Corrective Action Plans

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2025-010 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are review...
2025-010 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: ETA 9130 reports are jointly reviewed by Finance and program staff before submission and certification. Supporting documentations are cross-checked for accuracy and completeness, and all relevant files are maintained in a centralized, shared folder to ensure transparency and accountability. This multi-layered review and documentation process has been incorporated into a standard quarterly reporting procedures to prevent future discrepancies and ensure federal reporting integrity. New internal controls and procedures were established 8/30/2025, in which this audit has not reviewed yet. Name(s) of the contact person(s) responsible for corrective action: Finance: Sarah Shannon, Ken Luke, Vina Yung, DUA: Mark Costello Planned completion date for corrective action plan: Already completed – staff trained and provided with new SOP on 8/30/2025.
2025-009 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review and update its reporting procedures and controls to ensure that ETA 9052 - Nonmonetary Determination Time Lapse Detection reports are submitted timely and that copies of report submissions ar...
2025-009 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review and update its reporting procedures and controls to ensure that ETA 9052 - Nonmonetary Determination Time Lapse Detection reports are submitted timely and that copies of report submissions are maintained and are readily available for audit. Reports should be reviewed for accuracy prior to submission. Action taken in response to finding: A staff member has been identified as the owner of UIR 9052. Staff have been trained in the submission of 9052 in both SUN and the new UIRS system that has replaced the SUN. Master list of report owners has been updated to reflect accurate ownership. Master List Report owner will notify 9052 owner in advance that report is coming due. The department will make sure that reports are reviewed for accuracy prior to submission and copies of report submissions are maintained. Name(s) of the contact person(s) responsible for corrective action: John Saulnier / Director of Benefits Planned completion date for corrective action plan: Corrected. The 9052 is now being submitted timely.
2025-008 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review and update its reporting procedures and controls to ensure that ETA 2208A reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhance...
2025-008 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review and update its reporting procedures and controls to ensure that ETA 2208A reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: Finance has implemented a formal review and reconciliation process requiring reported totals to be verified against supporting source documentation before submission, standardized and locked required workbook formulas, and establish a pre-submission checklist to document review. Written procedures will be updated to formalize these control enhancements and ensure continued compliance. Name(s) of the contact person(s) responsible for corrective action: Finance: Vina Yung, Anna Yong Planned completion date for corrective action plan: 6/30/2026
2025-007 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review its procedures to ensure that ETA 2112 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are review...
2025-007 Unemployment Insurance - Assistance Listing No. 17.225 Recommendation: The Department should review its procedures to ensure that ETA 2112 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: Action was taken to address the issue prior to audit findings, and we do not anticipate similar situations to exist now that we have EMT generates the ETA 2112. Also, we have internal control for both preparer and approver to review each line item with the supporting documents. Name(s) of the contact person(s) responsible for corrective action: Finance: Messay Araya, Anna Yong Planned completion date for corrective action plan: 6/30/2026
2025-006 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that report...
2025-006 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: The Department should review its procedures to ensure that ETA 9130 reports are accurate and agree with supporting documentation. We further recommend that internal controls are enhanced to ensure that reports are reviewed for accuracy prior to submission. Action taken in response to finding: ETA 9130 reports are jointly reviewed by Finance and program staff before submission and certification. Supporting documentations are cross-checked for accuracy and completeness, and all relevant files are maintained in a centralized, shared folder to ensure transparency and accountability. This multi-layered review and documentation process has been incorporated into a standard quarterly reporting procedures to prevent future discrepancies and ensure federal reporting integrity. New internal controls and procedures were established 8/30/2025, in which this audit has not reviewed yet. Name(s) of the contact person(s) responsible for corrective action: Finance: Sarah Shannon, Ken Luke, Vina Yung, DCS: Dave Manning Planned completion date for corrective action plan: Already completed – staff trained and provided with new SOP on 8/30/2025.
2025-003 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should implement procedures and internal controls to ensure that all required subawards an...
2025-003 Employment Service Cluster - Assistance Listing No. 17.207, 17.801 Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. The Department should implement procedures and internal controls to ensure that all required subawards and subaward modifications are reported no later than the end of the month following the month of issuance. Action taken in response to finding: Reporting under FFATA is triggered when the department and the local areas agree on budgets — i.e., at the point when the state forms an official obligation amount. This change is meant to more closely align with FFATA guidance which specifies that “you must report each obligating action … no later than the end of the month following the month in which the obligation was made.” U.S. Election Assistance Commission. Importantly, the guidance states: “Only report on subaward obligations. Do not report individual payments made to subrecipients.” Previously, FFATA was triggered when an encumbrance was recorded. By aligning FFATA reporting with the point at which the state formally obligates funds through approved local budgets, rather than when encumbrances are recorded, the process more accurately reflects the definition of an obligating action and strengthens overall compliance with FFATA requirements. Ongoing monitoring will continue to ensure reporting remains timely and accurate, with periodic reviews conducted to assess performance and identify any needed updates to the SOP. These revisions were fully implemented by 09/30/2025. New internal controls and procedures were established 9/30/2025, in which this audit has not reviewed yet. Name(s) of the contact person(s) responsible for corrective action: Finance: Sarah Shannon, Sam Potel Planned completion date for corrective action plan: Already completed – staff trained and provided with new SOP on 9/30/2025.
2025-002 Child Nutrition Cluster - Assistance Listing No. 10.555, 10.582 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to SAM.gov no later than the end of the month following the month of ...
2025-002 Child Nutrition Cluster - Assistance Listing No. 10.555, 10.582 Recommendation: We recommend the Department develop procedures and internal controls to ensure that all required subawards are reported timely and accurately to SAM.gov no later than the end of the month following the month of issuance of each subaward. If the Department is unable to complete reporting in SAM.gov, it should follow up with the Service Desk and consult with their federal award contacts for assistance and guidance. Action taken in response to finding: The Department is reviewing and updating internal procedures to ensure all required subawards are reported timely and accurately in SAM.gov. While there have been some technical challenges with SAM.gov reporting, the Department is actively coordinating with U.S. Department of Agriculture contacts to resolve issues and ensure compliance and maintaining a record of each outreach attempt. Staff responsibilities and monitoring procedures are being strengthened to support accurate reporting. Name(s) of the contact person(s) responsible for corrective action: Julia Jou, Budget Director, Rob Curtin, Deputy Commissioner, Erica Gonzales, Associate Commissioner Data & Accountability, Rob Leshin, Director, Food and Nutrition Programs Joseph Valchuis, Audit Supervisor Planned completion date for corrective action plan: April 15, 2026
Provided training to staff on HUD EIV requirements and documentation standards. Updated the tenant file checklist to include a mandatory EIV report verification step:  Conducted an internal audit of all tenant files to identify any additional missing or late EIV reports.  Implement a quarterly com...
Provided training to staff on HUD EIV requirements and documentation standards. Updated the tenant file checklist to include a mandatory EIV report verification step:  Conducted an internal audit of all tenant files to identify any additional missing or late EIV reports.  Implement a quarterly compliance review process to ensure ongoing adherence to EIV requirements.
DCH is enhancing its application risk management and system security review practices through the following corrective actions: • Enterprise Risk Management Framework: DCH operates under a HITRUST i1-validated information security program and is pursuing HITRUST r2 validation in Fall 2026. This fram...
DCH is enhancing its application risk management and system security review practices through the following corrective actions: • Enterprise Risk Management Framework: DCH operates under a HITRUST i1-validated information security program and is pursuing HITRUST r2 validation in Fall 2026. This framework provides standardized, risk-based controls for identifying, assessing, and managing security risks across Medicaid and CHIP systems and supporting services. • ServiceNow IRM, SecOps, and TPRM Implementation: DCH is implementing ServiceNow modules for Integrated Risk Management (IRM), Security Operations (SecOps), and Third-Party Risk Management (TPRM) to centralize risk identification, SOC report intake, CUEC tracking, issue management, and remediation evidence. These capabilities will support consistent documentation, traceability, and auditability of risk management and third-party oversight activities. • System Security Reviews (SSRs) and SOC Report Validation: DCH will formalize and document its System Security Review (SSR) process for in-scope systems and third-party service providers. This includes: o Establishing documented procedures for annual review of SOC Type II reports and applicable CUECs. o Performing and retaining evidence of management review to assess control design and operating effectiveness. o Tracking SSR results, deficiencies, and remediation activities through ServiceNow IRM/TPRM. Ensuring SSRs are performed consistently and retained as auditable artifacts. These corrective actions are designed to provide reasonable assurance that application-level and third-party risks are identified, reviewed, documented, and managed in compliance with state and federal requirements.
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in month...
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in monthly unit meetings. DHS will complete targeted Medical Assistance case reviews, and a review of system (Gateway) designs will be conducted to identify any necessary changes, updates, and additional improvements.
Currently, DCH continues to meet with DHS/DFCS to ensure synchronization of the Georgia Gateway and GAMMIS systems. DCH is proposing additional procedures and policies for DHS/DFCS caseworkers to implement that will terminate members who have been determined ineligible in Gateway but remain active i...
Currently, DCH continues to meet with DHS/DFCS to ensure synchronization of the Georgia Gateway and GAMMIS systems. DCH is proposing additional procedures and policies for DHS/DFCS caseworkers to implement that will terminate members who have been determined ineligible in Gateway but remain active in GAMMIS.
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in month...
DHS will review existing Medical Assistance and income calculation policies, make any necessary changes, and provide refresher training for staff at all levels of eligibility for various types of Medical Assistance. In addition, reminders about the Medical Assistance Policy will be included in monthly unit meetings. DHS will complete targeted Medical Assistance case reviews, and a review of system (Gateway) designs will be conducted to identify any necessary changes, updates, and additional improvements.
DHS Division of Family and Children Services (DFCS), Temporary Assistance for Needy Families (TANF) program, will review existing TANF and expense statement review policies, and provide refresher training on these policies and applicable forms for staff at all levels of eligibility. TANF management ...
DHS Division of Family and Children Services (DFCS), Temporary Assistance for Needy Families (TANF) program, will review existing TANF and expense statement review policies, and provide refresher training on these policies and applicable forms for staff at all levels of eligibility. TANF management will complete targeted case reviews to ensure that all applicable documentation is included in the file, and peer reviews will be initiated. In addition, a review of the Gateway System will be conducted, and any required form(s) will be updated and included in the case file, if required.
We have documented our procedure for performance reporting so that reports are appropriately reviewed and approved prior to submission.
We have documented our procedure for performance reporting so that reports are appropriately reviewed and approved prior to submission.
GDOL acknowledges that this is a repeat finding from prior years. While the issue has been partially resolved, the Department provides the following response. Claimants who established PUA entitlement with a weekly benefit amount (WBA) greater than the minimum amount, or who were later determined to...
GDOL acknowledges that this is a repeat finding from prior years. While the issue has been partially resolved, the Department provides the following response. Claimants who established PUA entitlement with a weekly benefit amount (WBA) greater than the minimum amount, or who were later determined to be ineligible, did so based on wages self-reported by the claimant and/or wages reported by the employer. Under the CARES Act, claimants were required to submit proof of wages only; however, if proof was not provided, federal guidance permitted payment only at the minimum WBA and did not allow for disqualification of benefits solely due to lack of documentation. For PUA claims initially established at a higher WBA without sufficient proof, the WBA was subsequently reduced to the minimum amount as required. To date, the claimants cited in this finding have not provided the required documentation. The identified PUA claim was adjusted accordingly, and an Overpayment has been established. Disaster Unemployment Assistance (DUA) claims are established under a similar framework as PUA claims, with one key difference: payment requests are currently submitted via paper certification forms. Claimants submit these requests by mail, fax, or email. Because this process is manual, there is an increased risk of misfiling or errors, as occurred in the DUA claim identified. To address these findings and strengthen program integrity, GDOL has implemented and will continue implementing corrective actions and additional safeguards. As system deficiencies were identified, mitigation measures were implemented as quickly as possible to reduce the risk of improper payments. In addition, GDOL’s current UI Information Technology (IT) system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated processes and corrective controls cannot be easily implemented. As a result, numerous tasks, including the validation and processing of all PUA and DUA documentation to determine eligibility, must be performed manually by staff. As a long-term measure to strengthen internal controls and improve overall UI program administration, GDOL has partnered with a vendor to implement a modernized UI system. This new system will offer enhanced eligibility determination, improved payment controls, and technological safeguards to support both current and future unemployment programs. Migration to the modernized system is expected in late 2026.
GDOL’s current UI Tax system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated financial record-keeping processes and corrective controls cannot be easily implemented. As a long-term solution to strengthen internal controls and enhance...
GDOL’s current UI Tax system was developed in 1982 using mainframe legacy technology. Due to its age and structural limitations, many automated financial record-keeping processes and corrective controls cannot be easily implemented. As a long-term solution to strengthen internal controls and enhance overall UI program administration, GDOL has contracted with a vendor to implement a more efficient method for maintaining documentation of taxes due and received. Migration to the modernized system is anticipated in late 2026. A review of the thirteen accounts identified the source of each payment, the amounts remitted, and the associated tax account allocations. Our records showed all payments, except for one, were submitted electronically via ACH Debit or ACH Credit. These ACH transactions are reflected as components of the total daily ACH Debits or Credits shown on the agency’s bank statement spreadsheets for the dates associated with the payments. The Contribution Tax amount represents only a portion of the total tax due. Therefore, the payment amount and the Contribution Tax amount may differ.
Identifying Number: 2025-002 Finding: The Organization should have effective internal controls around reporting to LSC, to ensure timely reporting in accordance with 45 CFR 1644. Corrective Action Taken or Planned: CVLAS’ Director of Operations shall institute an administrative calendar containing a...
Identifying Number: 2025-002 Finding: The Organization should have effective internal controls around reporting to LSC, to ensure timely reporting in accordance with 45 CFR 1644. Corrective Action Taken or Planned: CVLAS’ Director of Operations shall institute an administrative calendar containing all required reports due LSC. The Executive Director and the Director of Development are responsible for ensuring that all reports are timely filed in accordance with LSC regulations. Name of Contact Person: Steve Dickinson, Executive Director Phone Number of Contact Person: (804) 200-6049 Projected Completion Date: December 31, 2026
2025-002 Staffing for Adequate Fire and Emergency Response (SAFER) – CFDA No. 97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal co...
2025-002 Staffing for Adequate Fire and Emergency Response (SAFER) – CFDA No. 97.083 Recommendation: The City should provide training for the grant administrator and/or include an additional review by individual that has been fully trained on the compliance requirements of the grant. The internal control process should include a formal way to document the review and approval of Fire Safety salary costs charged to the grant to provide evidence that internal controls are effectively designed and implemented and functioning in a timely manner throughout the year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned and taken in response to finding: The City has authorized a full-time grants specialist position within the Finance Department to oversee the administration of grants separate from the programming department. The City will strengthen internal controls over grant compliance by implementing formal policies and procedures for allowable costs, documentation, and review. All grant expenditures will be reviewed and approved by Finance prior to submission, with supporting documentation maintained for eligibility determinations. Name(s) of the contact person(s) responsible for corrective action: Rebeca Holden Planned completion date for corrective action plan: 06/30/26 If the Tennessee Comptroller of the Treasury has questions regarding this plan, please call Rebecca Holden at 931-451-0782
Planned Corrective Action Plan: The District will ensure all supporting documentation is prepared and ready for Auditors. In addition, audit services will be procured with sufficient time to submit the single audit by the required timeline. Anticipated Completion Date: June 30, 2026 Responsible Cont...
Planned Corrective Action Plan: The District will ensure all supporting documentation is prepared and ready for Auditors. In addition, audit services will be procured with sufficient time to submit the single audit by the required timeline. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Lorna Villaruel, Business Manager
Condition: The Organization obtained a short term line of credit without formal approval from HUD from Park National Bank in 2024 with access to credit up to $15 million, which exceeds the limits in section 20b(iii) of the HUD agreement. Planned Corrective Action: On February 21, 2024, Change Health...
Condition: The Organization obtained a short term line of credit without formal approval from HUD from Park National Bank in 2024 with access to credit up to $15 million, which exceeds the limits in section 20b(iii) of the HUD agreement. Planned Corrective Action: On February 21, 2024, Change Healthcare / Optum sustained a cyber-attack and completely shut down claim’s submission processes for Knox Community Hospital. With over 3 weeks of not releasing insurance claims that amounted to over $40M, this impacted the cashflow greatly on the organization. The CFO at that time made the decision to seek a Line of Credit with Park National Bank for $15M to fund operations. Due to the urgency and short timeline, formal approval was not obtained from HUD. A detailed event log was maintained around the cyber-attack and provided to our Board and HUD representative. In the future, all regulatory agreements’ requirements will be reviewed by the CFO and in time there are new agreements or modifications made to existing agreements to ensure compliance with each agreement. HUD has since issued a letter approving KCH’s $15M Line of Credit. Contact person responsible for corrective action: Danielle O’Brien, CFO Anticipated Completion Date: 4/30/2026
Finding 2025-004 – Reporting Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action Plan: The Town will strengthen controls over federal reporting by establishing a formal review and approval process prior to submission of financial and performance reports. Pr...
Finding 2025-004 – Reporting Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action Plan: The Town will strengthen controls over federal reporting by establishing a formal review and approval process prior to submission of financial and performance reports. Procedures will require verification that reported amounts agree to accounting records and that narrative descriptions accurately reflect the use of funds. Evidence of review and approval will be documented and retained. Responsible Official: Clerk/Treasurer Mayor Planned Completion Date: May 2026
Finding 2025-002 – Cash Management (Reimbursement Request Error) Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action Plan: The Town will strengthen internal controls over reimbursement requests by implementing a reconciliation process between requested amou...
Finding 2025-002 – Cash Management (Reimbursement Request Error) Significant Deficiency in Internal Control Over Compliance and Noncompliance Corrective Action Plan: The Town will strengthen internal controls over reimbursement requests by implementing a reconciliation process between requested amounts and supporting documentation prior to submission. A secondary review and approval will be required for all reimbursement requests. Responsible Official: Clerk/Treasurer Mayor Planned Completion Date: May 2026
Management acknowledged the finding and will ensure all proper approvals are received prior to any withdrawals from the replacement reserve.
Management acknowledged the finding and will ensure all proper approvals are received prior to any withdrawals from the replacement reserve.
Management acknowledged the finding and will ensure they confirm with the USDA representative regarding the required monthly deposit amount at the beginning of the year in future. In addition, management will make a deposit for the underfunded amount of $2,642 during 2026 related to 2025 required de...
Management acknowledged the finding and will ensure they confirm with the USDA representative regarding the required monthly deposit amount at the beginning of the year in future. In addition, management will make a deposit for the underfunded amount of $2,642 during 2026 related to 2025 required deposits.
Management acknowledged the finding and will ensure all proper approvals are received prior to any withdrawals from the replacement reserve.
Management acknowledged the finding and will ensure all proper approvals are received prior to any withdrawals from the replacement reserve.
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