Corrective Action Plans

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The Finance Staff will collaborate with Police Department Staff during the budgeting process to ensure that revenue is not inappropriately budgeted. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Finance Staff will collaborate with Police Department Staff during the budgeting process to ensure that revenue is not inappropriately budgeted. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Finance Department staff will review all items prior to completing the report. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Finance Department staff will review all items prior to completing the report. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
With the help of a consulting firm, the City has reviewed our internal controls, processes and procedures to correct these issues. Within the last six months, experienced staff have increased our ability to more closely monitor and record budgeting issues in a timely manner, according to federal gra...
With the help of a consulting firm, the City has reviewed our internal controls, processes and procedures to correct these issues. Within the last six months, experienced staff have increased our ability to more closely monitor and record budgeting issues in a timely manner, according to federal grant requirements. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Linda H. Conover, Interim Finance Director
Finding Number: 2025-002 Application of Rent Reasonableness Standards Planned Corrective Action: 1. Rent reasonableness forms will undergo a secondary review to ensure proper comparability. 2. If the assisted unit is above those of comparable units, documentation will be made and relevant support wi...
Finding Number: 2025-002 Application of Rent Reasonableness Standards Planned Corrective Action: 1. Rent reasonableness forms will undergo a secondary review to ensure proper comparability. 2. If the assisted unit is above those of comparable units, documentation will be made and relevant support will be retained to explain the justifiable reason to ensure no departures occur. Person Responsible for Corrective Action: Heather Ryan-Figueroa, VP of Programs and Colleen Cooper, Director of Finance. Anticipated Date of Completion: July 31, 2026.
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review th...
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review the process to re-establish time-and-effort reporting through the timesheet entry process and the consolidation of time-and-effort information into reporting that can be easily summated by department/project and uploaded to MIP · Determine the allocation and cost distribution methods needed and the resulting detail reporting needed to substantiate the allocation methods used for propriety · Reinstitute the timesheet entry process by project/cost code and train staffing at an upcoming All Staff meeting to reset the view of timesheets and their importance of timesheet tracking to minimize errors for cost allocation purposes · Have staff begin using timesheets in Paylocity (by December 1st) · Complete update of Fiscal Policies Manual (inclusive of Cost Allocation methodology and philosophy) and timely reviews (i.e. at a minimum semiannually or with major program changes/contracts) to ensure no substantive changes needed to policy or actions needed to ensure appropriate accounting updates
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Contact Person Derek Johnson, Managing Agent Corrective Action Plan The Authority recognizes the deficiency and plans to implement the auditor's recommendations. Planned Completion Date for CAP Immediately.
Finding 2025-005 - Untimely Release of Title IV Credit Balances (Significant Deficiency): Condition - During testing of student account activity, we identified that fourteen (14) out of sixty (60) sampled students had Title IV created credit balances that remained on their accounts for more than 14 ...
Finding 2025-005 - Untimely Release of Title IV Credit Balances (Significant Deficiency): Condition - During testing of student account activity, we identified that fourteen (14) out of sixty (60) sampled students had Title IV created credit balances that remained on their accounts for more than 14 days without being released to the student or parent. All refunds were eventually released to the students. Corrertive Action Plan The College experienced significant staff turnover within the business office. In addition, the College is undergoing conversion to a new Enterprise Resource Planning (ERP) system which affected its ability to complete some functions within a timely manner. A new bursar was hired in May 2026. Timely processing of student refunds was emphasized during her training. Going forward, student refunds will be released within 14 days after credit balances are reflected on student accounts." Completion Date - September 30, 2026 Responsible Party - Chief Financial Officer
Finding 2025-004 - Various Federal Programs: Cash Management- Excess Federal Cash, Untimely Reconciliations [Material Weakness}: Condition - At June 30, 2025, the College maintained excess federal cash balances across multiple federal programs, indicating that cash drawdowns and/or payable balances ...
Finding 2025-004 - Various Federal Programs: Cash Management- Excess Federal Cash, Untimely Reconciliations [Material Weakness}: Condition - At June 30, 2025, the College maintained excess federal cash balances across multiple federal programs, indicating that cash drawdowns and/or payable balances were not aligned with immediate cash needs for allowable program expenditures. These balances represented federal funds drawn or recorded as payable to federal agencies that were not supported by actual and immediate allowable program expenditures at year-end. The following table summarizes excess federal cash balances identified by program as of June 30, 2025: "Federal Program" "Excess Cash" "Minority Science and Engineering Improvement Program" 120,031 "Science Consortium of Minority Schools" 169,907 "NSF - Empowerment of Undergraduate STEM Majors" 94,801 "NSF - Tennessee Louis Stokes TLSAMP" 54,834 "Title III" 455,679 "FUTURE" 188,215 "Total Identified Excess Cash" 1,083,467 The College did not adequately reconcile federal cash activity to underlying grant expenditures on a timely basis and did not ensure that drawdowns were limited to amounts necessary to meet immediate cash needs. In addition, the College lacked effective monitoring controls to identify and resolve excess cash positions across federal programs in a timely manner. Federal bank reconciliations were untimely and error prone. Corrections occurred only after auditor inquiry. Federal accounts also earned excess interest. Corrective Action Plan The College requests drawdowns for Title Ill and FUTURE programs on a reimbursable basis, including review and approval procedures. Of the total amount identified for the Title Ill program, a $181,433 receivable related to FY2025. The balance related to prior year(s) activity. The College will review its Federal program cost allocation procedures to ensure all eligible costs are properly identified and supported going forward. The College has engaged two accounting firms to assist with staff training and bring all reconciliations current. In addition, standard month-end and year-end closing procedures will be implemented to address timely, accurate Federal program reconciliations and audit readiness going forward. The College experienced significant staff turnover within its business office. In addition, the College is undergoing conversion to a new Enterprise Resource Planning (ERP) system which affected its ability to complete some functions within a timely manner. Completion Date - September 30, 2026 Responsible Party - Chief Financial Officer
2025-003 – Allowable Costs Corrective Action: Implement a process to ensure that unallowable costs are not charged to the grants. Person Responsible: Executive Director, Seth Kirshenberg Estimated corrective action completion date: Fiscal year 2026\
2025-003 – Allowable Costs Corrective Action: Implement a process to ensure that unallowable costs are not charged to the grants. Person Responsible: Executive Director, Seth Kirshenberg Estimated corrective action completion date: Fiscal year 2026\
Contact Persons – Greg Welch, Finance Director & Jarek Wigness, City Engineer Corrective Action Plan – City officials have already implemented internal controls to ensure the proper oversight of federal programs according to the Uniform Grant Guidance Policy for Federal Revenue Sources. Completion D...
Contact Persons – Greg Welch, Finance Director & Jarek Wigness, City Engineer Corrective Action Plan – City officials have already implemented internal controls to ensure the proper oversight of federal programs according to the Uniform Grant Guidance Policy for Federal Revenue Sources. Completion Date – Ongoing
Identification: 10.766 United States Department of Agriculture (USDA), Community Facilities Loans and Grants; Noncompliance Finding; Special Tests and Provisions Corrective Action Plan: The Medical Center will take the necessary steps outlined in the bond indenture and retain a financial consultant ...
Identification: 10.766 United States Department of Agriculture (USDA), Community Facilities Loans and Grants; Noncompliance Finding; Special Tests and Provisions Corrective Action Plan: The Medical Center will take the necessary steps outlined in the bond indenture and retain a financial consultant to review operations and make recommendations to restore the days cash on hand ratio above the minimum requirement. Anticipated completion date: The Medical Center has engaged a financial consultant and will work with the consultant during 2026 to improve operations.
Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for rev...
Condition/Finding: There were instances in which payroll timesheets and resolutions authorizing payroll expenseswere not available for review at the time of audit. Recommendation:The District should ensure that all payroll timesheets and resolutions authorizing payroll expenses are available for review at the time of audit. Method of Implementation: The district will improve the filing and retention of payroll timesheets and resolutions authorizing payroll expenses for federal programs. All payroll documentation will be properly maintained and made readily available for review at the time of audit.
Management agrees with the finding above. Management will review the existing accounting policies and procedures and implement additional controls to validate timely submission of reports.
Management agrees with the finding above. Management will review the existing accounting policies and procedures and implement additional controls to validate timely submission of reports.
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code with...
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code within the Union College system specifically related to graduation and withdrawal dates. A report that includes status code changes will be reconciled with student status changes transmitted by the National Student Clearinghouse (NSC) to the National Student Loan Database System (NSLDS), and any necessary corrections will be made in the appropriate time frame. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented at the end of the Spring 2026 term.
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal con...
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal controls over the application of indirect cost rates to federally funded awards. Although corrective actions were initiated following the prior year's finding, the College has identified opportunities to enhance the review and monitoring of indirect cost rate calculations to ensure consistent compliance with Uniform Guidance. Going forward, the accounting group, in collaboration with the Office of Sponsored Programs, will maintain the current federally negotiated indirect cost rates, apply approved rates to applicable awards, and perform periodic reviews to verify that the correct rates are consistently applied. Timeline for Implementation of Corrective Action Plan: The College will finalize written procedures governing the application and review of indirect cost rates, implement a documented review process for indirect cost calculations prior to posting, and provide guidance to employees responsible for grant accounting. These actions will be completed by September 30, 2026. Management will periodically monitor compliance to ensure indirect cost rates are applied accurately and in accordance with federal requirements.
Finding #2025-002 – Reporting Description of Finding: As a recipient of a direct federal award under the Public Safety Partnership and Community Policing Grants (ALN 16.710) program, the County is required to comply with mandatory compliance requirements. Per the OMB Compliance Supplement, this fede...
Finding #2025-002 – Reporting Description of Finding: As a recipient of a direct federal award under the Public Safety Partnership and Community Policing Grants (ALN 16.710) program, the County is required to comply with mandatory compliance requirements. Per the OMB Compliance Supplement, this federal award has a financial reporting requirement and a performance reporting requirement. The County’s year end financial report submitted to the grantor indicated that the project was completed as of December 31, 2025, and the full grant award had been expended. Additionally, the performance report submitted for the period ending July 31, 2025, indicated that all equipment had been purchased and delivered. However, per the financial records of the County, there were unexpended grant funds as of December 31, 2025, as the final program deliverables had not been received or invoiced. Statement of Concurrence of Nonconcurrence: Concurrence Planned Corrective Action: This was a unique circumstance where federal awards were being suspended by our federal government and then reinstated. Our goal was to draw down on the COPS Grant for $715,000 and spend the funds on the Dispatch radios as quickly as possible before the funds were suspended again. Reported to the federal award program as such and then there was a delay in the purchasing of all radios and equipment. Anticipated Completion Date: The specified federal award program has been completed and closed.
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreeme...
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreement and related funder documentation for indicators of federal funding, including an Assistance Listing Number, a federal award identification number, the originating federal agency, the pass-through entity identifying number, and references to the Uniform Guidance, and should confirm the federal funding status with the pass-through entity when it is not clear. Management will maintain a centralized listing of awards that is reconciled to the general ledger and reviewed for completeness in preparing the schedule of expenditures of federal awards. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Completion Date: July 31,2026
Agency: Colorado Coalition for the Homeless Audit Period: 2025 Audit Finding Number: 2025-001 Audit Finding Title Sliding Fee Health Center Cluster Department of Health and Human Services Assistance Listing Number 93.224 Behavioral Health Services, 93.527 Bridge Access Program Award Numbers: 4 H8NCS...
Agency: Colorado Coalition for the Homeless Audit Period: 2025 Audit Finding Number: 2025-001 Audit Finding Title Sliding Fee Health Center Cluster Department of Health and Human Services Assistance Listing Number 93.224 Behavioral Health Services, 93.527 Bridge Access Program Award Numbers: 4 H8NCS53841-01-02 and 5 H80CS00040-24-00 Award Years: January 1, 2023-December 31, 2025 Criteria or Specific Requirement: Special Tests and Provision: Sliding Fee Discounts (42 USC 254(k)(3)(g); 42 CFR sections 51c.303(g); and 42 CFR sections 56.303 (f)) Condition: The Organization has a policy that includes homelessness when applying the sliding fee discount in addition to income and household size. The Health Center Compliance Manual only identifies income and household size as determining factors for the sliding fee program. Documentation to support income or household size were not maintained adequately for some patients who received sliding fee discount adjustments. Cause: The Organization's sliding fee discount policy includes homelessness, which is not specifically listed as an applicable determining factor for the sliding fee discount. The Health Center Compliance Manual specifically identifies income and household size as determining factors for the sliding fee program. Additionally, the Organization's controls did not clearly document eligibility for all patients with the sliding fee discount policy. Effect or potential effect: Other adjustments were not distinct from sliding fee adjustments applied to patient charges and, therefore, all patients received a full discount for services. Questioned Costs: None Context: A sample of 25 patients out of a population of 13,454 patients were tested.  Four of the patients sampled lacked appropriate documentation of income and/or household size. Seven of the patients sampled between 100% and 200% of the FPL were adjusted to no patient responsibility under the sliding fee discount program based on their homelessness status as identified in the Organization’s policy. The sampling methodology used is not and is not intended to be statistically valid. Identification as a repeat finding: Not a repeat finding. Recommendation: The Organization should revise its sliding fee discount policy to focus only on income and household size and further eliminate homelessness as a factor. Furthermore, the Organization should implement a process to review sliding fee discount eligibility to ensure compliance with its revised policy. Other adjustments should also be captured separately from sliding fee adjustments within the Organization's billing system. Views of responsible officials and planned corrective actions: The Organization agrees with the finding. Specific steps to be taken to correct the situation (including a timetable for performance of the CAP) or reason why corrective action is not necessary (including disagreement with the finding) NextGen, the electronic health record and practice management system CCH utilizes for revenue cycle operations has been reconfigured to separate the sliding fee adjustments from other adjustments. This was identified and corrected before the audit was completed on April 21, 2026. CCH will revise and update the Sliding Fee Discount Program policy to clarify that the only two factors for application of the sliding fee discount are family size and income. The Sliding Fee Discount Policy will no longer include ‘homelessness’ as a factor for this particular discount. CCH will review the sliding fee discount process regularly to ensure compliance with the revised policy. Additionally, appropriate documentation of self-attestation of income and family size will be collected as required. CCH will also revise and update existing policies related to Billing and Collections and for Waiving or Reducing Fees Beyond the Sliding Fee Scale to define the other discounts CCH provides to clients including those who do not provide complete data for sliding fee discount eligibility determination Finally, appropriate staff will receive updated training on the updated policies. Anticipated completion date The billing system change occurred on April 21, 2026. The policy revisions will be completed and approved by the Board by October 31, 2026 Training on the updated policies will be implemented upon final approval by the Board and be completed by November 30, 2026. Name(s) and title(s) of contact person(s) responsible for corrective action Billing system changes: Rob Plimpton, Controller /Kathy Hatfield, Interim Revenue Cycle Director Policies and Training: Andrew RobGrimm, Chief Integrated Health Operations Officer
Condition: For the year ended December 31, 2025, the Township submitted reports timely, however, these reports were not reviewed prior to submission. Planned Corrective Action: The Township will implement and document controls to ensure reviews of all required reports are done by an individual indep...
Condition: For the year ended December 31, 2025, the Township submitted reports timely, however, these reports were not reviewed prior to submission. Planned Corrective Action: The Township will implement and document controls to ensure reviews of all required reports are done by an individual independent of the individual preparing the reports. Contact person responsible for corrective action: Barbara Miller, Accounting Mgr. Anticipated Completion Date: 9/30/2026
Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges...
Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges this finding. City has communicated directly with Housing and Urban Development for clarification on reporting requirements and intends on following the updated guidance they provided. Anticipated Completion Date: July 31, 2026
Finding 1223673 (2025-002)
Material Weakness 2025
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 200...
Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410 and 20020, Contract Year: 10/01/24 – 09/30/25, 10/01/25 - 09/30/26, Department of Agriculture, Assistance Listing #: 10.561 – State Administrative Matching Grants for the Supplemental Nutrition Assistance Program (SNAP Cluster), Passed through Houston-Galveston Area Council, Contract Number: 20020, Contract Year: 10/01/25 - 09/30/26. Condition and context: During our testing of 40 federal and state payments to childcare providers under the Houston-Galveston Area Council contract, we noted that 1 childcare provider was paid at an incorrect provider rate resulting in an overpayment of $9.10. Recommendation: Re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Corrective action: BakerRipley will re-emphasize training of personnel and adherence to BakerRipley’s and TWC’s policies and procedures. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026
Finding 1223672 (2025-001)
Material Weakness 2025
Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contra...
Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: Department of Health and Human Services, Assistance Listing #: 93.575 – Childcare and Development Block Grant (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contract Year: 10/01/24 - 09/30/25, Assistance Listing #: 93.596 – Child Care Mandatory and Matching Funds of the Child Care and Development Fund (CCDF Cluster), Passed through Houston-Galveston Area Council, Contract Number: 13410, Contract Year: 10/01/24 - 09/30/25. Condition and context: During the planning phase of the audit, management disclosed that childcare providers were paid $3.6 million in duplicate childcare assistance payments in July 2025. As of May 15, 2026, $2.5 million of the duplicate payments have been recovered. Recommendation: Implement prevention procedures to identify duplicate payments prior to payment. Corrective action: BakerRipley has reviewed internal processes and procedures to determine the cause and implement prevention procedures related to the duplication of payments prior to payment. Responsible officer: Neil Hanson. Estimated date of completion: December 31, 2026
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