Corrective Action Plans

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Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on t...
Finding reference: 2024-010 - 93.224, 93.527 – Health Center Program Cluster Material Weakness and Noncompliance over Special Tests and Provisions Recommendation: All elements required for the sliding fee discount should be properly maintained in Allscripts. Employees should be properly trained on the software, and a user manual should be created related to patient intake so patient records are consistent and documented appropriately. Action taken: All elements required for the sliding fee discount are being properly maintained. All employees have been properly trained in software.
Program disbursements lacked proper documented support. MSCIL recognizes the importance of maintaining proper authorization and documentation for all federally funded expenditures and has taken steps to strengthen these practices. Management is improving its internal and program review systems to en...
Program disbursements lacked proper documented support. MSCIL recognizes the importance of maintaining proper authorization and documentation for all federally funded expenditures and has taken steps to strengthen these practices. Management is improving its internal and program review systems to ensure that disbursements are properly reviewed and handled in accordance with grant requirements . Program disbursements will be stored within MSCIL's accounting software to improve consistency across departments. The Administrative Coordinator will assist in monitoring program documentation, and The Fyffe Jones Group will review these processes as part of their monthly reconciliation procedures to identify areas of improvement. These modification s will help ensure that MSCIL's reporting aligns with federal expectations.
United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will wor...
United States Environmental Protection Agency Capitalization Grants for Clean Water Revolving Funds ALN: 66.458 Condition: The Village has not updated its existing policies and written procedures to conform to Uniform Guidance requirements. Planned Corrective Action: The Village’s Treasurer will work on updating all policies and procedures relating to the U.S. Office of Management and Budget Uniform Guidance to ensure the Village policies are in compliance with these guidelines. Responsible Contact Person: Linda M. Morrisey Village Treasurer Village of Ocean Beach Bay & Cottage Walks, P.O. Box 457 Ocean Beach, NY 11770 Anticipation completion date: March 31, 2026
RE: CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) Contact Person Responsible for Corrective Action: Coleen Laprise, Finance Director Corrective Action: The Town of Bridgton will take the following actions to address finding 2024-001: The Town of Bridgton will review and update the current Mun...
RE: CORRECTIVE ACTION PLAN (Concerning Finding 2024-001) Contact Person Responsible for Corrective Action: Coleen Laprise, Finance Director Corrective Action: The Town of Bridgton will take the following actions to address finding 2024-001: The Town of Bridgton will review and update the current Municipal Purchasing and Sale of Supplies, Materials or Equipment Policy (Approved 9/22/2015) to fully incorporate all elements required by 2 CFR sections 200.317-200.327. We will also implement a regular review policy to ensure we remain in compliance with federal regulations and share the updated policy with all Department Heads and Foremen responsible for procurement. Anticipated Completion Date: June 30, 2026. It is our intention to have a revised, compliant document completed by the end of our fiscal year.
Full text of the Corrective Action Plan includes a chart, table or footnotes.
Full text of the Corrective Action Plan includes a chart, table or footnotes.
The Ward Burton Wildlife Foundation will implement an enhanced internal process to ensure timely completion and submission of all future audit requirements. This corrective action focuses on improving the management and monitoring of Suralink assignments. Going forward Jacob will be the primary cont...
The Ward Burton Wildlife Foundation will implement an enhanced internal process to ensure timely completion and submission of all future audit requirements. This corrective action focuses on improving the management and monitoring of Suralink assignments. Going forward Jacob will be the primary contact and receive notifications whenever a new Suralink task is assigned to ensure visibility and shared accountability. Additionally, a tracking protocol will be implemented whereby any assigned task not completed by Jacob within two weeks of assignment will trigger follow-up review and reassignment or escalation as necessary. This internal control is intended to prevent delays in document submission and ensure consistent progress throughout the audit process. These improvements are designed to ensure that all required documentation is completed and submitted in a timely manner, allowing the Foundation to meet all audit deadlines and complete future audits within the required nine-month reporting window.
Audit Finding Reference: 2024-003 Improve Internal Controls Over Procurement Planned Corrective Action: The Town will review and revise its procurement procedures to ensure that federal requirements under the Uniform Guidance are followed for all federally funded transactions. For future federally f...
Audit Finding Reference: 2024-003 Improve Internal Controls Over Procurement Planned Corrective Action: The Town will review and revise its procurement procedures to ensure that federal requirements under the Uniform Guidance are followed for all federally funded transactions. For future federally funded contracts, the Town will maintain documentation demonstrating adherence to Uniform Guidance procurement requirements, including appropriate justifications for exemptions. The Town will ensure program staff are trained on the distinction between federal and state procurement requirements. Planned Implementation Date of Corrective Action: February 2, 2026
Audit Finding Reference: 2024-006 Improve Documentation and Controls over Allowable Costs Planned Corrective Action: The Town will implement and enforce procedures to ensure all employees whose salaries or wages are charged to federal grants maintain and retain appropriate time and effort documentat...
Audit Finding Reference: 2024-006 Improve Documentation and Controls over Allowable Costs Planned Corrective Action: The Town will implement and enforce procedures to ensure all employees whose salaries or wages are charged to federal grants maintain and retain appropriate time and effort documentation, including timesheets for hourly staff and semi-annual certifications for salaried staff, in compliance with Uniform Guidance. Management has made staff aware of the Time and Effort reporting requirements associated with Federal grants and will work with grant managers and finance department staff to ensure this requirement is implemented during Fiscal 2026; on or about March 18th.
Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are n...
Finding Number 2024-002 Planned Corrective Action: CAMcare has implemented enhanced controls over the financial screening and sliding fee discount application process to ensure compliance with 42 CFR §56.303(g)(2). Prior to the application of any sliding fee discount, financial screening staff are now required to verify that the patient’s application rating (based on income and family size) aligns with the corresponding Federal Poverty Level (FPL) category and discount level configured within the Epic system. Discounts will not be applied unless this validation is completed. To address inconsistencies identified during the audit period, CAMcare has formalized procedures requiring that all updates to the sliding fee discount schedule, including changes to FPL thresholds or discount percentages, are communicated to registration, financial screening, and billing staff prior to implementation. Additionally, system-level updates within Epic must be validated by designated personnel to ensure that the updated fee schedule is accurately reflected before being used in patient billing. Supervisory review controls have also been strengthened. Financial screening supervisors will perform monthly spot checks of a defined sample of patient accounts to verify that sliding fee discounts have been applied correctly and are supported by complete and accurate patient application data. Any discrepancies identified will be documented, corrected, and escalated for follow-up training or process improvement as necessary. In addition, CAMcare will reinforce staff training on financial screening policies and procedures on a periodic basis and maintain documentation of completed training. Management will monitor compliance through ongoing supervisory review and periodic evaluation of screening and billing accuracy to ensure adherence to established policies. These corrective actions are designed to strengthen internal controls over financial screening and billing processes, ensure accurate application of sliding fee discounts, and reduce the risk of noncompliance in future reporting periods. Anticipated Completion Date: January 1st, 2025, with ongoing monthly monitoring and periodic training. Responsible Contact Persons: Eshan Singh, Vice President of Finance, Analytics & Technology
2024-002 – All Federal Programs – Compliance – Data Collection Form Finding: For the fiscal year ended September 30, 2023, the Village did not submit the data collection form to the Federal Clearinghouse by the required due date of June 30, 2024, in accordance with the federal requirements. In addit...
2024-002 – All Federal Programs – Compliance – Data Collection Form Finding: For the fiscal year ended September 30, 2023, the Village did not submit the data collection form to the Federal Clearinghouse by the required due date of June 30, 2024, in accordance with the federal requirements. In addition, due to the late issuance of the 2024 fiscal year audit, the submission deadline for FY 2024 of June 30, 2025 has passed and as such, the Village did not meet the submission deadline. Correction Action: The Village will ensure the data collection form for the fiscal year ending September 30, 2025 is submitted at the completion of the audit. Responsible Parties: Village Administrator, Community and Economic Development Coordinator and Accounting Supervisor. Anticipated Completion Date: June 2026
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immedi...
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immediately filed. The Agency will prepare a checklist of required federal reports by the finance department, which will be monitored by the Program Director. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Pr...
TOFMHS concurs with the finding. There was turnover in the finance department, moving forward TOFMHS will implement adequate and sufficient internal controls to ensure that approvals charged to the grant are reviewed and approved by authorized members of TOFMHS. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audi...
TOFMHS concurs with the finding. The agency retained new auditors for the June 30,2024 fiscal year, subsequent to the due date for submission of the data collection reports. Corrective Action to be Taken: The Agency will take all reasonable measures to work with the new auditors to complete the audit process and submit the data collection report within the required time period. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
Moving forward, the District will ensure that all supporting documents are retained for reporting elements related to grants. Additionally, the District will add additional review procedures for any reporting items related to grants.
Moving forward, the District will ensure that all supporting documents are retained for reporting elements related to grants. Additionally, the District will add additional review procedures for any reporting items related to grants.
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice a...
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.
Finding Number: 2024-003 Finding Title: Reporting Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: The account activity will be reviewed and reconciled monthly to check for chart of accounts errors. When quarterly repo...
Finding Number: 2024-003 Finding Title: Reporting Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: The account activity will be reviewed and reconciled monthly to check for chart of accounts errors. When quarterly reports are completed two fiscal staff will have reviewed the chart of accounts codes. Anticipated Completion Date: 1/31/2025
STRATEGIC CAPACITY GROUP CORRECTIVE ACTION PLAN For the Year Ended December 31, 2024 U.S. DEPARTMENT OF STATE Strategic Capacity Group (SCG) submits the following corrective action plan for the year ended December 31, 2024. Independent Public Accounting Firm: CBIZ CPAs P.C. 1899 L Street NW, Suite 8...
STRATEGIC CAPACITY GROUP CORRECTIVE ACTION PLAN For the Year Ended December 31, 2024 U.S. DEPARTMENT OF STATE Strategic Capacity Group (SCG) submits the following corrective action plan for the year ended December 31, 2024. Independent Public Accounting Firm: CBIZ CPAs P.C. 1899 L Street NW, Suite 850 Washington, DC 20036 Audit Period: The finding from the December 31, 2024 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDING - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS Finding No. 2024-001: Late Filing of Data Collection Form - Compliance Finding – All Federal Awards Criteria In accordance with the Uniform Guidance, the audit package and the Data Collection Form must be submitted within 30 days after receipt of the auditors’ report or nine months after the end of the fiscal year, whichever comes first. Condition and Context The Data Collection Form for the year ended December 31, 2024 was not submitted to the Federal Audit Clearinghouse by the September 30, 2025 deadline. Recommendation It was recommended that management continue its efforts to ensure that all filing requirements under federal awards are met. Views of Responsible Officials and Planned Corrective Actions SCG has consistently ensured that all audits preceding fiscal year 2023 were completed by the annual September 30 deadline. Both the 2023 and 2024 audit delays resulted from SCG’s appeal to the U.S. Department of State on December 20, 2023, concerning differing interpretations surrounding the configuration and application of the Negotiated Indirect Cost Rate Agreement (NICRA). Additionally, in January 2025, the U.S. Department of State suspended 100 percent of SCG’s funding. Although SCG subsequently resumed programmatic activities, the disruption of funding paused the in-progress 2023 audit and delayed its rescheduling. It also delayed the start of the 2024 audit. SCG received a response to its appeal only on September 24, 2024. Had it not been for these unique circumstance and the timing of the U.S. Department of State’s appeal determination, SCG’s 2023 audit would have been filed by the deadline, and SCG’s 2024 audit would have been completed and submitted by September 30, 2025. Because of these unique circumstances, SCG believes no corrective action is warranted. Contact Person Responsible for Corrective Action: Querine Hanlon, President _______________ If the US Department of State has questions regarding this plan, please call Querine Hanlon, President, (202) 746-7317. Sincerely, Querine Hanlon, Ph.D. President Strategic Capacity Group
Corrective Action Plan for Finding 2024-002 Finding Title: Noncompliance with Single Audit Report Submission Requirements Federal Program(s): All programs included in the FY 2024 Single Audit Contact Person Responsible for Corrective Action: Dr. Veronica Morley, Superintendent Anticipated Completion...
Corrective Action Plan for Finding 2024-002 Finding Title: Noncompliance with Single Audit Report Submission Requirements Federal Program(s): All programs included in the FY 2024 Single Audit Contact Person Responsible for Corrective Action: Dr. Veronica Morley, Superintendent Anticipated Completion Date: March 31, 2025 Corrective Action Plan: Management concurs with the finding. The delay in submitting the Single Audit reporting package to the Federal Audit Clearinghouse was due delayed completion of audited financial statements. The school is in the process of getting current with audited financials statements.
Condition: Of the 40 students selected for Return of Title IV (R2T4) testing, 1 student did not have the appropriate amount returned to the federal agency. Planned Corrective Action: To prevent human error from occurring in the future, the Office of Financial Aid has immediately implemented the foll...
Condition: Of the 40 students selected for Return of Title IV (R2T4) testing, 1 student did not have the appropriate amount returned to the federal agency. Planned Corrective Action: To prevent human error from occurring in the future, the Office of Financial Aid has immediately implemented the following process: When a recipient of Title IV grant or loan assistance withdraws from Eastern Michigan University and a Return of Title IV calculation is performed, a Senior Financial Aid Advisor or member of the Financial Aid Management staff will review all required returns completed to ensure accuracy. This review will occur on a weekly basis. Contact person responsible for corrective action: Jennifer Tremewan, Asst. Director Office of Financial Aid Anticipated Completion Date: December 31, 2024
Condition: Of the 40 students selected for enrollment reporting testing, 5 students did not have their status updated appropriately. Planned Corrective Action: The Office of Financial Aid has implemented a process to communicate and confirm with the office responsible for enrollment reporting to ver...
Condition: Of the 40 students selected for enrollment reporting testing, 5 students did not have their status updated appropriately. Planned Corrective Action: The Office of Financial Aid has implemented a process to communicate and confirm with the office responsible for enrollment reporting to verify that enrollment rosters will not be/have not been sent after a semester has officially ended. Contact person responsible for corrective action: Jennifer Tremewan, Asst. Director Office of Financial Aid Anticipated Completion Date: December 31, 2024
Management Response/Corrective Action Plan: The city and school will draft formal compliance procedures to ensure Davis-Bacon wages are met. These procedures will start with having our attorney’s construct a contract specific to federally funded projects that contains necessary language for Davis-Ba...
Management Response/Corrective Action Plan: The city and school will draft formal compliance procedures to ensure Davis-Bacon wages are met. These procedures will start with having our attorney’s construct a contract specific to federally funded projects that contains necessary language for Davis-Bacon compliance. The Augusta School Department has maintained consistent compliance with Davis-Bacon Act requirements. These requirements are integrated into their bid process regularly and are fully implemented. Going forward, the formal procedure will include that we are to require a signed copy of the contractor’s payroll be sent to us for each week the contract work is performed.
Partnership Homes, Inc. Greensboro, North Carolina CORRECTIVE ACTION PLAN February 11, 2026 Federal Audit Clearinghouse 1201 East 10th Street Jeffersonville, Indiana 47132 Partnership Homes, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard ...
Partnership Homes, Inc. Greensboro, North Carolina CORRECTIVE ACTION PLAN February 11, 2026 Federal Audit Clearinghouse 1201 East 10th Street Jeffersonville, Indiana 47132 Partnership Homes, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2024. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 Audit period: Year ended December 31, 2024 The finding from the December 31, 2024 Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Findings - Federal Award Programs Audits Finding No. 2024-001: HOME Investment Partnerships Program , CFDA #14.239 Recommendation: We recommend management ensure that the data collection forms are submitted electronically to the FAC within the required due dates each fiscal year going forward. Management's Response: We agree with Finding 2024-001 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will provide additional oversight to ensure the data collection forms are submitted electronically to the FAC each fiscal year going forward within required due dates. The data collection form for the year ending December 31, 2023 was submitted to the FAC on August 27, 2025. If you have questions regarding this plan, please call Mike Cooke at (336) 707-5289. Sincerely yours, Mike Cooke Executive Director Partnership Homes, Inc.
The Board of Directors for the district will be monitoring all filing to be able to account for documentation available within the district. Also, there will be implementing document control procedures for all costs and invoices within the district.
The Board of Directors for the district will be monitoring all filing to be able to account for documentation available within the district. Also, there will be implementing document control procedures for all costs and invoices within the district.
U.S. Department of Treasury • Material Weakness in Internal Control over Compliance Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During audit testing of financial reporting for the Coronavirus State and Local Fiscal Recovery Funds program, the Organiza...
U.S. Department of Treasury • Material Weakness in Internal Control over Compliance Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During audit testing of financial reporting for the Coronavirus State and Local Fiscal Recovery Funds program, the Organization was unable to locate three of ten financial reports requested for review. As a result, auditors were unable to verify the accuracy, completeness, or timeliness of the reported financial information for those reporting periods. Recommendation: The Organization should strengthen internal controls over financial reporting and record retention by establishing clear procedures to ensure that all required reports are accurately prepared, timely submitted, and retained in accordance with federal requirements. Management should designate responsible personnel and implement monitoring procedures to verify compliance with reporting and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will require that all supporting documentation related to financial reporting—including reports, source data, approvals, and correspondence—be retained electronically within Sage Intacct using standardized attachment and naming conventions. Management will implement periodic monitoring procedures, including supervisory review and internal spot checks, to verify that reports are timely submitted and that documentation is properly retained in Sage Intacct in accordance with applicable federal record-retention requirements. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2025.
U.S. Department of Health and Human Services U.S. Department of Treasury • Significant Deficiency in Internal Control over Compliance Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During ...
U.S. Department of Health and Human Services U.S. Department of Treasury • Significant Deficiency in Internal Control over Compliance Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During our testing of performance and special reporting, we noted that the Organization did not maintain documentation evidencing review or approval of submitted reports. The reports tested did not include evidence demonstrating that an authorized individual reviewed and approved the performance and special reports prior to submission. Recommendation: The Organization should implement formal internal controls over performance and special reporting by establishing documented procedures that require review and approval of all reports prior to submission. Management should define clear roles and responsibilities for report preparation and independent review, ensure that reviews are performed by an authorized individual, and maintain documentation evidencing review and approval, such as signatures, dates, or electronic approvals, to support compliance with performance reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will implement formal internal controls over performance and special reporting by developing and documenting standardized procedures for the preparation, review, and approval of all required federal performance and special reports. These procedures will clearly define roles and responsibilities for report preparation and independent review, including identification of authorized individuals responsible for final approval. Evidence of review and approval—including signatures, dates, or electronic approval records—will be retained in the grant file to support compliance with reporting requirements. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2026.
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