Corrective Action Plans

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Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 202...
Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Children and Families Federal Program Name: Temporary Assistance for Needy Families Assistance Listing Number: 93.558 Award Number: 2301KSTANF, 2401KSTANF, and 2501KSTANF Period: October 1, 2023 – September 30, 2025 Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Condition: The entity did not have a documented control in place to evidence an independent review of the ACF‑199 TANF Data Report for accuracy and completeness prior to submission to the federal awarding agency. The report was generated from system data and submitted without documented supervisory review or approval before transmission. Recommendation: We recommend that management design and implement a documented review and approval control over the ACF‑199 TANF Data Report prior to submission to the federal awarding agency. The control should include evidence of review to verify the accuracy and completeness of the report, such as documented supervisory sign‑off, electronic approval, or retention of review documentation. Implementing a consistent pre‑submission review process will strengthen internal controls over federal reporting and provide reasonable assurance of compliance with reporting requirements. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: DCF will design and implement a documented review and approval control over the ACF-199 TANF Data Report prior to submission to the Administration for Children and Families (ACF). DCF will include in the documented process the manner in which DCF will verify the accuracy and completeness of the report prior to submission to ACF. DCF will also include in the documented process the manner in which DCF will ensure the process is followed consistently and thoroughly. Name(s) of the contact person(s) responsible for corrective action: Carla Whiteside-Hicks, Economic and Employment Services Director and Melissa Vo, Program Integrity Assistant Director Planned completion date for corrective action plan: June 30, 2026
Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment (KDHE) Federal Program Name: Medicaid Cluster Assistance Listing Numbers: 93.775, 93.777, 93.778 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Co...
Federal Agency: U.S. Department of Health and Human Services State Department/Agency: Kansas Department of Health and Environment (KDHE) Federal Program Name: Medicaid Cluster Assistance Listing Numbers: 93.775, 93.777, 93.778 Award Period: July 1, 2024 through June 30, 2025 Award Number: Various Compliance Requirement: Special Tests and Provisions – Provider Health and Safety Standards Type of Finding: Material Weakness in Internal Control Over Compliance, Material Noncompliance (Modified Opinion) Condition: Kansas Department of Health and Environment (Department) was unable to provide supporting documentation that it had performed recertification surveys within the required timeframe which is used to meet the provider health and safety standards. Recommendation: We recommend the Department complete implementation of its corrective action plan from the prior year. We recommend the Department ensure appropriate measures are in place to verify providers are meeting the prescribed health and safety and maintain all records of these verifications. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: In response to the findings, the SSA will initiate a comprehensive review of all surveys remaining open status within ACO to determine the scope and underlying causes of incomplete administrative closure. A structured tracking tool will be developed to reconcile each survey and verify that required documentation, compliance dates, and certification actions were properly entered. The SSA will engage CMS Regional Office for guidance and coordination on appropriate closure actions and implement enhanced quality assurance controls, including routine reconciliation and verification prior to finalizing surveys. This will hopefully prevent recurrence. The SSA is also in the process of upgrading its information technology software systems to accommodate these processes. The SSA will generate a report of all surveys remaining in open status in ACO and prioritize reviews of initial certification or recertifications surveys and enforcement-related cases. Each survey will be reconciled to confirm required actions. Each survey will be reconciled to confirm required actions were completed, including issuing of the CMS 2567, if applicable, acceptance of the plans of corrections, entry of revisit and compliance dates, and completion of certification actions. To help prevent recurrence, the SSA will implement routine ACO reconciliation and establish a Quality Assurance (QA) verification step prior to finalizing surveys. Name(s) of the contact person(s) responsible for corrective action: Jerry Smith, LSCSW, Bureau Director Marilyn St Peter, RN, Deputy Director Bureau of Facilities and Licensing Catherine Lenz BS RN, Deputy Bureau Director Planned completion date for corrective action plan: October 1, 2026
2. Finding 2025-002: a. Comments on the findings and Recommendation: At the time of the Audit, we agree with the findings. b. Action (s) Taken or planned on the finding: Work orders had fallen behind due to staff changes, and unit turns. Regional Asset Manager has advised the staff that this cannot ...
2. Finding 2025-002: a. Comments on the findings and Recommendation: At the time of the Audit, we agree with the findings. b. Action (s) Taken or planned on the finding: Work orders had fallen behind due to staff changes, and unit turns. Regional Asset Manager has advised the staff that this cannot continue, and all work orders must be completed within less than (30) days from date of receipt. Since completion of Audit, maintenance has been working to get all work orders completed and caught up and to make sure they will continue to be completed in a timely manner. Regional Asset Manager will also check to make sure this is being accomplished at each quarterly site visit.
1. Finding 2025-001: a. Comments on the findings and Recommendation: At the time of the audit, we agree with the findings. b. Action (s)Taken or planned on the finding: The preventative maintenance and painting schedules were started to be maintained by management as of May 2025. Regional Asset Mana...
1. Finding 2025-001: a. Comments on the findings and Recommendation: At the time of the audit, we agree with the findings. b. Action (s)Taken or planned on the finding: The preventative maintenance and painting schedules were started to be maintained by management as of May 2025. Regional Asset Manager has advised staff of the importance of these tasks and schedules to be maintained and carried out on a routine basis. Moving forward they will be maintained properly and kept current throughout the year. Regional Asset Manager will continue to check these schedules at each quarterly site visit.
Recommendation: We recommend the University implement procedures to ensure evidence of the key control review over payments to program participants is documented and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to...
Recommendation: We recommend the University implement procedures to ensure evidence of the key control review over payments to program participants is documented and retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Eastern Oregon University implemented a standardized internal review and documentation process for new scholarship and other program participant payment requests. The process now requires documentation showing that award criteria were reviewed and met, a secondary review was completed, the payment or disbursement amount was verified for accuracy before release, and post-disbursement reconciliation was performed. To support this process, the University created a form to document each step of the review and retain evidence of completion. The responsible department has also been instructed on the documentation expectations and records retention requirements so that evidence of these control activities is maintained and available for future audit review. This corrective action has been implemented for all new requests going forward. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Financial Aid Director Planned completion date for corrective action plan: Completed.
Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response ...
Recommendation: We recommend the University review the GLBA Safeguards Rule and implement appropriate processes and controls to ensure compliance with all applicable provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The IT Department, in conjunction with Human Resources and individual directors and department heads, will institute an annual system inventory of data classification and owner, ensuring job roles and position descriptions are mapped to access profiles. The CIO will review the current classification process for assigning role-based access and the related IT ticketing process for access to ensure existence of documented approvals for provisioning and role changes through a defined access request and approval workflow. IT will also work with HR to establish onboarding/position change/separation controls and timelines triggered by HR provisioning with same-day termination (within 24-hours) upon termination and role change reviews with transfers. IT will also enforce multi-factor authentication (MFA) administrative access where feasible. The relevant Policy and Procedure Manuals will be updated to define access privileges and approval processes, and staff will be trained annually and with onboarding. Name(s) of the contact person(s) responsible for corrective action: Russ Fagan, Chief Information Officer Planned completion date for corrective action plan: March 31, 2026
Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to ...
Recommendation: We recommend the University enhance its procedures for reviewing professional judgement decisions to ensure that evidence of review is documented and retained Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will review its procedures and document retention practices to ensure that key controls related to professional judgment determinations are documented and evidenced for audit purposes. The University will evaluate existing processes and supporting records and will implement any needed improvements to strengthen documentation and audit support. Name(s) of the contact person(s) responsible for corrective action: Jason Hibbert, Director of Financial Aid Planned completion date for corrective action plan: Completed
Views of Responsible Officials and Planned Corrective Action Management agrees with the finding and is committed to strengthening our internal controls. We will review and enhance our invoice coding and approval procedures to ensure expenses are properly allocated to the correct property and to prev...
Views of Responsible Officials and Planned Corrective Action Management agrees with the finding and is committed to strengthening our internal controls. We will review and enhance our invoice coding and approval procedures to ensure expenses are properly allocated to the correct property and to prevent similar issues from occurring in the future. We believe the improvements underway will further support accurate financial reporting and continued compliance with HUD requirements.
Budget Based Rent increase has been submitted to HUD and is in queue for approval. The request includes funding for the reimbursement of the Replacement Reserve. We anticipate that this will be approved.
Budget Based Rent increase has been submitted to HUD and is in queue for approval. The request includes funding for the reimbursement of the Replacement Reserve. We anticipate that this will be approved.
AL 14.871, 14.879, 14. EHV Housing Voucher Cluster Finding: HQS inspections as required by N.4 of the 2025 OMB Compliance Supplement were not performed biennially. Auditor Recommendation: The County should hire and retain adequate staffing to ensure HQS inspections for all tenants are performed bien...
AL 14.871, 14.879, 14. EHV Housing Voucher Cluster Finding: HQS inspections as required by N.4 of the 2025 OMB Compliance Supplement were not performed biennially. Auditor Recommendation: The County should hire and retain adequate staffing to ensure HQS inspections for all tenants are performed biennially. Corrective Actions Taken or Planned: The County agrees and concurs. During FY26, the County hired additional staff to conduct inspections, with a current total of 3.5 FTE. Point of Contact for corrective actions: Sarah Keane, Deputy CFO sarah_keane@washingtoncountyor.gov
AL 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding: Documentation supporting the expenditures included in the Project and Expenditure Report was not retained after the report was submitted. Auditor Recommendation: The County should develop and implement policies and proced...
AL 21.027, COVID-19 Coronavirus State and Local Fiscal Recovery Funds Finding: Documentation supporting the expenditures included in the Project and Expenditure Report was not retained after the report was submitted. Auditor Recommendation: The County should develop and implement policies and procedures to ensure that all ARPA/SLFRF program report support is retained. Corrective Actions Taken or Planned: The County agrees and concurs. In addition to the grants coordinator position a new grant accountant will be starting in the spring of 2026 to improve grant oversight and administration. The board adopted a Grants Policy on 1/20/2026. Point of Contact for corrective actions: Sarah Keane, Deputy CFO sarah_keane@washingtoncountyor.gov
2025-003 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are obligated and/or incurred within the period of performance. Explanation of disagreement with audit fin...
2025-003 Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are obligated and/or incurred within the period of performance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City acknowledges the finding related to documentation supporting the period of performance for expenditures reported under the SLFRF revenue loss category. Because the City applied the standard allowance for revenue loss and did not track specific expenditures to the grant at the transaction level, some expenditures initially provided for testing were outside the period of performance, although sufficient eligible expenditures existed within the allowable period. To address this issue, the Finance Department will implement procedures to maintain supporting schedules identifying government service expenditures incurred within the applicable period of performance that support amounts reported under the revenue loss category. Finance will also implement a review process to verify that expenditures identified for compliance or audit testing meet applicable period of performance and obligation requirements. These procedures will strengthen documentation and ensure expenditures supporting SLFRF revenue loss are clearly identified and supported for compliance purposes. Name(s) of the contact person(s) responsible for corrective action: Michael Tucker, Deputy Finance Director Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.
2025-002 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding:...
2025-002 Special Education Cluster - Assistance Listing Number 84.027, 84.173 Recommendation: We recommend procedures be strengthened to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City will implement procedures to ensure that expenditures charged to federal awards are incurred within the approved period of performance in accordance with 2 CFR §§ 200.308, 200.309, and 200.403. The School Department will enhance its grant monitoring procedures by maintaining a tracking schedule of grant periods of performance and reviewing invoices and payment requests for compliance with grant award dates prior to processing. School Department Finance staff will also provide guidance to departments administering grants to ensure expenditures are incurred and submitted within the allowable grant period. These procedures will strengthen internal controls and reduce the risk of expenditures being charged outside the approved period of performance. Name(s) of the contact person(s) responsible for corrective action: Brian Cisneros, Business Administrator Planned completion date for corrective action plan: Implemented immediately and effective for all current and future federal awards.
Finding 2025-003 Significant deficiency in internal controls over compliance and instance of noncompliance related to matching requirements. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: Management identified that the required matching report was not submitted t...
Finding 2025-003 Significant deficiency in internal controls over compliance and instance of noncompliance related to matching requirements. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: Management identified that the required matching report was not submitted to the funder in accordance with the grant deliverable requirements. The organization has since reviewed the grant agreement to ensure full understanding of all reporting and matching obligations. Corrective actions have been implemented. A centralized grant compliance checklist has been developed to outline all required deliverables, including matching report deadlines. Matching requirements have been incorporated into the organization’s grant reporting calendar with reminder controls in place. Responsibility for tracking and submitting match documentation has been formally assigned to designated Finance personnel, with supervisory review prior to submission. These measures strengthen internal controls over grant compliance and are designed to ensure timely submission of all required matching documentation going forward. Anticipated completion date: Implemented as of December 31, 2025
Finding 2025-002 Significant deficiency in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: Management will revise the organization's procurement policy to amen...
Finding 2025-002 Significant deficiency in internal control over compliance with procurement procedures meeting the requirements of 2 CFR Part 200. Contact Person(s): Nicholas Lee, Chief Financial Officer Corrective action planned: Management will revise the organization's procurement policy to amend the current dollar threshold, which was determined to be overly restrictive and inconsistent with operational needs and federal procurement standards under 2 CFR Part 200. The updated threshold will align with the Uniform Guidance requirements and provide clear guidance for competitive procurement processes. In addition, the organization will implement a standardized Vendor Justification Form. This form will be required for applicable purchases and will document the rationale for vendor selection, including the price analysis, sole source justification (if applicable), and confirmation that the procurement procedures were followed in accordance with federal requirements. These corrective actions are intended to strengthen internal controls over procurement, improve documentation consistency, and ensure compliance with 2 CFR 200 requirements. Anticipated completion date: August 31, 2026
Management has implemented a new software program which automates utility allowance calculations reducing the risk of error.
Management has implemented a new software program which automates utility allowance calculations reducing the risk of error.
Condition: Out of 40 students tested for return to Title IV, we identified 2 students whose calculation were performed outside of the required timeframe. Planned Corrective Action: Once the report identifying students who have completely withdrawn from their classes is ran, the calculations are done...
Condition: Out of 40 students tested for return to Title IV, we identified 2 students whose calculation were performed outside of the required timeframe. Planned Corrective Action: Once the report identifying students who have completely withdrawn from their classes is ran, the calculations are done (currently by the Dean) The completed report is given to the FA Specialist to review and send the letters. The specialist then gives the report to the Assistant Director who then prints off a Return of Title IV summary report showing the calculations and charges for final review. Had this last step been done previously, it would have been identified that the Institutional Charges were missing and not requiring corrections. Contact person responsible for corrective action: Nikki Jewell Anticipated Completion Date: June 30, 2026
Condition: Out of 22 students tested for Pell eligibility we identified one student whose student aid index (formerly known as expected family contribution) was changed, however the additional award was never disbursed to the student. Planned Corrective Action: System generated ISIR’s and correction...
Condition: Out of 22 students tested for Pell eligibility we identified one student whose student aid index (formerly known as expected family contribution) was changed, however the additional award was never disbursed to the student. Planned Corrective Action: System generated ISIR’s and corrections will be reviewed for changes and then given to the Director for weekly review to ensure the updates and awards are accurate and complete Contact person responsible for corrective action: Nikki Jewell Anticipated Completion Date: June 30, 2026
Condition - The same individual is responsible for preparing and submitting quarterly expenditure reports for the Education Stabilization Fund without an independent review or approval prior to submission. Plan - All subsequent expenditure reports will be prepared by the assistant superintendent and...
Condition - The same individual is responsible for preparing and submitting quarterly expenditure reports for the Education Stabilization Fund without an independent review or approval prior to submission. Plan - All subsequent expenditure reports will be prepared by the assistant superintendent and reviewed and submitted by the superintendent using their separate IWAS logins. Anticipated Date of Completion - January 2026; Name of Contact Person - Keith Brown, Superintendent; Management Response - We agree with the finding and will implement the the corrective action plan as stated above.
Finding Number: 2025-001 Finding Name: Reporting Finding Summary: The Medical Center had discrepancies between the amounts reported in the quarterly progress reports and the actual expenditures. Specifically, the amounts reported in the progress reports did not accurately reflect the total expenditu...
Finding Number: 2025-001 Finding Name: Reporting Finding Summary: The Medical Center had discrepancies between the amounts reported in the quarterly progress reports and the actual expenditures. Specifically, the amounts reported in the progress reports did not accurately reflect the total expenditures incurred during the reporting period by $89,900. CLIENT PLANNED ACTION: The Medical Center agrees with the finding. The reported expenditures were corrected in later reporting periods. Going forward, we have adjusted procedures to include a review of items eligible for SLFRF reimbursement to identify items received during the reporting period, rather than items requested. CLIENT RESPONSIBLE PARTY: Daniel Goris, Accounting Manager COMPLETION DATE: March 31, 2026
Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance ...
Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken Staff Training Quality Assurance and Monitoring To ensure sustained compliance, the organization is implementing the following monitoring process: • Monthly random chart audits of sliding fee documentation. • Minimum sample size of 40 patient records • Audit elements will include: o Income documentation present o Household size documented o Correct FPG calculation o Correct discount level applied • Findings will be reported to senior leadership and the compliance committee. Corrective coaching is provided when deficiencies are identified. Comprehensive training is being conducted for all relevant staff including: • Patient access / front desk staff • Financial counselors • Billing staff • Site managers Training topics include: • HRSA Sliding Fee Discount Program requirements • Determining household size • Calculating FPG percentage • Acceptable income documentation • Proper EHR documentation • Self-attestation procedures
Views of Responsive Officials of Auditee: In the past year we have developed a written policy and procedure manual over procurement. We will ensure that this manual is updated in a reasonable amount of time to ensure all applicable policies are addressed. With our increasing federal grant funding th...
Views of Responsive Officials of Auditee: In the past year we have developed a written policy and procedure manual over procurement. We will ensure that this manual is updated in a reasonable amount of time to ensure all applicable policies are addressed. With our increasing federal grant funding this is a high priority for the City.
Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person (Superintendent) compares the meal counts in the claim to: the SDS daily meal...
Condition - The same individual is responsible for preparing and submitting monthly reimbursement claims for the Child Nutrition Program without an independent review or approval prior to submission. Plan - A second person (Superintendent) compares the meal counts in the claim to: the SDS daily meal count reports, monthly participation summary, eligibility rosters (free, reduced, paid) and USDA reimbursement rates. The reviewer will then sign and date a reconciliation sheet before submission. Anticipated Date of Completion - July 1, 2026; Name of Contact Person - Dr. Beau Fretueg, Superintendent; Management Response - The corrective action plan was discussed with the employee responsible for filing the claim, the business manager, and the superintendent. After discussion, the plan was approved by the superintendent.
Finding 2025-002 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-002, Financial Aid will use a daily credit change report generated automatically from academ...
Finding 2025-002 Name of Responsible Individuals: Mrs. Tiffany Grandy, Assistant Director of Financial Aid and Mr. Jared Peterson, Financial Aid Counselor Corrective Action: As a result of Audit Finding 2025-002, Financial Aid will use a daily credit change report generated automatically from academic records to make any manual credit updates in the PowerFAIDS financial system. Additionally, Financial Aid will use selection sets within PowerFAIDS to identify any credit hour mismatches between what is manually reported versus what is integrated from Power Campus, the academic records database. Anticipated Completion Date: March 19, 2026
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend that the University verifies the enrollment intensity for each student receiving the Federal Pell Grant prior to finalizing their award package. Explanation of disagreement with audit finding: There is no disa...
Student Financial Aid Cluster – Assistance Listing No. 84.063 Recommendation: We recommend that the University verifies the enrollment intensity for each student receiving the Federal Pell Grant prior to finalizing their award package. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is working with a PowerFAIDS consultant to ensure that the correct number of credits populates based on the courses inputted. The issue has also been added to their procedures to check the Class Load and Credits field whenever packaging or revising a student’s aid. Name(s) of the contact person(s) responsible for corrective action: Michael Moos, Vice President of Finance Planned completion date for corrective action plan: June 30, 2026
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