our testing of the County’s compliance with reporting requirements, we noted the County did not submit the required subaward data to FSRS. Cause: The department was unaware of this compliance requirement. Effect: Reports were not submitted to FSRS in accordance with the reporting requirements per Appendix A to Part 170I(a)(2). Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling : We identified that the FFATA reporting was not completed as required by 2 CFR Part 170 for the following instances: (Refer to Chart/Table to Finding 2025-003) Repeat Finding from Prior Years: No. Recommendation: We recommend that the County adhere to their policies and procedures in accordance with 2 CFR Appendix A to Part 170I(a)(2). Management Response and Corrective Action Plan: 1. Person Responsible: Francisco Padilla, Community Development Analyst 2. Corrective action plan: Concur. We will adhere to our policies and procedures to ensure reports are submitted to FSRS in accordance with 2 CFR Appendix A to Part 170I(a)(2). 3. Anticipated Implementation date: April 30, 2026
Corrective Action Plan – Management concurs with this finding. During the student system set-up for academic year 2024-25, the appropriate screen was not properly updated with the new ISIR codes to set the tracking requirements to be posted for ISIR C Flags. Because the appropriate tracking document...
Corrective Action Plan – Management concurs with this finding. During the student system set-up for academic year 2024-25, the appropriate screen was not properly updated with the new ISIR codes to set the tracking requirements to be posted for ISIR C Flags. Because the appropriate tracking documents were not posted, the system allowed the students to pass through packaging and disbursement. The Law School Financial Aid Office will implement a structured verification process as part of the student system setup for each academic year. Every step of the setup will be documented. To ensure accuracy, one staff member will complete the setup, and a separate staff member will independently review and verify the configuration. Management believes these enhancements will be sufficient to prevent future errors. Completion date: November 2025 Persons responsible: Vonda Garcia, Director of Law School Financial Aid
Finding No. 2025-009 ALN No. 17.225 Program Title: Unemployment Insurance Grant Award No.: 25-A55-UI-000105 Condition Based on our analysis of the claims processing data, the State is not in compliance with the BAM State Operations Guidance Part 602, as the minimum number of cases for paid claims wa...
Finding No. 2025-009 ALN No. 17.225 Program Title: Unemployment Insurance Grant Award No.: 25-A55-UI-000105 Condition Based on our analysis of the claims processing data, the State is not in compliance with the BAM State Operations Guidance Part 602, as the minimum number of cases for paid claims was not met. Corrective Action Plan Concur. 1. The BAM unit continues to have vacancies and remain understaffed. 2. The unit is in the process of filling a vacancy with an experienced adjudicator. Once the position is filled, the new staff member will be trained in BAM methodology. At this time, the BAM supervisor continues to help the unit toward achieving its BAM requirements. 3. The unit anticipates increasing the number of cases for paid claims beginning June 2026. Person Responsible Sheryl-Lynn Ozaki, UI Quality Control Supervisor Anticipated Date of Completion June 2027 In response to the finding State of Hawaii – Single Audit 2025 finding, the DLIR offers the following: The auditor’s recommendation for the DLIR to develop new policies and procedures to handle the increase in unemployment claims fails to recognize the true source of the deficiency. The shortcoming is a direct result of staffing shortages. A key requirement of the BAM program is for the unit to be staffed with a sufficient number of knowledgeable and skilled investigators to ensure prompt and in-depth investigations. The investigator should be knowledgeable about and trained in the application of federal and state unemployment insurance laws, regulations/rules, and official policies; able to interpret and apply laws and official policies to each claimant's situation; proficient in fact-finding and determination procedures, including the process of interviewing interested parties and providing the opportunity for fair hearings and rebuttals; use independent judgment to develop and analyze evidentiary facts, assess credibility, weigh the evidence obtained, and decide when information is sufficient to issue legally binding decisions; determine appropriate administrative actions required; authorized to change computerized records as needed to pay or stop payment of benefits; prepare timely written decisions to deny or allow benefits which clearly communicate the facts, conclusions and reasoning used to support the decisions; be knowledgeable of the methods to effectively deal with claimants/customers, employers, or others who are under stress, experiencing negative emotions, etc. including handling and controlling conflict; knowledgeable about and skilled in the navigation of the state’s benefit, employment service, and tax systems; and knowledgeable about and compliant with BAM methodology and coding instructions. Regardless of new policies and procedures, the shortcoming is a direct result of the lack of available skilled investigators with the required skills to conduct prompt and in-depth investigations in the BAM program.
Finding No. 2025-007 ALN No. 11.419 Program Title: Hawaii Coastal Zone Management Program Grant Award No.: NA22NOS4190022 NA23NOS4190139 NA24NOSX419C0023 NA22NOS4190065 Condition Accuity noted that the State did not submit FFATA reports for most of the active grant agreements open for the program. C...
Finding No. 2025-007 ALN No. 11.419 Program Title: Hawaii Coastal Zone Management Program Grant Award No.: NA22NOS4190022 NA23NOS4190139 NA24NOSX419C0023 NA22NOS4190065 Condition Accuity noted that the State did not submit FFATA reports for most of the active grant agreements open for the program. Corrective Action Plan DBEDT OPSD will strengthen internal controls over subaward identification and reporting. This will include hiring and training staff to support federal grant administration and management-level review of all subawards to ensure FFATA reporting is complete and timely. Person Responsible Mary Alice Evans, Director of Office of Planning and Sustainable Development Anticipated Date of Completion April 1, 2026
Finding No. 2025-005 ALN No. 10.179 Program Title: Micro-Grants Food Security Program Grant Award No.: AM200100XXXG132 21MGFSPHI1003-00 AM22MGFSPHI1007-04 23MGFSPHI1011-00 24MGFSPHI1016-00 Condition An elapsed time of 583 days between the drawdown and disbursement date of funds for the program and t...
Finding No. 2025-005 ALN No. 10.179 Program Title: Micro-Grants Food Security Program Grant Award No.: AM200100XXXG132 21MGFSPHI1003-00 AM22MGFSPHI1007-04 23MGFSPHI1011-00 24MGFSPHI1016-00 Condition An elapsed time of 583 days between the drawdown and disbursement date of funds for the program and that the check date of 01/24/2025 occurred after the grant period expiration of 09/29/2024. Indicating that cash management controls were not operating to minimize time between transfer and disbursement and that the period of performance was unauthorized to be extended past the budget date. Corrective Action Plan Concur. The Hawaii Department of Agriculture and Biosecurity (DAB) will change administrative procedures for drawdown and disbursement of federal funds under the Micro-Grants Food Security Program. DAB will process the grant contracts and payments in batches of about 100 micro-grants per month, and federal drawdown will not occur until about a batch of 100 contracts have been executed. Additional staff hired for grant processing will expedite the payment process to ensure conformity with the 25-day disbursement timeline. Person Responsible Brendan Akamu, Market Development Branch Manager Anticipated Date of Completion Corrective action plan will be implemented in April 2026.
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement p...
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement procedures and controls to ensure pre-approval in accordance with the Uniform Guidance compliance requirements.
Finding 1191716 (2025-002)
Material Weakness 2025
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting ...
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting workpapers. Therefore, the CECL adjustment was not recorded at the beginning of the audit and required multiple attempts before a reasonable estimate was determined and recorded. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We will capture detailed documentation of the CECL calculation process, including training and detailed written procedures. Anticipated Completion Date: January 1, 2026
Finding 1191698 (2025-001)
Material Weakness 2025
Finding 2025-001 Material Weakness Limited Segregation of Duties Over Cash Receipts Finding Summary: The person responsible for opening the mail, preparing the deposit summary, and depositing funds was granted full access to the accounting software, including the ability to enter, modify, and delete...
Finding 2025-001 Material Weakness Limited Segregation of Duties Over Cash Receipts Finding Summary: The person responsible for opening the mail, preparing the deposit summary, and depositing funds was granted full access to the accounting software, including the ability to enter, modify, and delete transactions. While it is not this person’s responsibility to record deposits in the accounting system, they have the ability to do so. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: Our process has been updated to ensure the person opening mail, preparing the deposit summary, and depositing funds do not have access to the accounting software. Anticipated Completion Date: January 1, 2026
Condition: Out of 60 students tested for return to Title IV, we identified 4 students whose calculations were performed outside of the required time frame. Planned Corrective Action: The College will work with its Director of Financial Aid to ensure the semester end procedures include steps to ident...
Condition: Out of 60 students tested for return to Title IV, we identified 4 students whose calculations were performed outside of the required time frame. Planned Corrective Action: The College will work with its Director of Financial Aid to ensure the semester end procedures include steps to identify those students who unofficially withdrew. Once the students are identified, individuals with appropriate skills and knowledge will be able to determine if a return of Title IV calculation is necessary and appropriately return any funds, as necessary. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: March 31, 2026
Finding 2025-003: Material Weakness in Internal Control over Compliance and Noncompliance – Eligibility Program: 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: To address the identified material weakness and ensure future compliance with SSG Fox S...
Finding 2025-003: Material Weakness in Internal Control over Compliance and Noncompliance – Eligibility Program: 64.055 Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program Planned Corrective Action: To address the identified material weakness and ensure future compliance with SSG Fox SPGP eligibility and documentation requirements, the organization has implemented the following systemic enhancements: • Standardized Eligibility Controls: The organization has developed and deployed a mandatory Case File Compliance Checklist for all program participants. This control ensures that all federally mandated documentation—including signed program agreements, grievance procedures, religious protections, individualized service plans, and all five required baseline mental health screenings—is present and verified for every file. • Enhanced Management Oversight: To ensure the effectiveness of these controls, the Department Director has implemented a Monthly Quality Assurance (QA) Review. On a monthly basis, the Director will perform a formal audit of active case files to verify compliance. This review will be documented via a formal sign-off, providing a clear audit trail of supervisory oversight. • Records Retention & Security: Management oversight has been expanded to include specific verification of Data Integrity and Retention. Monthly reviews will ensure that all required documentation is maintained in accordance with 2 CFR § 200 standards—ensuring records are secure, unalterable, and readily accessible for future audits. • Continuous Professional Development: The organization has institutionalized a Mandatory Training Curriculum. All relevant staff will undergo initial onboarding and recurring periodic training focused on SSG Fox SPGP compliance standards, participant eligibility, and rigorous documentation procedures. • Personnel Realignment: The organization has undergone a restructuring of the program staff to ensure that all personnel are fully aligned with the agency's internal control environment and commitment to federal compliance. Anticipated completion date: April 30, 2026 Contact Information: Louise Chikigak, Chief Financial Officer, (907) 222-4250
The College will enforce policies and procedures to ensure that compliance with the requirements. New internal controls are expected to be implemented to address these findings.
The College will enforce policies and procedures to ensure that compliance with the requirements. New internal controls are expected to be implemented to address these findings.
The College will enforce policies and procedures to ensure that compliance with the requirements. New internal controls are expected to be implemented to address these findings.
The College will enforce policies and procedures to ensure that compliance with the requirements. New internal controls are expected to be implemented to address these findings.
The College will enforce policies and procedures to ensure that compliance with the requirements. New internal controls are expected to be implemented to address these findings.
The College will enforce policies and procedures to ensure that compliance with the requirements. New internal controls are expected to be implemented to address these findings.
Management will follow procedures as outlined in its policies and procedures to ensure all stages of the process adequately conducted and documented.
Management will follow procedures as outlined in its policies and procedures to ensure all stages of the process adequately conducted and documented.
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