Corrective Action Plans

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Description of Finding Material Weakness in Internal Control over Compliance - Reporting Statement of Concurrence or Nonconcurrence Please note that Town of Waterford Management concurs with this finding. Corrective Action After contacting the US Treasury Department regarding the error in reporting ...
Description of Finding Material Weakness in Internal Control over Compliance - Reporting Statement of Concurrence or Nonconcurrence Please note that Town of Waterford Management concurs with this finding. Corrective Action After contacting the US Treasury Department regarding the error in reporting ARPA obligations/encumbrances versus an expenditure, I was advised to correct when submitting my April 2026 expenditure report. As advised, the upcoming report will correct the reporting of obligations and expenditures.
2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experi...
2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experienced some staff turnover in the prior fiscal year. In addition, the Village has not historically been subject to single audits, which created some challenges with the preparation of the Schedule of Expenditures of Federal Awards. Going forward, the Village has a better understanding of the requirements for completing the Schedule.
Corrective Action Planned: The Organization has updated its policies and procedures to ensure proper approvals are performed and documented. Anticipated Completion Date: Continuous. Responsible Parties: Management and the Board of Directors.
Corrective Action Planned: The Organization has updated its policies and procedures to ensure proper approvals are performed and documented. Anticipated Completion Date: Continuous. Responsible Parties: Management and the Board of Directors.
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.
Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specif...
Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specifically for payments made to subrecipients. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Denise Fair Razo Regina Greear Terri Daniels Anticipated completion date: March 2026 Planned Corrective Action: The three payments made were paid one to two days after the 30 day reimbursement requirement. The City will review its subrecipient payment terms and implement additional processes to help ensure compliance with federal payment requirements.
FINDING: FINANCIAL REPORTING – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Finding Type: Material Weakness in Compliance and Internal Control over Compliance Finding No. 2025-002 Recommendation: Management should implement procedures to ensure an accurate schedule of expenditures of federal awards wi...
FINDING: FINANCIAL REPORTING – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Finding Type: Material Weakness in Compliance and Internal Control over Compliance Finding No. 2025-002 Recommendation: Management should implement procedures to ensure an accurate schedule of expenditures of federal awards with a corresponding reconciliation to the accrual basis trial balance. It is recommended that management establish and enforce review and approval procedures related to the schedule of expenditures of federal awards and the accrual basis trial balance. Responsible Official: Anthony D’Agostino, CEO Corrective Action Plan: The Organization acknowledges the importance regarding the accuracy of the schedule of expenditures of federal awards and corresponding reconciliation to the accrual basis trial balance. The Organization is taking steps to ensure the accuracy and completeness of the schedule of expenditures of federal awards. The Organization will also consider the employment of additional personnel with suitable knowledge, skills, and experience to contribute to the functions of the finance department. Planned completion date for corrective action plan: Fiscal year 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
Material Weakness Item 2025-003 - Period of Performance - 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 H8LCS50772-01-00 and 6 H8/-ICS46163-03-01 During our audit,...
Material Weakness Item 2025-003 - Period of Performance - 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 H8LCS50772-01-00 and 6 H8/-ICS46163-03-01 During our audit, we noted that LBUCC drew down $190,688 of federal grant funds under the Section 330 program for the budget period beginning June 1, 2024 to reimburse salary expenses incurred in May 2024. Recommendation: We recommend that LBUCC implement procedures to ensure that all drawdowns are supported by expenses incurred strictly within the grant's approved period of performance and train staff on grant compliance requirements. Action Taken: A change in the process to draw down funds has been implemented to determine that the funds were incurred in the proper funding period rather than the period it was paid. Effectivity Date: Process change was implemented 12/1/2025.
Material Weakness Item 2025-002 - 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 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our a...
Material Weakness Item 2025-002 - 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 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our audit, we noted that LBUCC did not properly determine the sliding fee discount provided to certain eligible patients based on information provided during the patient registration process. Additionally, we could not ascertain if the sliding fee discount provided to certain eligible patients were correct as LBUCC did not maintain documentation of the proof of income of those eligible patients. Recommendation: We recommend that LBUCC conduct training of all of its personnel who are involved in determining and applying the sliding fee scale of patients. We also recommend LBUCC to maintain complete and auditable documentation supporting each patient's eligibility for sliding fee discount. Action Taken: Eligibility was provided additional training which included training on a tool to assist them in determining the proper sliding fee discount. Effectivity Date: Training was held on October 28, 2025, and the tool to assist them was reviewed and provided at that time and implemented immediately thereafter.
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025
ELIZABETHTON CITY SCHOOLS Material Weakness JUNE 30, 2025 School Nutrition Fund 2025-001 Response and Corrective Action Plan Prepared by: Beth Wilson, Director of Finance, Elizabethton City Schools Person Responsible for Implementing the Corrective Action: Regina Isaacs, School Nutrition Coordinator...
ELIZABETHTON CITY SCHOOLS Material Weakness JUNE 30, 2025 School Nutrition Fund 2025-001 Response and Corrective Action Plan Prepared by: Beth Wilson, Director of Finance, Elizabethton City Schools Person Responsible for Implementing the Corrective Action: Regina Isaacs, School Nutrition Coordinator, Elizabethton City Schools Anticipated Completion of Corrective Action: May 31, 2025 Repeat Deficiency: No Planned Corrective Action: The student numbers were corrected and the USDA claims were adjusted before the end of the fiscal year. The School Nutrition Coordinator has been instructed to ensure that all students are counted correctly. Richard VanHuss Director of Schools
Management will continue to rely on their independent certified public accountant for assistance with their financial statement preparation.
Management will continue to rely on their independent certified public accountant for assistance with their financial statement preparation.
The District will be utilizing the consulting service with Julian & Grube in the future.
The District will be utilizing the consulting service with Julian & Grube in the future.
Audit Recommendation a) 2025-004: Full Service Community Schools-Assistance Listing No. 84.215J Grant NO. - S215J220016 Grant Period-Year ended June 30, 2025 the auditors recommend the District to implement a process that ensures an understanding of the grant revenue and expenditure recognition proc...
Audit Recommendation a) 2025-004: Full Service Community Schools-Assistance Listing No. 84.215J Grant NO. - S215J220016 Grant Period-Year ended June 30, 2025 the auditors recommend the District to implement a process that ensures an understanding of the grant revenue and expenditure recognition process. Regular reconciliations should be performed and monitored against the grant finance reports. Expenditures should be monitored against the approved budgets and overspent grants. Corrective Action Plan a) 2025-004: The District plans to ensure in-depth training on all grants the District receives and require regular reconciliations to the general ledger by using our financial program as well a spreadsheet at the end of every month and institute more oversight over the grant process. Implementation Date - June 30, 2026 Person Responsible for Implementation - Colleen Bellinger, School Business Manager
Views of Responsible Officials and Planned Corrective Actions: The District will implement a secondary review process for verifying, entering, and confirming the status of the free and reduced applications. Documentation will be maintained to indicate the individuals performing completion and second...
Views of Responsible Officials and Planned Corrective Actions: The District will implement a secondary review process for verifying, entering, and confirming the status of the free and reduced applications. Documentation will be maintained to indicate the individuals performing completion and secondary review of required steps to verify timeliness and accuracy of eligibility determination and reporting.
Condition: The School District does not properly review students’ institutional Student Information Records (ISIR) to determine that the student is eligible for federal student financial aid. Planned Corrective Action: The School District has implemented a formal review process to ensure all Institu...
Condition: The School District does not properly review students’ institutional Student Information Records (ISIR) to determine that the student is eligible for federal student financial aid. Planned Corrective Action: The School District has implemented a formal review process to ensure all Institutional Student Information Records (ISIRs) are accurately evaluated for student eligibility prior to awarding federal student aid. Staff have been trained on the new procedures, including resolving required data elements and confirming eligibility criteria. The District has also instituted periodic internal checks to ensure consistent and compliant ISIR review practices moving forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: October 2025
Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to v...
Condition: The School District relies on two-third party vendors to manage key financial aid systems, including student information, eligibility determinations, disbursement calculations, and reporting. During the audit period, the institution did not perform any oversight activities or testing to verify the integrity, accuracy, or compliance of the systems managed by the vendor. There were no documented controls, service-level agreements, or monitoring procedures in place. Planned Corrective Action: The School District will establish formal oversight procedures for all third-party vendors supporting financial aid functions. This will include developing and maintaining service-level agreements, implementing documented monitoring and testing protocols, and conducting periodic reviews to verify system accuracy, data integrity, and federal compliance. Staff will be trained on these updated processes to ensure ongoing accountability. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The School District is eligible to participate in Title IV federal student aid programs; however, it does not conduct an annual review of its institutional eligibility requirements nor maintain documentation supporting such assessments. Planned Corrective Action: The School District will ...
Condition: The School District is eligible to participate in Title IV federal student aid programs; however, it does not conduct an annual review of its institutional eligibility requirements nor maintain documentation supporting such assessments. Planned Corrective Action: The School District will implement an annual review process to verify its institutional eligibility for participation in Title IV programs. Procedures will include maintaining thorough documentation of all eligibility assessments and required approvals. Staff responsible for compliance will be trained on these updated requirements to ensure accurate and timely completion each year. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution does not have a process or controls in place for a timely review of program eligibility, ECAR. Planned Corrective Action: The School District will establish a formal process to ensure timely and documented reviews of program eligibility in accordance with federal requireme...
Condition: The institution does not have a process or controls in place for a timely review of program eligibility, ECAR. Planned Corrective Action: The School District will establish a formal process to ensure timely and documented reviews of program eligibility in accordance with federal requirements. Staff will be trained on the new procedures, and the School District will implement internal controls to monitor program eligibility on a regular schedule. These steps will help ensure ongoing compliance and accurate determinations moving forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution did not reimburse students with credit balances within 14 days of the balance being posted to their student ledger. Planned Corrective Action: The School District will strengthen its procedures to ensure all student credit balances are identified and refunded within the re...
Condition: The institution did not reimburse students with credit balances within 14 days of the balance being posted to their student ledger. Planned Corrective Action: The School District will strengthen its procedures to ensure all student credit balances are identified and refunded within the required 14-day timeframe. Staff will receive training on the updated process, and the District will implement regular monitoring to verify timely issuance of refunds going forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The institution’s policy maintains that any unchased check must be returned to the State of Colorado after the financial statement year-end to the Great Colorado Payback program and does not include a carve-out for uncashed Title IV aid checks. Planned Corrective Action: The School Distri...
Condition: The institution’s policy maintains that any unchased check must be returned to the State of Colorado after the financial statement year-end to the Great Colorado Payback program and does not include a carve-out for uncashed Title IV aid checks. Planned Corrective Action: The School District will revise its policy to ensure uncashed Title IV aid checks are returned to the U.S. Department of Education in accordance with federal regulations, rather than to the State of Colorado. The updated policy will include a specific carve-out for Title IV funds, and staff will be trained on the revised procedures to ensure accurate handling and timely returns. Contact Person Responsible for corrective action: Lisa Bollers Anticipated Completion Date: June 30, 2026
Condition: The School District does not calculate or process any post-withdrawal disbursements for students that have withdrawn from the institution. Planned Corrective Action: The School District has implemented procedures to ensure post-withdrawal disbursements are calculated and processed in acco...
Condition: The School District does not calculate or process any post-withdrawal disbursements for students that have withdrawn from the institution. Planned Corrective Action: The School District has implemented procedures to ensure post-withdrawal disbursements are calculated and processed in accordance with federal Return of Title IV (R2T4) requirements. Staff have been trained to identify eligible students, complete the required calculations, and issue timely notifications and disbursements. The School District will also conduct periodic reviews to ensure that all post-withdrawal disbursements are consistently met. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: October 2025
Condition: The School District did not report the status changes of certain students to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The School District will update its procedures to ensure all student status changes are reported to NSLDS accurately a...
Condition: The School District did not report the status changes of certain students to the NSLDS in an accurate and timely manner during the fiscal year. Planned Corrective Action: The School District will update its procedures to ensure all student status changes are reported to NSLDS accurately and within required federal timelines. Staff responsible for reporting will be retrained on the updated process and monitoring requirements. The School District will also implement a periodic internal review to verify the timely and accurate submission of information going forward. Contact Person Responsible for corrective action: Almir Hodzic Anticipated Completion Date: June 30, 2026
Condition: The School District did not utilize the cost of attendance when determining the maximum amount of aid a student is eligible to receive. The School District also does not maintain updated cost of attendance calculations for its programs. Planned Corrective Action: The School District will ...
Condition: The School District did not utilize the cost of attendance when determining the maximum amount of aid a student is eligible to receive. The School District also does not maintain updated cost of attendance calculations for its programs. Planned Corrective Action: The School District will implement procedures to ensure the cost of attendance (COA) is used when determining each student’s maximum eligible aid in accordance with federal requirements. The District will also develop and maintain updated COA calculations for all programs and review them annually. Staff will be trained on these processes to ensure accurate and compliant aid determinations moving forward. Contact Person Responsible for corrective action: Mary Cooper Anticipated Completion Date: June 30, 2026
Condition: The School Districts awarded aid to students using the full-time, three-quarter time, half-time, etc, schedule and improperly recorded students under a credit program versus appropriately recording them under a clock hour program, for which students would have been considered full-time in...
Condition: The School Districts awarded aid to students using the full-time, three-quarter time, half-time, etc, schedule and improperly recorded students under a credit program versus appropriately recording them under a clock hour program, for which students would have been considered full-time in their enrollment status if they did not attend less than half-time. Planned Corrective Action: The School District has revised its policies to ensure students in clock-hour programs are correctly classified and awarded according to federal requirements. As a result, we are now awarding full aid to all eligible students based on proper enrollment status determinations. Staff have been retrained on the updated procedures to ensure ongoing compliance. Contact Person Responsible for corrective action: Amy Beruan Anticipated Completion Date: November 2025
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