Corrective Action Plans

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Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters as noted below and have described our planned actions as a result. 2025-001: FINANCIAL REPORTING OF FEDERAL PROGRA...
Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters as noted below and have described our planned actions as a result. 2025-001: FINANCIAL REPORTING OF FEDERAL PROGRAMS Management Assessment: We concur with the audit assessment regarding this matter. Planned Corrective Action: The County will implement procedures to help ensure required reports are submitted timely. Responsible Party: Moses Sanzo, Administrator/Controller and Jacky Bennett, Interim Chief Financial Officer Date of Planned Corrective Action: September 30, 2026
The fiscal year 2024-2025 Single Audit Report will be submitted through the Federal Audit Clearinghouse (FAC) no later than April 30, 2026. In terms of the subsequent year Single Audit Report (FY 2025-2026), we engaged the audit services on March 24, 2026, and we are in the process to request profes...
The fiscal year 2024-2025 Single Audit Report will be submitted through the Federal Audit Clearinghouse (FAC) no later than April 30, 2026. In terms of the subsequent year Single Audit Report (FY 2025-2026), we engaged the audit services on March 24, 2026, and we are in the process to request professional services proposals to assist our Finance Department staff to compile the fiscal year 2025-2026 financial statements no later than December 31, 2026 to comply with fiscal year 2025-2026 Single Audit Report submission dateline. Implementation Date: March 31, 2027. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure submission of financial reports within the required timeframe. Implementation Date: July 1, 2026. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
We gave instructions to the Finance Department Director to strengthen internal procedures and controls to ensure submission of financial reports within the required timeframe. Implementation Date: July 1, 2026. Responsible Person: Mrs. Rosa J. La Torre Santiago, Executive Director
With new department heads and Town Manager for FY2026 the town will implement procedures to verify and maintain proper documentation for all procurement projects.
With new department heads and Town Manager for FY2026 the town will implement procedures to verify and maintain proper documentation for all procurement projects.
Finding Number: 2025-002 The District should review its reporting internal control processes and procedures and emphasis the need for timely reporting to ensure compliance. Response: Administration will implement a formal compliance calendar mandating the Grant Administrator to monitor and verify al...
Finding Number: 2025-002 The District should review its reporting internal control processes and procedures and emphasis the need for timely reporting to ensure compliance. Response: Administration will implement a formal compliance calendar mandating the Grant Administrator to monitor and verify all expenditure reports. This internal schedule will ensure all findings are submitted no later than 20th day following the close of each quarter to maintain compliance with reporting requirements.
Finding Number: 2025-004 It is recommended that that district review the design of its internal control over compliance to ensure the documentation requirements are incorporated into the control design. Response: To enhance internal controls to ensure the segregation of duties, the Assistant Directo...
Finding Number: 2025-004 It is recommended that that district review the design of its internal control over compliance to ensure the documentation requirements are incorporated into the control design. Response: To enhance internal controls to ensure the segregation of duties, the Assistant Director of Food Services will be responsible for the initial preparation and completion of all the claims. Subsequently, a secondary review and approvable will be preformed by either the Director or the Chief School Business Official (CSBO) prior to submission.
Management agrees with the above finding and has implemented a plan to reduce expenses and increase cash flows going forward. Specifically, we have outlined the following steps that we are taking as an organization to get back on track:  Cash flow is monitored weekly and forecasted on a rolling 12-...
Management agrees with the above finding and has implemented a plan to reduce expenses and increase cash flows going forward. Specifically, we have outlined the following steps that we are taking as an organization to get back on track:  Cash flow is monitored weekly and forecasted on a rolling 12-week basis.  Existing vendor contracts were reviewed and changes made to reduce expenses moving forward into the 2026 fiscal year. Contracts are continually evaluated and renegotiated, where possible, for potential cost savings.  We implemented a robust and detailed budget development process to continue cost-cutting measures into 2026 and beyond. Directors are accountable to their budget guidelines to ensure expenses are appropriately managed.  The 36-unit Independent Living expansion project remains a high priority. The model home construction was completed in November 2025, with showings and open houses now underway. New homes are expected to commence construction in 2026. The sale and occupancy of these units are expected to generate substantial future cash flows for the organization.  We continue to prioritize aggressive staff recruitment to eliminate agency staffing needs. The steady decline in contract staff utilization continued in 2025, with a decrease in contract nursing costs of $317,000 or 15.6% compared to prior year. It is our goal to fully eliminate agency staffing in 2026. Rising labor costs continue to challenge cost savings measures; however, the organization is committed to managing labor costs appropriately and reducing expenses where possible. For example, in 2026, incentive bonuses for nursing shift pick-ups have been eliminated.  Management enacted a progressive plan to increase census in each of its business lines to increase revenue through focused marketing efforts and referral partnerships. Average daily census improved from 133 beds or 79% occupancy in 2024 to 145 beds or 92% occupancy in 2025. Looking ahead to 2026, the organization is focusing its efforts on achieving a more favorable skilled nursing payer mix while maintaining a strong occupancy.
Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health...
Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health and Human Services – National Institutes of Health (NIH) – Cancer Control ALN: 93.399 Finding Description The audit identified material weakness and material noncompliance with federal program requirements related to payroll, fringe benefits and indirect costs. Specifically, FTCH did not comply with NIH Salary Cap requirements, which resulted in questioned costs that were quantitatively and qualitatively material. Cause of the Finding FTCH did not apply the NIH salary cap limitations correctly during the period under review. Corrective Action Planned • The Entity will take the following corrective actions to address the material noncompliance:  Performing a comprehensive review of all FTCH grants, both under consideration and currently active, to determine whether a salary cap limitation applies. Where applicable, management will confirm that the salary cap is being consistently and accurately applied in accordance with governing requirements. Any discrepancies identified have been or will be corrected in a timely manner.  Enhancing pre-award and pre-submission compliance controls through updates to grant review procedures and compliance checklists. These updates are designed to ensure that grants subject to salary cap limitations are clearly flagged and that salary calculations are reviewed and documented prior to submission and award acceptance.  Providing targeted training for staff involved in grant administration, budgeting, payroll processing, and financial reporting to ensure consistent understanding and application of salary cap requirements and related internal control procedures.  Conducting periodic internal monitoring reviews of salary charges to federal awards to assess ongoing compliance, validate the effectiveness of internal controls, and identify potential issues before they result in noncompliance. Results of these reviews will be documented, and corrective actions implemented as appropriate. Personnel Responsible: SVP Finance Anticipated Completion Date: May 31, 2026 Status of Corrective Action Corrective action has been initiated and will be completed within the stated timeframe. Management Certification Management certifies that the corrective actions described above are accurate, appropriate, and will be implemented as represented. ____________________ Matt Partridge SVP Finance April ___, 2026
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations We concur that the Corporation did not maintain the property in good repair and condition. S3800-130 Response Indicator Agree S3800-140 Completion Date 12/31/2025 S3800-150 Response The Corporation has addressed...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations We concur that the Corporation did not maintain the property in good repair and condition. S3800-130 Response Indicator Agree S3800-140 Completion Date 12/31/2025 S3800-150 Response The Corporation has addressed the exigent health and safety issues. S3800-160 Contact Person First Name Jimmy S3800-180 Contact Person Last Name Wilson
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Reporting - FFATA Criteria: The Federal Funding Accountability and Transparency Act (FFATA), as implemented by OMB at 2 CFR Part 170, requires prime recipients of federal awards to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition: The Foundation did not complete the required FFATA reporting in FSRS for applicable first-tier subawards. Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: The Foundation has corrected missed FFATA reporting by submitting outstanding subaward information to FSRS as of February 2026. Additionally, the Foundation will establish and document a FFATA reporting policy that defines the FFATA threshold and timing requirements. The Foundation will also assign clear responsibility for FFATA compliance and implement a monthly reconciliation of subaward obligations to FSRS submissions. Lastly, the Foundation will provide periodic training to grants, procurement, and finance staff on FFATA requirements and FSRS processes.
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Ow...
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Owner's/Management Agent's Certification. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management of the property transitioned to the Agent on June 1, 2025 and the Agent received a HUD-aproved Project Owner's/Management Agent's Certification for the Property.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agent's procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson , Chief Financial and Operating Officer.
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in acco...
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they document and maintain tenant files in accordance with HUD and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson , Chief Financial and Operating Officer.
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certification...
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they document and maintain tenant files in accordance with HUD and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agent's procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Special Provisions: Rent Reasonableness Federal Agency: Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: January 1, 2025 – December 31, 2025 Compliance Requirement Section: Special Provisions Type of ...
Special Provisions: Rent Reasonableness Federal Agency: Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: January 1, 2025 – December 31, 2025 Compliance Requirement Section: Special Provisions Type of Finding: Material Weakness in Internal Control Over Compliance and Other Matters Recommendation: The agency should update its rent reasonableness procedures to ensure: • Rental comparison data is current and regularly refreshed; • Comparable non-assisted units are consistently used; and • Staff are trained on proper rent reasonableness documentation and review standards. The agency should also review a sample of recent rent reasonableness determinations to ensure corrective actions are fully implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has taken the following steps to correct the finding: • Updated and refreshed rent reasonableness software data to reflect current market rents. • Configured and are using the software to require selection of comparable non assisted units. • Revisee procedures to document software generated rent reasonableness results in tenant files. • Train staff on correct use of the rent reasonableness software and regulatory requirements. • Conduct supervisory reviews of software based determinations for compliance. Name of the contact person responsible for corrective action: Karen Young, Finance Director Planned completion date for correct action plan: The corrective action plan has already been implemented and will be corrected before December 31, 2026.
The District will strengthen its internal control system to ensure that each entry within the Nutrition Services data management system meets required program criteria and is fully supported by appropriate documentation. A more robust process of review and verification will be implemented to safegua...
The District will strengthen its internal control system to ensure that each entry within the Nutrition Services data management system meets required program criteria and is fully supported by appropriate documentation. A more robust process of review and verification will be implemented to safeguard the integrity of originating data and prevent compromise. System access controls will also be reinforced to ensure that granted access is appropriate and used in accordance with established protocols. Ensuring the accuracy of meal data will support accurate revenue reporting and, in turn, reliable financial reporting. Moreover, the District will continue to foster a culture of integrity in which all allegations of fraud are taken seriously and addressed promptly. The District will also enhance the visibility and accessibility of its WeTip reporting system to ensure employees, students, and community members can report concerns.
Views of Responsible Officials and Planned Corrective Action CRRUA’s fiscal agent, Dona Ana County, implemented a new ERP system, along with key staff changes, that necessitated financial documentation being run several times which delayed complete financial information being provided to the audit t...
Views of Responsible Officials and Planned Corrective Action CRRUA’s fiscal agent, Dona Ana County, implemented a new ERP system, along with key staff changes, that necessitated financial documentation being run several times which delayed complete financial information being provided to the audit team. CRRUA has a new fiscal agent, the City of Sunland Park, for the upcoming fiscal year. CRRUA Board approval of fiscal agent happened in July 2026. CRRUA’s new fiscal agent, the City of Sunland Park, started providing services in FY26. Executive director and assistant director will work with the City of Sunland Park to ensure timely submission of information to the audit team. Finding resolution timeline: June 30, 2026 Designation of employee position responsible for meeting this deadline: Juan Carlos Crosby, Executive Director and David Espinoza, Assistant Director
Corrective Action: LSA will provide training to the appropriate departments and individuals to reinforce disbursement and purchase order policies and procedures within 30 days of the audit submission. Additionally, LSA will provide training to employees emphasizing the organizational policies requir...
Corrective Action: LSA will provide training to the appropriate departments and individuals to reinforce disbursement and purchase order policies and procedures within 30 days of the audit submission. Additionally, LSA will provide training to employees emphasizing the organizational policies requiring employee certification of their payroll timesheets. This change will be made within the next 90 days. Contact Person: George Fort, Director of Finance, (334) 223-0251; gfort@alsp.org
Corrective Action: LSA follows a monthly accounting checklist which includes PAI expenditures reconciliations. LSA will expand the checklist to include detailed year-end procedures and provide training that covers the expanded checklist within 30 days of the audit submission. Additionally, LSA will ...
Corrective Action: LSA follows a monthly accounting checklist which includes PAI expenditures reconciliations. LSA will expand the checklist to include detailed year-end procedures and provide training that covers the expanded checklist within 30 days of the audit submission. Additionally, LSA will provide annual accounting training to support year-end accounting activities and processes including PAI carryforward calculations and analysis. In addition, LSA will increase efforts to meet the 1614 minimum by expanding PAI training and education and evaluating activities for qualification as PAI activities. This change will be made within the next 90 days. Contact Person: George Fort, Director of Finance, (334) 223-0251; gfort@alsp.org
Corrective Action: Legal Services Alabama takes this finding seriously and is committed to full compliance with all case documentation and case coding requirements. We recognize the importance of maintaining complete and accurate client files, including ensuring that all required retainers, statemen...
Corrective Action: Legal Services Alabama takes this finding seriously and is committed to full compliance with all case documentation and case coding requirements. We recognize the importance of maintaining complete and accurate client files, including ensuring that all required retainers, statements of fact, signatures, and service classifications are properly entered and preserved in LegalServer. As part of Mission 2026, our statewide initiative to strengthen operations and improve consistency across all offices, leadership has been traveling throughout Alabama to meet in person with each office to reinforce expectations, improve cohesion, and emphasize compliance standards. A central component of this effort is the review of random case selections from each office, followed by written feedback identifying areas where improvement is needed, including documentation practices, case coding accuracy, and file completeness. In response to this finding, we will continue targeted training on the distinction between limited service and extended service case closures, reinforce documentation requirements for extended representation, and monitor compliance through periodic file reviews. Legal Services Alabama is fully committed to ensuring that all information maintained in LegalServer is accurate, complete, and supported by the proper documentation in every case file. This change will be made within the next 90 days. Contact Person: Michael Forton, Director of Advocacy, (256) 551-2671; mforton@alsp.org
Finding: 2025-084 - The University did not properly maintain documentation to demonstrate a student’s intent to become a permanent resident. Questioned Costs: None Assistance Listing Number: 84.044 Assistance Listing Title: TRIO Cluster Views of Responsible Officials (state whether your agency agree...
Finding: 2025-084 - The University did not properly maintain documentation to demonstrate a student’s intent to become a permanent resident. Questioned Costs: None Assistance Listing Number: 84.044 Assistance Listing Title: TRIO Cluster Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): There is no disagreement with the audit finding. Corrective Action (corrective action planned): Services for the students involved have been terminated. UAA has reviewed the current procedures and implemented system improvements to prevent similar omissions in the future. The existing student eligibility verification checklist has been reviewed thoroughly to ensure all required documentation is in place; and a random sample of students files will be reviewed semi-annually to proactively identify any issues. In addition, all the staff involved have completed the necessary training. Completion Date (list anticipated completion date): Completed Agency Contact (name of person responsible for corrective action): Tamika Dowdy, UAA TRIO Programs Director, 907-786-4520
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