Corrective Action Plans

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Finding #2025-001 – Internal Control Over Compliance - Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 15, 2025 Corrective Action Plan: Effective immediately, the Organiz...
Finding #2025-001 – Internal Control Over Compliance - Activities Allowed or Unallowed and Allowable Costs/Cost Principles Contact – Suzanne Tobin, Chief Financial Officer Telephone Number – (301)-832-3810 Completion Date – December 15, 2025 Corrective Action Plan: Effective immediately, the Organization will strictly enforce its policy for supervisory review and approval of employees’ time sheets and invoices. To ensure compliance with this policy, the Organization will conduct random checks of time sheets and invoices every pay period to verify that supervisory approval is performed. Appropriate disciplinary action will be implemented for non-compliance.
Finding 1165233 (2025-003)
Material Weakness 2025
2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Do...
2025-003: Inaccurate Eligibility Classification and System Entry Issue: Eligibility classifications in CACFP were entered incorrectly due to manual processes and inconsistent verification. In some cases, the eligibility category recorded in the system did not match the approved paper application. Documentation of income verification and classification checks was incomplete or not retained. Corrective Actions: Porter-Leath will strengthen controls over eligibility determination by requiring a complete review of all eligibility documents before system entry. 1. Applications will first be checked by administrative or Family Services staff to verify household size, income documentation, and appropriate eligibility category. 2. Site Managers will review the classification for accuracy and ensure the approved determination is entered consistently into ChildPlus or ProCare. 3. A final review by the Preschool Coordinator will confirm that the eligibility classification on the application matches the classification stored in the system prior to claim submission. 4. A reconciliation step will be built into the monthly workflow so discrepancies between documentation and system data are identified and corrected promptly. Responsible Personnel: Family Services Liaisons, Site Administrative Staff, Site Managers, Preschool Coordinator, CACFP Coordinator Timeline: Revised procedures implemented within 15 days; staff training completed within 30 days. Monitoring: Periodic quarterly reviews of at least 25 percent of eligibility files will be conducted to confirm proper classification and system accuracy, with results reported to management.
Finding 1165232 (2025-002)
Material Weakness 2025
2025-002: Eligibility Determination Not in Place or Consistently Applied Across all Programs Issue: Eligibility documentation for TANF-funded services was incomplete, inconsistently applied, or missing required verification of residency, citizenship, income, resources, or other eligibility factors. ...
2025-002: Eligibility Determination Not in Place or Consistently Applied Across all Programs Issue: Eligibility documentation for TANF-funded services was incomplete, inconsistently applied, or missing required verification of residency, citizenship, income, resources, or other eligibility factors. Documentation was not always collected, reviewed, or signed before services were provided, and eligibility determinations were not supported by a uniform process. Corrective Actions: Porter-Leath will implement a standardized eligibility checklist that incorporates all TANF eligibility requirements, including verification of residency, identity, citizenship, household composition, income, resources, and work participation when applicable. 1. Staff must complete the checklist and compile all supporting documents before any TANF-funded benefits are provided. 2. When allowed under governing regulations, the Organization will also accept and retain documented eligibility determinations from other qualified programs, including SNAP, TANF acceptance letters or other qualifying documentation to determine eligibility, as part of the verification packet. 3. Each eligibility packet will require supervisory review and signature confirming that all required elements are present, accurate, and complete prior to approving eligibility. 4. The final approved packet will be maintained in accordance with DHS documentation and retention requirements. Responsible Personnel: Program Managers, Family Services Staff, Supervisors Timeline: Checklist finalized within 10 days; training within 30 days; full training and implementation immediately thereafter. Monitoring: Quarterly file reviews will confirm that eligibility checklists are correctly completed, include required documentation or accepted verification from other programs when applicable, and contain supervisory approval.
Finding 1165231 (2025-001)
Material Weakness 2025
2025-001: Meal Count Forms Not Reconciled to Claim for Reimbursement Issue: Daily and monthly meal count forms were not reconciled to the claim for reimbursement, and in several instances meals claimed exceeded participant attendance. Supervisory review was not documented, and meal count reconciliat...
2025-001: Meal Count Forms Not Reconciled to Claim for Reimbursement Issue: Daily and monthly meal count forms were not reconciled to the claim for reimbursement, and in several instances meals claimed exceeded participant attendance. Supervisory review was not documented, and meal count reconciliation occurred through manual processes that increased the likelihood of error. Corrective Actions: Porter-Leath will implement a unified reconciliation process for CACFP meal counts that requires attendance, point-of-service meal counts, and delivery counts to be reviewed together before the monthly claim is submitted. 1. Site Managers will verify that meals served never exceed daily attendance and that all claims agree to supporting census and meal documentation. 2. The Food Service Lead will prepare the monthly claim only after attendance data from ChildPlus or ProCare and meal count forms are validated and matched. 3. A supervisory review will be required at each site and documented prior to submission to CACFP leadership. 4. The CACFP Coordinator will conduct a final reconciliation to confirm accuracy and resolve discrepancies before Finance processes the claim. Responsible Personnel: CACFP Coordinator, Site Managers, Food Service Lead, Health, Disabilities & Nutrition Manager Timeline: Procedures finalized within 10 days; staff trained within 30 days; full implementation with the next monthly claim cycle after training is complete. Monitoring: Quarterly monitoring will verify adherence to reconciliation and review requirements, including documented supervisory approval.
Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend that management assign a designated individual to ensure rent reasonableness, income verification, and recertifications are completed accurately and on time, in accordance with HUD guidelines and the Aut...
Moving to Work Demonstration Program -Assistance Listing No. 14.881 Recommendation: We recommend that management assign a designated individual to ensure rent reasonableness, income verification, and recertifications are completed accurately and on time, in accordance with HUD guidelines and the Authority's administrative plan. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Director of HCV Program Administration and Ass istant Director of HCV Program Administration will be in charge of reviewing all Rent Reasonableness. Name(s) of the contact person(s) responsible for corrective action: Teresa J. Gonzalez, and Darrell Mciver. Planned completion date for corrective action plan: Effective immediately.
Finding 2025-001 Condition During the year, there were no documented internal controls in place over the Title IV refund calculations. In the sample of 5 students who withdrew from the University, there was one student for whom the return was miscalculated. The result was too much aid being refunded...
Finding 2025-001 Condition During the year, there were no documented internal controls in place over the Title IV refund calculations. In the sample of 5 students who withdrew from the University, there was one student for whom the return was miscalculated. The result was too much aid being refunded. The sample was not statistically valid. Corrective Action Plan To address this issue, the Title IV Return of Funds Policy has been updated to strengthen accountability and compliance. All R2T4 calculations will be completed by the Financial Aid Counselor and reviewed by the Director, with signatures documenting internal controls. A checklist and quarterly reviews will ensure accuracy, and ERP integration within Ellucian Colleague, set for full implementation by October 31, 2025, will automate calculations and improve compliance monitoring. Name(s) of Contact Person(s) Responsible for Corrective Action: Susan Collins, Director of Financial Aid Anticipated Completion Date: October 31, 2025 Linda Scholting CFO 10/29/2025
Management agrees with the auditors’ finding and their recommendation. In August 2025, $712 of Federal Pell Grant funds were awarded to the first student in question and $260 of Federal Pell Grant funds were returned to the Department of Education for the fifth student in question. Since the remaini...
Management agrees with the auditors’ finding and their recommendation. In August 2025, $712 of Federal Pell Grant funds were awarded to the first student in question and $260 of Federal Pell Grant funds were returned to the Department of Education for the fifth student in question. Since the remaining three students were due additional Unsubsidized Federal Direct Loan funds, the College awarded additional institutional aid of $62, $93, and $93 to students two, three, and four, respectively. The Student Financial Aid Director will communicate with the Online Education Director and/or the Registrar to verify semester and enrollment dates and attend additional training webinars on R2T4 calculations hosted by the Department of Education. Anticipated Completion Date:The corrective action was completed in August 2025. Contact Person Brian Rains, Director of Financial Aid 417-268-6045
Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action tak...
Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Augustana intends to modify the NSC/NSLDS monthly data file to ensure that campus and program enrollment dates are pulled from the appropriate data fields in the student information system. Additionally, Augustana intends to implement a step in the withdrawal process to ensure the change in status is reported accurately and timely. Name of the contact person responsible for corrective action: John Cage at johncage@augustana.edu Planned completion date for corrective action plan: January 30, 2026
Finding 2025-004 Lack of Internal Controls over Reporting Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Records will be reviewed monthly by two individuals to ensure they are complete. Back up documentation shall be kept in a secure location where at least two oth...
Finding 2025-004 Lack of Internal Controls over Reporting Name of Contact Person: Jennifer Phillip, Kary Delsignore Corrective Action Plan: Records will be reviewed monthly by two individuals to ensure they are complete. Back up documentation shall be kept in a secure location where at least two other budget supervisors are aware and have access to same. Proposed Completion Date: Fiscal Year 2026
KCU will meet the requirements in accordance with 34 CFR Section 685.309 by reviewing the enrollment reporting submitted to NSLDS through the National Student Clearinghouse (NSC) each month and comparing to KCU’s student information system to ensure that all dates and information submitted for the m...
KCU will meet the requirements in accordance with 34 CFR Section 685.309 by reviewing the enrollment reporting submitted to NSLDS through the National Student Clearinghouse (NSC) each month and comparing to KCU’s student information system to ensure that all dates and information submitted for the month is accurate and timely. Contact Person: Cindy Miller Anticipated Completion Date: August 15, 2025
Finding 2025-002 Lack of Internal Control Over Reporting Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all federal reports are properly prepared and values reflect actual values in the accounting software. Proposed Completion Date: December 31, 2025.
Finding 2025-002 Lack of Internal Control Over Reporting Name of Contact: Rayna Bowdre Corrective Action: The District will ensure all federal reports are properly prepared and values reflect actual values in the accounting software. Proposed Completion Date: December 31, 2025.
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 157096-0 Award Year: October 1, 2022 – September 30, ...
Item: 2025-001 Assistance Listing Number: 21.027 Program: COVID-19 – Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of the Treasury Pass-Through Agencies: City of Phoenix Pass-Through Grantor Identifying Number: 157096-0 Award Year: October 1, 2022 – September 30, 2025 Compliance Requirement: Reporting Criteria: Per the grant agreements, Maricopa County Community College District Foundation (the “Foundation”) must submit several programmatic reports throughout the grant period with various due dates. Condition: A required programmatic report was submitted 6 days after the due date. Name of Contact Person: Judy Sanchez, Interim CEO Phone Number: 602-402-5062 Anticipated Completion Date: June 30, 2026 Views of Responsible Officials and Corrective Action Plan: The Foundation will design and implement controls regarding the tracking of reporting due dates and retention of concurrent documentation when obtaining extensions or approval for late submissions.
The Business Manager will review all the employee timesheets and contract pay and verify on the gross pay detail reports to authorize payroll prior to finalizing submission of payroll. Intern control procedures will be updated to reflect this process.
The Business Manager will review all the employee timesheets and contract pay and verify on the gross pay detail reports to authorize payroll prior to finalizing submission of payroll. Intern control procedures will be updated to reflect this process.
Strengthening Institutions Program – Department of Education Federal Financial Assistance Listing #84.031 P031A080196 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Section 3 of the Title III Endowment Report for the year ending June 30, 2...
Strengthening Institutions Program – Department of Education Federal Financial Assistance Listing #84.031 P031A080196 Reporting Material Weakness in Internal Control over Compliance and Material Noncompliance Finding Summary: Section 3 of the Title III Endowment Report for the year ending June 30, 2024, was completed materially incorrect for Type of Savings Account Security line items and Total Invested line item. Responsible Individuals: Michael Van Surksum, Vice President for Business and Finance Corrective Action Plan: Management will review their current process to ensure reporting requirements are met and amounts are materially correct. Anticipated Completion Date: Already complete – annual report for the year-ending June 30, 2025 has now been submitted with the correct amounts.
The New Albany Housing Authority is converting its financial systems and will be changing process to identify and reduce spending that may cause the Use of Operating Funds by any other fund.
The New Albany Housing Authority is converting its financial systems and will be changing process to identify and reduce spending that may cause the Use of Operating Funds by any other fund.
Funds were drawn outside of the approved grant period because construction began before the grant start date. A reimbursement request was submitted and approved erroneously by the Environmental Protection Agency (EPA) for work completed prior to the eligible period. To correct this, the City is work...
Funds were drawn outside of the approved grant period because construction began before the grant start date. A reimbursement request was submitted and approved erroneously by the Environmental Protection Agency (EPA) for work completed prior to the eligible period. To correct this, the City is working with the EPA and has submitted a corrective request for reimbursement that will apply the funds already received to eligible work performed within the grant period. No additional funds will be transferred, as the total eligible amount in the corrective request will equal the amount previously received, ensuring all reimbursements align with allowable costs. To prevent recurrence, the City will avoid beginning construction before the official grant period begins and will ensure future grant budget periods include adequate contingencies for early project start dates. Additionally, all future reimbursement requests will undergo a thorough internal review to verify that costs were incurred within the approved grant period, rather than relying solely on federal approval.
Management concurs with the finding and has developed a plan to correct the finding by implementing internal control processes and procedures over the review approval and request for reimbursement of grant expenditures.
Management concurs with the finding and has developed a plan to correct the finding by implementing internal control processes and procedures over the review approval and request for reimbursement of grant expenditures.
Condition: The School District did not have a sufficiently detailed control in place to ensure that the number of meals served and claimed for reimbursement in the Michigan Nutrition Data (MiND) system was supported by School District records of actual meals served. As a result, the School District ...
Condition: The School District did not have a sufficiently detailed control in place to ensure that the number of meals served and claimed for reimbursement in the Michigan Nutrition Data (MiND) system was supported by School District records of actual meals served. As a result, the School District was unable to provide support for the complete number of meals requested for reimbursement, within our audit sample. Planned Corrective Action: The School District will implement a secondary review of the monthly summary sheet used for MIND system claim submission to ensure it fully reconciles with the supporting daily tally sheets. The reviewer will initial and date the summary sheet upon completion of the review. In addition, the newly appointed Food Services Director will establish and maintain an organized filing system (physical and/or electronic) containing all claim-supporting documentation, ensuring records are complete and readily accessible for monitoring or audit purposes. These procedures will be in place effective December 1, 2025 and will be monitored for sustained compliance. Contact person responsible for corrective action: David Bergeron, Assistant Superintendent Anticipated Completion Date: December 1, 2025
2025-002 Contact Person Kelsie Harris, Business Manager Corrective Action Plan The time certifications that were missed during the year under audit was an isolated incident. The time certifications have already been done this month for our current fiscal year and we will ensure that time certificati...
2025-002 Contact Person Kelsie Harris, Business Manager Corrective Action Plan The time certifications that were missed during the year under audit was an isolated incident. The time certifications have already been done this month for our current fiscal year and we will ensure that time certifications are properly filed so this does not happen again. Completion Date Souris Valley Special Services will implement immediately.
Below you will find our corrective action plan to address the one finding in our FY 2025 Federal Single Audit, which received an unmodified opinion from our auditor Audit Finding #: 2025-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Hom...
Below you will find our corrective action plan to address the one finding in our FY 2025 Federal Single Audit, which received an unmodified opinion from our auditor Audit Finding #: 2025-1 Eligibility Determination Grantor: Department of Health and Human Services Federal Program Name: Low Income Home Energy Assistance (LIHEAP) Federal Assistance Listing (CFDA#): 93.568 Description: During the audited year July 2024 – June 2025, Access paid benefits for one individual whose income was over the threshold of 60% of the CT state median income. The income was documented, but incorrectly calculated. Statement of Concurrence: Access management concurs with the audit finding: Corrective Action: Access has put in place written procedures as follows: ○Access will provide additional training support and resources to staff to ensure that all LIHEAPapplications are certified in an accurate manner. ○Access will expand its internal file audit process to continue maintining a master log of all filesreviewed and also note any major findings so a timely response can be made.
The district will routinely check the website, print out the list of vendors, and date the print out.
The district will routinely check the website, print out the list of vendors, and date the print out.
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. The College experienced some turnover during the year. The new director was unaware that the Cost of Attendance was not being updated when a change in the award ...
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. The College experienced some turnover during the year. The new director was unaware that the Cost of Attendance was not being updated when a change in the award was submitted COD due to a change in the student’s schedule. The director is now aware that these changes must be updated manually in COD and has implemented procedures to ensure that the COA is reviewed whenever a revision to the student award is submitted to COD. The college will also confer with the software vendor to determine if any settings in the student information need to be corrected for this update to be automated. The new director of financial aid has been through substantial training in the last six months to better understand how the college’s software communicates with COD and has implemented procedures to ensure the timely submission of disbursements to COD after the disbursements have been made in the student information system. Anticipated Completion Date: Prior records with issues were corrected on September 1, 2025 and ongoing monitoring is taking place
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. This was an unusual circumstance where a student was withdrawn from the college before they were awarded any federal aid. The director has put in place procedure...
Contact Person: Ron Dempsey, Controller Views of Responsible Officials and Planned Corrective Action: Management concurs with the finding. This was an unusual circumstance where a student was withdrawn from the college before they were awarded any federal aid. The director has put in place procedures to review the eligibility for federal aid of any student who withdraws to determine whether a post withdrawal disbursement is appropriate. Anticipated Completion Date: January 1, 2026
The District agrees with the findings. The omission occurred because an outdated private school contact list was used, and a newly opened private school was not identified during 2024 and 2025 Title I consultation periods. To prevent reoccurrence, the District will: 1) conduct an annual verification...
The District agrees with the findings. The omission occurred because an outdated private school contact list was used, and a newly opened private school was not identified during 2024 and 2025 Title I consultation periods. To prevent reoccurrence, the District will: 1) conduct an annual verification of all private schools within District boundaries before each Title I funding cycle, and 2) maintain and update a current contact list and document all outreach and consultation efforts. These steps will ensure full compliance with equitable services requirements moving forward.
Finding 1164982 (2025-001)
Material Weakness 2025
Actions taken: The Fiscal Department through the Revenue Cycle Manager (RCM) will continue to convene a regular task group made up of the RCM, two Front-desk Managers, and the EHR Support Analyst (ESA). The task group revised the verification form so that it requires sign-off/initials from the front...
Actions taken: The Fiscal Department through the Revenue Cycle Manager (RCM) will continue to convene a regular task group made up of the RCM, two Front-desk Managers, and the EHR Support Analyst (ESA). The task group revised the verification form so that it requires sign-off/initials from the front desk staff receiving and reviewing the form and conducted regular desk audits which improved compliance a great deal. This year, a copy of the form has been marked up to highlight the areas that must be reviewed prior to being accepted at the front desk. Front desk staff will continue to sign the forms as they receive them. Front desk managers will review forms to ensure they are completed correctly. The RCM and ESA will continue to conduct weekly desk-audits to determine if forms are being filled out correctly and if billings correctly reflect the form calculations. The task group will then determine specific training for front-desk staff that are identified during the desk audit. Anticipated first Completion Date: January 31, 2026 (for Month End January) Responsible Contact Person: Tina Kirk, Finance Director
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