Corrective Action Plans

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2024-004 INTERNAL CONTROLS OVER CASH MANAGEMENT Federal Agency: Department of Transportation Federal Program: Formula Grants for Rural Areas and Tribal Transit Program Assistance Listing Number: 20.509 Federal Award Identification Number and Year: MN-2020-020-01 Pass-Through Agency: Minnesota Depart...
2024-004 INTERNAL CONTROLS OVER CASH MANAGEMENT Federal Agency: Department of Transportation Federal Program: Formula Grants for Rural Areas and Tribal Transit Program Assistance Listing Number: 20.509 Federal Award Identification Number and Year: MN-2020-020-01 Pass-Through Agency: Minnesota Department of Transportation Pass-Through Number: MN-2020-020-01, MN-2023-045-00 Award Period: Year Ended December 31, 2024 Compliance Requirement: Cash Management Type of Finding: Significant Deficiency in Internal Controls over Compliance Recommendation: It is recommended the Transit Board designate qualified personnel for conducting the quarterly reporting review. The review should be performed and documented. Formal procedures should be documented to ensure consistency and effectiveness of the quality review process. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Transit Board will continue to evaluate their internal staff capacity to determine if an internal control policy over cash management and other areas is beneficial. Name of the contact person responsible for corrective action: Cecilia Mutharia, Transit Director Planned completion date for corrective action plan: June 30, 2026
Corrective Action Plan: GCI has since required all staff to complete form I-9. Estimated Correction Date: September 30, 2025 Responsible Official: Nedra Sims Fears, Executive Director
Corrective Action Plan: GCI has since required all staff to complete form I-9. Estimated Correction Date: September 30, 2025 Responsible Official: Nedra Sims Fears, Executive Director
GCI, with the completion of this 2024 audit, is now in compliance with the State of Illinois reporting requirements. GCI plans to complete its 2025 audit within the required timeframe to remain in compliance with the State of Illinois guidelines. Estimated Correction Date: The 2024 audit will be com...
GCI, with the completion of this 2024 audit, is now in compliance with the State of Illinois reporting requirements. GCI plans to complete its 2025 audit within the required timeframe to remain in compliance with the State of Illinois guidelines. Estimated Correction Date: The 2024 audit will be completed by February 30, 2026, or earlier. GCI will have an auditor complete its 2025 audit on or before August 2026 and submit it to the State of Illinois to ensure compliance for the 2026 fiscal year. Responsible Official:Nedra Sims Fears, Executive Director
2024-001 Supporting Documentation and Approval of Disbursements Contact Person – Erin Metcalf, Finance Director Description of Corrective Action – Since that time, the organization has developed an invoice and payment process. This ensures proper disbursement and approval processes and supporting do...
2024-001 Supporting Documentation and Approval of Disbursements Contact Person – Erin Metcalf, Finance Director Description of Corrective Action – Since that time, the organization has developed an invoice and payment process. This ensures proper disbursement and approval processes and supporting documentation are obtained for expenses incurred. We will ensure that the expenses for the grants are reviewed monthly and will make the correct adjustments on a timely basis to ensure that the funds are approved and paid in accordance with the grant documents. Completion Date – June 30, 2025 Root Cause – New program procedures were not in place
See Corrective Action Plan for chart/table
See Corrective Action Plan for chart/table
See Corrective Action Plan for chart/table
See Corrective Action Plan for chart/table
See Corrective Action Plan for chart/table
See Corrective Action Plan for chart/table
To mitigate further delays in completing our 2025 audit, SERC has discussed amending the agreement with its current auditing firm to conduct the 2025 audit. SERC has also contracted with an external consultant to facilitate the fiscal department's operations while we find a permanent fiscal departme...
To mitigate further delays in completing our 2025 audit, SERC has discussed amending the agreement with its current auditing firm to conduct the 2025 audit. SERC has also contracted with an external consultant to facilitate the fiscal department's operations while we find a permanent fiscal department head.
Response: The organization agrees with the finding. The organization has implemented a method to ensure prepaid insurance is appropriately adjusted and insurance costs are accurately recorded and allocated to grants.
Response: The organization agrees with the finding. The organization has implemented a method to ensure prepaid insurance is appropriately adjusted and insurance costs are accurately recorded and allocated to grants.
Response: The organization agrees with the finding. Now that the organization has filled the accounting director position and the delinquent audits have been completed, annual audits are expected to be completed in a timely manner.
Response: The organization agrees with the finding. Now that the organization has filled the accounting director position and the delinquent audits have been completed, annual audits are expected to be completed in a timely manner.
Action: HH has provided the necessary accounting personnel and contracts with an experienced accounting firm to ensure that the accounting functions are completed within nine months of the year end. The original delay is currently being worked through and HH personnel and an outside accounting firm ...
Action: HH has provided the necessary accounting personnel and contracts with an experienced accounting firm to ensure that the accounting functions are completed within nine months of the year end. The original delay is currently being worked through and HH personnel and an outside accounting firm are currently working to catch up on past due financial audits. FY2024-2025 is expected to be completed in FY2025-2026.
Management will ensure timely reporting for audit procedures in accordance with the Uniform Guidance 2 CFR.
Management will ensure timely reporting for audit procedures in accordance with the Uniform Guidance 2 CFR.
Finding 2024-002 – Career and Technical Education - Perkins CFDA No. 84.048 Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Criteria: Where employees work solely or partially on a si...
Finding 2024-002 – Career and Technical Education - Perkins CFDA No. 84.048 Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Criteria: Where employees work solely or partially on a single Federal award or cost objective, their salaries or wages must be supported by periodic certification that the employee worked solely on these programs for the period covered by the programs. The certifications should be prepared at least semi-annually, and should be signed by the employee or supervisory official having first-hand knowledge of the work performed by the employee. Condition: During our test of controls over compliance with time and effort certifications the School was not able to provide evidence that required semi-annual certifications of time and effort for those employees whose time was wholly spent on these programs was performed in a timely manner as required by Uniform Guidance. Questioned Costs: None Context: During our test of payroll transactions of the FY 2024 Perkins and FY 23 Perkins grants it was noted that the time and effort certifications were not completed in a timely manner as set forth by Uniform Guidance. Effect: The Assabet Valley Regional Technical High School was not in compliance with the time and effort certification requirements. Cause: Compliance of the past grants were not handled correctly due to employee staffing changes and training. Identification as a Repeat Finding: This is not a repeat finding Recommendation: We recommend the Assabet Valley Regional Technical High School follow procedures to ensure that semi-annual certifications are prepared and signed by either the employees or supervisory official having first-hand knowledge of the work performed by the employees in a timely manner in order to comply with the time and effort certification requirement. Responsible for Corrective Plan: Sabrina Howley Estimated Completion Date: 11/5/25 On going Action Taken: Grants compliance will be strictly enforced per DESE and Federal regulations. This includes payroll, time and effort sheets.
Finding 2024-001 – Career and Technical Education - Perkins CFDA No. 84.048 Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Criteria: Massachusetts Department of Education and Second...
Finding 2024-001 – Career and Technical Education - Perkins CFDA No. 84.048 Department of Education Massachusetts Department of Elementary and Secondary Education Other Matters Related to Internal Control over Compliance of the Major Program Criteria: Massachusetts Department of Education and Secondary Education Requires: • Final expenditure reports are required to be filed within 60 days of the grant period ending date. Condition: During our test of controls over compliance it was noted that the Student Organization grant, 21st Century grant, & Equitable Access grant final expense reports were not filed within 60 days of the grant period ending as required by Massachusetts Department of Education and Secondary Education. Questioned Costs: None Context: During our test of the Final Expenditure Reports it was noted that the Student Organization, 21st Century grant, & Equitable Access Grant final expense reports were not filed within 60 days of the grant period ending as required by Massachusetts Department of Education and Secondary Education. Effect: Assabet Valley Regional Technical High School was not in compliance with the Final Expenditure Reporting requirement date as set forth by the Massachusetts Department of Education and Secondary Education. Cause: In June 2023 Assabet’s staff member handling grants retired. They only came in once a week to help with grants until new staff could be hired. In October of 2023 our current grant manager was hired and had very limited training on grants before the retiree quit fully in January 2024. Due to this, training in Edgrants was extremely limited and the FY23 grants mentioned where not handled correctly. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Assabet Valley Regional Technical High School follow procedures to ensure that the Final Expenditure Reports are filed within the 60 days of the grant period ending date as required by the Massachusetts Department of Education and Secondary Education. Responsible for Corrective Plan: Sabrina Howley Estimated Completion Date: 11/5/25, Ongoing Action Taken: In June 2023 Assabet’s staff member handling grants retired. They only came in once a week to help with grants until new staff could be hired. In October of 2023 our current grant manager was hired and had very limited training on grants before the retiree quit fully in January 2024. Due to this, training in Edgrants was extremely limited and the FY23 grants mentioned where not handled correctly. All grants since FY24/25 in Gem$ have been managed correctly with processing the FER (no longer FR-1) within the 60 days of the grant period. This will be an ongoing every year for all Federal and State Grants.
Finding 2024-008 – Education Stabilization Fund – ESSER III AL No. 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Condition: Upon review of the Assabet...
Finding 2024-008 – Education Stabilization Fund – ESSER III AL No. 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Condition: Upon review of the Assabet Valley Regional Technical High School’s final expense report filed with the Massachusetts Department of Elementary and Secondary Education it was noted that the report did not agree with the School’s accounting ledgers and final amended budget. Criteria: Massachusetts Department of Education and Secondary Education Requires: • Final expenditure reports are required to be filed within 60 days of the grant period ending date and accounting ledgers. Context: The Final expense report for the ESSER III grant does not agree with the general ledger actual expenses and the final amended budget for ESSER III. Effect: Assabet Valley Regional Technical High School was not in compliance with the Final Expenditure Reporting requirement as set forth by the Massachusetts Department of Education and Secondary Education. Questioned Costs: N/A Cause: In June 2023 Assabet’s staff member handling grants retired. They only came in once a week to help with grants until new staff could be hired. In October of 2023 our current grant manager was hired and had very limited training on grants before the retiree quit fully in January 2024. Due to this, training in Edgrants was extremely limited and the FY23 grants mentioned where not handled correctly. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Assabet Valley Regional Technical High School follow procedures to ensure that the Final Expenditure Reports are in agreement with the School’s general ledger total expenses. Responsible for Corrective Plan: Sabrina Howley Estimated Completion Date: 11/5/25, ongoing Action Taken: In June 2023 Assabet’s staff member handling grants retired. They only came in once a week to help with grants until new staff could be hired. In October of 2023 our current grant manager was hired and had very limited training on grants before the retiree quit fully in January 2024. Due to this, training in Edgrants was extremely limited and the FY23 grants mentioned where not handled correctly. Esser III had been amended multiple times, by the time the FR-1 was completed the grant manager quickly went through not realizing it had to match funds and wasn’t automatically changed. Since that time Esser III has been amended and the FR-1 has been competed fully.
Finding 2024-007 – Education Stabilization Fund – ESSER III AL No. 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Condition: During our test of control...
Finding 2024-007 – Education Stabilization Fund – ESSER III AL No. 84.425U Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Condition: During our test of controls over compliance it was noted that there was an expenditure charged to the Education Stabilization Fund – ESSER III for services outside of the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education. Criteria: The Period of Performance for the Education Stabilization Fund – ESSER III was October 4, 2021 through September 30, 2024. Context: During our test of expenditures and review of the general ledger against the Education Stabilization Fund – ESSER III grant as it is related to compliance it was noted that the School paid in full a four year lease from 3/1/23 to 2/28/27 and charged 10/1/23 to 2/28/27 to the Education Stabilization Fund – ESSER III grant in the amount of $190,869 and thus the period from 10/1/24 to 2/28/27 would be outside the period of performance and thus would not be an allowable cost. Unallowable costs for this period was $52,426. Effect: Assabet Valley RTHS was not in compliance with the period of performance requirement as set forth by the Massachusetts Department of Elementary and Secondary Education. Questioned Costs: Questioned cost charged to the Education Stabilization Fund – ESSER III grant whose service period was beyond the grant end date of September 30, 2024 was in the amount of $52,426. Cause: Grant should have been amended. Identification as a Repeat Finding: 2023-003 Recommendation: We recommend the Assabet Valley RTHS follow procedures to ensure that expenditures charged to the grant is within the period of performance as set forth by the Massachusetts Department of Elementary and Secondary Education. Responsible for Corrective Plan: Maria Silva Estimated Completion Date: 2024 Action Taken: Grant has since been corrected and funds where moved to the correct account in our general ledger. Assabet staff is aware that leases cannot be past or before a grants end/start date.
Finding 2024-005 – Special Education Cluster – AL No. 84.027 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Program Condition: During our test of controls over co...
Finding 2024-005 – Special Education Cluster – AL No. 84.027 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Significant Deficiency Related to Internal Control over Compliance of the Major Program Condition: During our test of controls over compliance it was noted that there are expenditures charged to the Special Education Cluster for expenses that are unallowable costs. Criteria: Costs charged to the major programs should meet the requirements as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Context: During our test of expenditures and review of the general ledger against the Special Education Cluster as it is related to compliance it was noted that the FY 23 Special Education PL94-142 grant had two invoices charged to the grant for promotional items (mugs, shirts, totes, jackets, etc.…) to the budget line as classroom supplies. The FY 2024 Special Education IEP 274 grant had an expense whose supporting documentation was a quote as the invoice was not received. Effect: Assabet Valley RTHS was not in compliance with the allowable costs/ cost principals requirement as set forth by the Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles). Questioned Costs: Questioned costs for one of the invoices charged to the FY 23 Special Education PL94-142 was for 72 porcelain mugs was $292.46. Questioned costs for the other invoice charged to the FY 23 Special Education PL94-142 grant was for shirts, totes, jackets, apron, and windbreakers was $1,320.99. Questioned costs for the FY 2024 Special Education IEP 274 grant whose supporting documentation was a quote was $7,950.00. Cause: I glanced at the invoice quickly not paying attention as I normally would due to it was the end of the year and we were closing out the grant, also our former sped director had approved the purchase. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Assabet Valley RTHS follow procedures to ensure that expenditures charged to the grants are allowable costs as set forth by Uniform Guidance 2 CFR Part 200, subpart E (Cost Principles) Responsible for Corrective Plan: Sabrina Howley Estimated Completion Date: 11/5/25, Ongoing Action Taken: All requests for purchases will be double/triple checked. Before paying an invoice items will be checked again that they match the grant requested requirements and laws.
Finding 2024-006 – Special Education Cluster – AL No. 84.027 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Condition: Upon review of the Assabet Valley Region...
Finding 2024-006 – Special Education Cluster – AL No. 84.027 Department of Education Massachusetts Department of Elementary and Secondary Education Noncompliance and Material Weakness Related to Internal Control over Compliance of the Major Program Condition: Upon review of the Assabet Valley Regional Technical High School’s final expense report filed with the Massachusetts Department of Elementary and Secondary Education it was noted that the reports did not agree with the School’s general ledgers. Criteria: Massachusetts Department of Education and Secondary Education Requires: • Final expenditure reports are required to be filed within 60 days of the grant period ending date and agree with general ledgers. Context: The Final expense report for the FY 2023 Special Education PL94-142 reported that the grant was fully spent, however the grant was not fully spent per the School’s general ledger. Effect: Assabet Valley Regional Technical High School was not in compliance with the Final Expenditure Reporting requirement as set forth by the Massachusetts Department of Education and Secondary Education as it did not agree to the Schools accounting ledgers. Questioned Costs: N/A Cause: In June 2023 Assabet’s staff member handling grants retired. They only came in once a week to help with grants until new staff could be hired. In October of 2023 our current grant manager was hired and had very limited training on grants before the retiree quit fully in January 2024. Due to this, training in Edgrants was extremely limited and the FY23 grants mentioned where not handled correctly. Identification as a Repeat Finding: This is not a repeat finding. Recommendation: We recommend the Assabet Valley Regional Technical High School follow procedures to ensure that the Final Expenditure Reports are in agreement with the School’s general ledger. Responsible for Corrective Plan: Sabrina Howley Estimated Completion Date: 11/5/25, Ongoing Action Taken: In June 2023 Assabet’s staff member handling grants retired. They only came in once a week to help with grants until new staff could be hired. In October of 2023 our current grant manager was hired and had very limited training on grants before the retiree quit fully in January 2024. Due to this, training in Edgrants was extremely limited and the FY23 grants mentioned where not handled correctly. All grants since FY24/25 in Gem$ have been managed correctly with processing the FER (no longer FR-1) within the 60 days of the grant period. This will be an ongoing every year for all Federal and State Grants. FER’s will be completed once the grant is fully spent according to our general ledger.
The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is revie...
The Organization hired a new grant and partnership specialist. This specialist attaches all relevant support for expenditure to the internal monthly grant reporting and ensures that all expenditures are fully supported by appropriate detail. This detail is on a shared drive with finance and is reviewed by the vice president of finance.
Late Reporting (Significant Deficiency) Individuals Responsible for Corrective Action Plan: BGCA State Alliances Fiscal Team (Shelby Mahoney) in partnership with Ohio Alliance staff Corrective Action: Management will implement procedures to ensure timely completion and submission of future single au...
Late Reporting (Significant Deficiency) Individuals Responsible for Corrective Action Plan: BGCA State Alliances Fiscal Team (Shelby Mahoney) in partnership with Ohio Alliance staff Corrective Action: Management will implement procedures to ensure timely completion and submission of future single audits in compliance with Uniform Guidance reporting deadlines. Corrective actions include: - Developing a formal annual audit timeline with clearly defined internal deadlines for financial statement preparation, SEFA completion, auditor fieldwork, and submission to the Federal Audit Clearinghouse. - Assigning responsibility for monitoring audit progress and compliance deadlines to designated management personnel. - Holding periodic status meetings with auditors to proactively address issues that could delay completion. Anticipated Completion Date: June 30, 2026
Implementation of plan of action - Management will review control policies to ensure that approvals of purchases are documented prior to disbursement of federal funds. Implementation date - Anticipated completion February 28, 2026. Persons responsible for the implementation - The Board of Directors ...
Implementation of plan of action - Management will review control policies to ensure that approvals of purchases are documented prior to disbursement of federal funds. Implementation date - Anticipated completion February 28, 2026. Persons responsible for the implementation - The Board of Directors and Head of School.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
The Center is working with their third-party bookkeeper to ensure all federal funds are reported properly in their general ledger system in order to determine if a federal single audit is required.
Audit Finding: 2024-002 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates have been develop...
Audit Finding: 2024-002 – Procurement Documentation Planned Corrective Action(s): SIG-NAL will strengthen its procurement controls by fully implementing the updated Procurement Policy and Standard Operating Procedure adopted in 2025. Standardized procurement documentation templates have been developed and are now required for all purchasing actions, including documentation of procurement method, contractor selection, and cost/price analysis. Compliance is monitored by the Director of Operations and reviewed periodically by the external accounting firm. The organization will require that all procurement records are completed and retained in accordance with 2 CFR §§ 200.318–320. Anticipated Completion Date ● Ongoing - Full implementation expected by March 2026 Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director
Audit Finding: 2024-001 – Lack of Documentation of Review and Approval Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital ...
Audit Finding: 2024-001 – Lack of Documentation of Review and Approval Planned Corrective Action(s): SIG-NAL will enhance internal controls by implementing formal review and approval processes for payroll, expenses, and financial reporting. The organization will require documented evidence (digital or written) of all reviews and approvals and will maintain these records in a standardized, centralized system. The Finance Team will ensure that all controls are performed and documented in accordance with 2 CFR Part 200 requirements. Updated internal control policies and procedures were formally adopted in 2025 and implementation began immediately. Standardized review documentation is now required for payroll, expenses, and financial reporting, and oversight by the external accounting firm is ongoing to ensure compliance with 2 CFR Part 200. Anticipated Completion Date ● Implemented in 2025 (Monitoring ongoing) Responsible Party ● Director of Operations, with support from the Finance Team and Executive Director
Broadlawns Medical Center respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number ass...
Broadlawns Medical Center respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDITS DEPARTMENT OF AGRICULTURE 2024-001 Special Supplemental Nutrition Program for Women, Infants and Children – CFDA No. 10.557 Recommendation; We recommend the Medical Center review the WIC expenses monthly to ensure during month end close process that all costs are allowable and deemed to be reimbursable as a part of the federal award program. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization adopted a monthly review process as part of the monthly close process. Name of the contact person responsible for corrective action: Jim Lynch Planned completion date for corrective action plan: Next Fiscal Year If there are questions regarding this plan, please call Jim Lynch at 515-282-2296
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