Corrective Action Plans

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2025-003 Inadequate Contract Review Name of Contact Person: Samantha Hurd, DSS Director Corrective Action: The Deaprtment of Social Services will implement new review procedures to verify that all certifications and provisions are included in contracts for the purchase of services. Proposed Completi...
2025-003 Inadequate Contract Review Name of Contact Person: Samantha Hurd, DSS Director Corrective Action: The Deaprtment of Social Services will implement new review procedures to verify that all certifications and provisions are included in contracts for the purchase of services. Proposed Completion Date: May 31, 2026.
Finding Number: 2025-005 Planned Corrective Action: Management is implementing additional review and validation procedures for UDS reporting. Corrective actions include formal UDS preparation and review protocols, standardized validation checklists, retention of supporting documentation, and annual ...
Finding Number: 2025-005 Planned Corrective Action: Management is implementing additional review and validation procedures for UDS reporting. Corrective actions include formal UDS preparation and review protocols, standardized validation checklists, retention of supporting documentation, and annual training for personnel responsible for preparing and reviewing HRSA reports. Anticipated Completion Date: 12/31/2026 Responsible Contact Person: Charles Tong, Chief Financial Officer
Finding Number: 2025-004 Planned Corrective Action: Management has already begun to implement corrective actions to strengthen compliance with HRSA Sliding Fee Discount Program requirements. Corrective measures include updating sliding fee procedures, annual staff training, monthly quality assurance...
Finding Number: 2025-004 Planned Corrective Action: Management has already begun to implement corrective actions to strengthen compliance with HRSA Sliding Fee Discount Program requirements. Corrective measures include updating sliding fee procedures, annual staff training, monthly quality assurance reviews, and ongoing management oversight of sliding fee adjustments and supporting documentation. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Charles Tong, Chief Financial Officer
Implement cross training of staff member, maintain updated procedures for tasks, and establish backup coverage for critical reporting functions to mitigate the impact of future staffing changes in the reporting compliance process. Anticipated completion date: December 31, 2026. Responsible contact: ...
Implement cross training of staff member, maintain updated procedures for tasks, and establish backup coverage for critical reporting functions to mitigate the impact of future staffing changes in the reporting compliance process. Anticipated completion date: December 31, 2026. Responsible contact: Mike Gagliardi, Administrator.
Training for all Medicaid staff on correct determination of income, resources, ownership, household composition, proper verification requests (clarity and completeness), and timely processing of recertifications. Ongoing Quality Assurance Second-party reviews will continue to ensure compliance with ...
Training for all Medicaid staff on correct determination of income, resources, ownership, household composition, proper verification requests (clarity and completeness), and timely processing of recertifications. Ongoing Quality Assurance Second-party reviews will continue to ensure compliance with Medicaid policy and to catch errors in real time. Starting in 2026, the agency will conduct mandatory quarterly training sessions focused on accuracy, policy updates, and lessons learned from reviews and audits.
Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. To strengthen compliance with our sliding fee discount polic...
Management agrees with the finding that sliding fee discounts must be applied consistently and in accordance with our approved policy. We are committed to ensuring access to care while maintaining compliance with HRSA program requirements. To strengthen compliance with our sliding fee discount policy, East Valley Community Health Center has implemented several corrective measures. Re-training for intake and billing staff began in April 2025 and is ongoing as part of our quarterly training cycle. In addition, we are currently reviewing our sliding fee discount policy and procedures to ensure they are clear, consistently applied, and aligned with HRSA guidance and the Health Center Program Compliance Manual. Monthly audits of patient encounters involving sliding fee adjustments began in October 2024 by the billing department and are now a permanent component of our internal compliance process. Audit results are reviewed by our Revenue Cycle Manager and shared with Health Center Administrators and Patient Access Manager, Front Office Leads, and Senior Leadership to ensure accountability and timely corrective action when needed. The CFO is responsible for overseeing these processes and ensuring that all compliance measures are implemented effectively.
2025-003 – Controls Over Disbursements Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Department of Education – Child Nutrition Cluster CFDA – 10.553/10.555/10.556/10.559/10.579/10.582 Criteria: 2 CFR 200.303 Internal Controls Condition: ...
2025-003 – Controls Over Disbursements Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Department of Education – Child Nutrition Cluster CFDA – 10.553/10.555/10.556/10.559/10.579/10.582 Criteria: 2 CFR 200.303 Internal Controls Condition: During audit procedures, it was identified that the Supervisory Union did not have internal controls in place to ensure that invoices were properly approved and paid in a timely manner. Cause: Unknown Effect: The Supervisory Union did not always properly approve invoices, could not always locate invoices, and paid invoices beyond the due date. Identification of Questioned Costs: None identified. Context: Between both programs, a total of 43 disbursements were chosen for testing. 11 were adjusting entries. Of the remaining 32, 4 were not paid in a timely manner; 21 were missing either invoices or PO’s or not properly approved. Repeat Finding: This is a repeat finding. Recommendation: It is recommended that the Supervisory Union implement controls to ensure that invoices are managed and paid appropriately. Management Response: Management agrees with the recommendation and will implement controls to ensure that invoices are managed and paid appropriately. Anticipated completion date 7/1/2026
2025-002 – Equipment/Real Property Management Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Criteria: The following CFR(s) apply to this finding: 2 CFR 200.303 Internal Controls; 2 CFR 200.313(d)(1)(2)(3). Condition: During audit procedu...
2025-002 – Equipment/Real Property Management Federal Program Information: Department of Education – Special Education Cluster (IDEA) CFDA – 84.027/84.173 Criteria: The following CFR(s) apply to this finding: 2 CFR 200.303 Internal Controls; 2 CFR 200.313(d)(1)(2)(3). Condition: During audit procedures, it was identified that the Supervisory Union did not have internal controls in place to ensure that all appropriate equipment and real property management requirements were in place. Cause: Unknown Effect: The Supervisory Union may not be consistently following all appropriate equipment and real property management standards and procedures. There was an instance where the asset purchased equipment did not have a property record and was not recorded in the asset list. Identification of Questioned Costs: None identified. Context: Of the one, and only equipment purchase identified during FY25, there was no property record and it was not recorded on the asset list. Repeat Finding: This is not a repeat finding. Recommendation: It is recommended that the Supervisory Union implements controls to ensure that it follows all appropriate equipment and real property management standards and procedures. We also recommend that the Supervisory Union review its equipment and property policy to ensure that it is updated and complete. Management Response: Management agrees with the recommendation and will implement controls to ensure that we follow all appropriate equipment and real property management standards and procedures. We will also review our equipment and property policy to ensure it is updated and complete. Anticipated completion date 7/1/2026
Finding 2025-001 Program Affected Assistance Listing – 14.881 BangorHousing accepts the recommendations of the audit. Management will reinforce HQS enforcement procedures for timely resolution of inspection findings and termination of payments for units that fail to achieve compliance within the req...
Finding 2025-001 Program Affected Assistance Listing – 14.881 BangorHousing accepts the recommendations of the audit. Management will reinforce HQS enforcement procedures for timely resolution of inspection findings and termination of payments for units that fail to achieve compliance within the required timeframe. Management will ensure staff are property trained and will implement a regular and consistent oversight program to prevent recurrence.
Views of Responsible Officials and Planned Corrective Action Management concurred with the finding and indicated that steps will be taken to mitigate the impact of staffing absences and ensure timely submission of all required reports in future periods.
Views of Responsible Officials and Planned Corrective Action Management concurred with the finding and indicated that steps will be taken to mitigate the impact of staffing absences and ensure timely submission of all required reports in future periods.
Agency personnel will ensure all documentation and support is maintained.
Agency personnel will ensure all documentation and support is maintained.
Recommendation: We recommend that Eastern Lancaster County School District implement procedures to ensure that SNP Claim for Reimbursement Summary reports are independently reviewed and approved prior to submission to Program Electronic Application and Reimbursement System (PEARS). This review shoul...
Recommendation: We recommend that Eastern Lancaster County School District implement procedures to ensure that SNP Claim for Reimbursement Summary reports are independently reviewed and approved prior to submission to Program Electronic Application and Reimbursement System (PEARS). This review should be performed by an individual who is not involved in the preparation of the reports and evidence of the review should be documented. School District Response: (Corrective Action) Eastern Lancaster County School District will implement formal internal control procedures requiring review and documented approval of all SNP Claim for Reimbursement Summary reports prior to submission in PEARS. The following procedures will be implemented: 1. The Director of Food Services will prepare the monthly SNP Claim for Reimbursement Summary report and compile all supporting meal count documentation. 2. Prior to submission, the Administrative Assistant to the Director of Food Services or another designated individual independent of the preparation process will: o Review the claim for mathematical accuracy. o Verify meal counts against supporting documentation. o Confirm claims are submitted within required timelines. 3. Evidence of the review and approval will be documented through: o Signature or electronic approval on the reimbursement summary report. o Retention of supporting documentation in accordance with federal and state record retention requirements. 4. A written standard operating procedure (SOP) outlining these review and approval responsibilities will be developed and communicated to applicable personnel. 5. The Chief of Finance and Operation will periodically monitor compliance with the procedure to ensure controls remain effective. Anticipated Completion Date: The corrective action procedures will be fully implemented by June 1, 2026. Responsible Person for the Corrective Action: Keith D. Ramsey, Chief of Finance and Operations
2025-003 Eligibility Finding Type: Significant deficiency in Internal Controls over Compliance and Compliance Federal Program Title and AL Number: The Food Distribution Cluster (10.565, 10.568, 10.569). Criteria: Per Title 7 CFR § 247.8, to apply for or to be recertified for CSFP benefits, the appli...
2025-003 Eligibility Finding Type: Significant deficiency in Internal Controls over Compliance and Compliance Federal Program Title and AL Number: The Food Distribution Cluster (10.565, 10.568, 10.569). Criteria: Per Title 7 CFR § 247.8, to apply for or to be recertified for CSFP benefits, the applicant or caretaker of the applicant must be informed of his or her rights and responsibilities, in accordance with § 247.12, the local agency must ensure that the applicant or caretaker signs the application form. Condition and context: As part of our eligibility testing, and in order to determine compliance with the requirements, we verified that the CSFP participants had completed and signed applications or recertifications prior to receiving food distributions. For four out of 32 non-statistical samples, the application was completed but did not have the participants' signature. Cause: The Food Bank did not have controls in place to ensure the participant signatures were received prior to providing food assistance to the individual. Effect: The Food Bank was not able to demonstrate compliance with Title 7 CFR § 247.8. Questioned Costs: None Repeat finding: No Recommendation: We recommend the Food Bank implement controls to ensure CSFP applications and recertifications are signed by the applicant prior to the individual receiving food. Views of responsible officials and planned corrective actions: Management concurs with the finding and recommendation. Please see the attached corrective action plan. Management Response and Planned Corrective Action: Criteria: Per Title 7 CFR § 247.8, to apply for or to be recertified for Commodity Supplemental Food Program (“CSFP”) benefits, the applicant or caretaker of the applicant must be informed of his or her rights and responsibilities, in accordance with § 247.12, the local agency must ensure that the applicant or caretaker signs the application form. The Los Angeles Regional Food Bank (“Food Bank”) has submitted a request to “Oasis Insights”, the Food Bank’s software vendor utilized for CSFP, to reinstate mandatory field validation, or a “hard stop”, on CSFP applications to prevent case progression or assistance issuance when required signatures have not been captured. The Food Bank will verify that the mandatory field validation feature has been reinstated. Additionally, the Food Bank’s CSFP Program Manager will ensure that all Food Bank employees responsible for overseeing CSFP will be provided with retraining in the area of CSFP eligibility requirements. The Director of Compliance and Administration will verify that CSFP applications through Oasis are unable to progress forward without a required signature and that the aforementioned CSFP eligibility training has been completed. The Food Bank will complete these corrective actions on or before June 30, 2026. Individuals responsible for corrective action: Elizabeth Cervantes – Sr. Director of Product Acquisition and Agency Relations 323.974.0073 Hilda Ayala – Sr. Director of Programs and Policy 323.353.0114 Steven Meisberger – Chief Financial Officer 323.318.0319
Finding 2025-005 Lack of Internal Control over Special Tests and Provisions- Character Investigations Name of Contact Person: Alexis Russell, Human Resource Director Corrective Action: Background check verification will be added into the employee onboarding process for all Annette Island Service Uni...
Finding 2025-005 Lack of Internal Control over Special Tests and Provisions- Character Investigations Name of Contact Person: Alexis Russell, Human Resource Director Corrective Action: Background check verification will be added into the employee onboarding process for all Annette Island Service Unit employees to ensure required character investigations are completed and documented for all positions subject to Indian Child Protection and Family Violence Prevention Act requirements. In addition, Human Resources will conduct periodic internal reviews of personnel files to indentify and address any missing background check documentation for current employees Proposed Completion Date: Implemented in FY2026, ongoing monitoring in place.
Finding 2025-003 Noncompliance with Reporting Requirements Name of Contact Person: Kyonia Hudson, Finance Director Corrective Action: Responsibility for financial reporting and drawdown requests has been transitioned to the Grants Accountant and aligned with the reporting and reconciliation procedur...
Finding 2025-003 Noncompliance with Reporting Requirements Name of Contact Person: Kyonia Hudson, Finance Director Corrective Action: Responsibility for financial reporting and drawdown requests has been transitioned to the Grants Accountant and aligned with the reporting and reconciliation procedures used for MIC’s federal awards. Finance will continue monitoring grant reporting to ensure financial reports are reviewed, reconcile to the general ledger, and submitted timely to the granting agency. Proposed Completion Date: Implemented in FY2026, ongoing monitoring in place.
Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. Management plans on providing additional training to staff and performing periodic reviews of sliding fee write-offs to ensure compliance with the policies and procedures.
Management concurs with the recommendation and will review the policies and procedures surrounding sliding fee write-offs. Management plans on providing additional training to staff and performing periodic reviews of sliding fee write-offs to ensure compliance with the policies and procedures.
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that the residual receipts account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corporation, through v...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that the residual receipts account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits. S3800-160 Contact Person First Name Kit S3800-180 Contact person Last Name Vallhonrat
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that the replacment reserve account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corporation, through ...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that the replacment reserve account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits. S3800-160 Contact Person First Name Kit S3800-180 Contact person Last Name Vallhonrat
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations 2025-2, 2024-2: The Corporation concurs that the residual receipt account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corpora...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations 2025-2, 2024-2: The Corporation concurs that the residual receipt account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits. S3800-160 Contact Person First Name Kit S3800-180 Contact person Last Name Vallhonrat
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations 2025-1, 2024-1: The Corporation concurs that the replacment reserve account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corpo...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations 2025-1, 2024-1: The Corporation concurs that the replacment reserve account is underfunded as of June 30, 2025. S3800-130 Response Indicator Agree S3800-140 Completion Date 6/30/2026 S3800-150 Response The Corporation, through various efforts of management, has begun to start receiving past due rental assistance payments from HUD and will make the required deposits as cash flow permits. S3800-160 Contact Person First Name Kit S3800-180 Contact person Last Name Vallhonrat
CORRECTIVE ACTION PLAN May 21, 2026 The City of Daytona Beach, Florida respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Carr, Riggs & Ingram, L.L.C. 7506 Lynx Way, Suite 201 Melbourne, Florida 329...
CORRECTIVE ACTION PLAN May 21, 2026 The City of Daytona Beach, Florida respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Carr, Riggs & Ingram, L.L.C. 7506 Lynx Way, Suite 201 Melbourne, Florida 32940 Audit Period: Fiscal Year October 1, 2024 – September 30, 2025 The finding from the Schedule of Findings and Questioned Costs is discussed below. The finding number corresponds to the number assigned in the schedule. Section III–Federal Award Findings and Questioned Costs 2025-001 GRANT REPORTING U.S. Department of Homeland Security ALN 97.036 – Disaster Grants – Public Assistance Contract No. PA-B3-06-74-01-312 and PA-DR-06-74-01-166 Passed through the Florida Division of Emergency Management 2025 Funding Criteria: 2 CFR 200.303 requires non-federal entities to establish and maintain effective internal controls. Reports and reimbursement requests should be subject to independent review for the full fiscal year to verify completeness, validity and timeliness of submission. The grant agreement requires quarterly progress reports to be filed with the pass-through entity, Florida Division of Emergency Management. Condition: Review of quarterly reports and reimbursement requests were not documented by the City before submittal. Cause of condition: The department at the City that is responsible for managing the grant does not have a process in place to document their review of quarterly reports and reimbursement requests submitted to the Florida Division of Emergency Management. Potential effect of condition: Reports submitted to the Florida Division of Emergency Management may be incomplete, include errors, or be submitted late. Perspective: The department of the City that manages the grant did not have a documented process in place for the review and approval of quarterly reports and reimbursement requests prior to submittal to the grantor. Questioned costs: None noted. Reported finding is a deficiency in internal control. Recommendation: The City should develop procedures to ensure documented management review of all reporting prior to submission to grantors. Management’s Response: The City updated its control process to ensure that reports prepared are reviewed by City staff or management prior to being submitted to grantor. Responsible Parties: David Waller, Public Works Director, Natalia Eckroth, CFO and Christine Aiken, Assistant Finance Director. Anticipated Completion: March 31, 2026.
McMullin Area Groundwater Sustainability Agency Joint Power Authority (the Authority) understands that the requested reports were not provided to the auditor early enough to allow time for review, preparation, and submission by the auditor. The Authority will endeavor to provide all schedules, repor...
McMullin Area Groundwater Sustainability Agency Joint Power Authority (the Authority) understands that the requested reports were not provided to the auditor early enough to allow time for review, preparation, and submission by the auditor. The Authority will endeavor to provide all schedules, reports, exhibits, and supporting documents to the auditor at least thirty (30) days prior to the 3/31 deadline.
Finding 1217346 (2025-004)
Material Weakness 2025
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend the county implement processes and procedures to ensure all reports have a timely review documented by someone other than the preparer. Explanatio...
Internal Control Over Reporting Department of Human Services – Grants to States for Medicaid – Assistance Listing No. 93.778 Recommendation: We recommend the county implement processes and procedures to ensure all reports have a timely review documented by someone other than the preparer. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: County will continue to train staff to ensure they are aware of the requirements. Names of the contact person responsible for corrective action: Denise Gaida, Auditor- Treasurer Planned completion date for corrective action plan: December 31, 2026
Reference Number: 2025-002 Description: Special Tests and Provisions Corrective Action Plan: Guest House has implemented stronger process controls to ensure that Rent Reasonableness forms are completed prior to executing lease agreements. Staffing changes have been made to support compliance, and en...
Reference Number: 2025-002 Description: Special Tests and Provisions Corrective Action Plan: Guest House has implemented stronger process controls to ensure that Rent Reasonableness forms are completed prior to executing lease agreements. Staffing changes have been made to support compliance, and enhanced review procedures have been put in place. In addition, all previously outstanding Rent Reasonableness forms are in the process of being completed. Anticipated Corrective Action Plan Completion Date: July 1, 2026 Contact Information: For additional information regarding these corrective actions, contact Stephen Bauer, CEO at 414.345.3240. Stephen Bauer CEO Guest House of Milwaukee
2025-005: WAGE RATE REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Pass-Through Agency: Direct award Grantor Number: Not applicable Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in...
2025-005: WAGE RATE REQUIREMENTS Program: Impact Aid Federal Assistance Listing Number: 84.041 Federal Agency: U.S. Department of Education Pass-Through Agency: Direct award Grantor Number: Not applicable Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: N. Special Tests and Provisions – Wage Rate Requirements Repeat Finding: Yes. Same as finding 2024-001 and 2023-002. Criteria or Specific Requirement: Federal regulations require that contractors and subcontractors performing work on federally funded construction projects pay laborers and mechanics wages at rates not less than those prevailing on similar projects in the locality. These requirements are established under the Davis-Bacon Act and incorporated into federal grant compliance requirements under 2 CFR Part 200. Adequate monitoring of compliance with these wage requirements is required to ensure that workers are being paid correctly per 29 CFR 5.5 compliance provisions. Per 2 CFR section 200.303(a), a non-Federal entity must establish and maintain effective internal control over Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in “Standards for Internal Control in Federal Government” issued by the Comptroller General of the United States or the “Internal Control-Integrated Framework,” issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: During our testing for one of 2 contractors that were tested and funded under the Impact Aid program, we noted that the District did not obtain or review certified payroll reports from contractors to verify compliance with federal prevailing wage requirements. As a result, the District could not demonstrate that contractors complied with required wage provisions for the sampled projects. Corrective Action: The District will ensure wage rate requirements are maintained for all vendors as appropriate under Uniform Guidance and the provision of the Davis Bacon Act. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Kay Morris, Superintendent
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