Corrective Action Plans

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Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and...
Condition: The Commission was unable to send failed HQS inspection notices promptly to participants who needed to correct deficiencies. Planned Corrective Action: HCV will hire additional internal support for HQS inspections to work alongside external vendors and ensure timely updates/mailings/, and closeouts are uploaded to the work management system, Yardi. Contact person responsible for corrective action: Felicia Burris, HCV Program Manager Anticipated Completion Date: 6/30/2026
Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead ...
Primary Health Care Corrective Action Plan – Sliding Fee Finding: During the External Financial Audit for FY 2025, it was determined that certain patients had received sliding fee discounts that were not consistent with the stated sliding fee discount categories under PHC’s policy. Action Step Lead Support Due Date Update resource materials associated with sliding fee discounts and distribute to necessary staff. Provide training to necessary staff on sliding fee discount policy and any changes to discounts. Beth Frantum, CFO Revenue Cycle Director Patient Services Director March 2026 Develop and implement an internal review process to provide reasonable assurance that Slide calculations are accurate and EPIC reflects the correct amount expected for services. Beth Frantum, CFO Revenue Cycle Director Patient Services Director John Shaw, Director of Clinics April 2026
Finding Synopsis: Amounts were submitted to the state for reimbursement were higher than costs with required supporting documentation. The district had difficulty in providing supporting documentation for the amounts submitted for reimbursement, and expenditures could not be easily separated between...
Finding Synopsis: Amounts were submitted to the state for reimbursement were higher than costs with required supporting documentation. The district had difficulty in providing supporting documentation for the amounts submitted for reimbursement, and expenditures could not be easily separated between the last two fiscal years the grant was received. Action Steps: The district implemeted changes in control activites to ensure that proper review controls are in place and that all grant reimbursements have adequate documentation. Contact Person: Alicia Cieszykowski, Assistant Superintendent for Business Services, 630-295-5430 Anticipated Completion Date: 06/30/2026
The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to A...
The purpose of the Goods Receipt (GR) is to record receipt of goods or services as soon as they are delivered and verified to be in acceptable condition. A Goods receipt must be posted in SAP for all items actually received. Vendors submit invoice(s) referencing the purchase order (PO) directly to Accounts Payable after delivery, indicating that the goods or services have been provided and requesting payment. Accounts Payable then reviews the vendor invoice, purchase order, and goods receipt in SAP to perform the required three-way match (PO, GR, and vendor invoice) before processing payment. 1. The Accounts Payable team will collaborate with the Procurement Services Division to establish and implement a process that ensures the timely review and reconciliation of Goods Receipt (GR) entries. This will include the development of clear guidance / training materials for schools and offices to periodically review their GR balances. Training will be conducted via Virtual Office Hours on a quarterly basis for sites to make necessary adjustments when the goods or services received differ from the original Purchase Order (PO) or the corresponding invoice. 2. The Accounts Payable team will collaborate with the Procurement Services Division to develop supplemental documentation and guidance regarding proof of delivery for goods and services received. 3. Accounts Payable staff will receive ongoing training throughout the year on documentation and reconciliation requirements, particularly when new internal controls, procedures, and processes are created. Training will be incorporated into regular team meetings, procedural updates, and onboarding for new team members to maintain alignment and accuracy across the department. The implementation target date for the above corrective action plan is June 30, 2026. Name: Rocio Saucedo Title: Director of Accounts Payable Contact Information: Rocio.Saucedo@lausd.net
The Food Services Division is committed to providing great food and maintaining rigorous internal controls and continuous monitoring to safeguard program integrity. The discrepancy found at one school is not representative of our program, as we do ongoing random audits of submitted claims to verify ...
The Food Services Division is committed to providing great food and maintaining rigorous internal controls and continuous monitoring to safeguard program integrity. The discrepancy found at one school is not representative of our program, as we do ongoing random audits of submitted claims to verify the accuracy of submitted data. These layered oversight measures provide multiple levels of verification to minimize and eliminate the likelihood of reporting errors and ensure compliance with applicable state and federal program requirements. At Annalee El, the school with an overclaim of 104 meals, we found that the manager had moved from the school, and in the interim, our review protocol fell short. Given the large volume of meals served annually across the District, the over-claim discrepancy identified during the FY 24-25 audit represents an isolated incident rather than a systemic deficiency in LAUSD Food Services operations. The claim verification process followed at schools is stated below: • The Food Service Manager conducts a weekly review of the prior week’s daily meal count documents to identify and correct any discrepancies. • The Food Service Manager generates and reviews a weekly Meal Counts Report from the Cafeteria Management System (CMS) to verify recorded data. • The Food Service Manager compares the daily meal count documents against the five-day Meal Counts Report to ensure data alignment and accuracy. • The Manager performs an additional verification by reconciling daily meal count documents with the five-day Meal Counts Report from CMS. Any identified errors are corrected immediately in CMS. This reconciliation process is completed prior to the submission of claims to the Child Nutrition Information and Payment System. • The Area Food Services Supervisor (AFSS) and Regional Manager (RM) conduct random weekly reviews of meal counts for accuracy, utilizing reports provided by Central Office staff to support this verification process. • Central Office staff perform a monthly audit of meal count records and prepare a draft report for review by the AFSS and RM to validate findings and confirm accuracy. Retraining of the staff at Annalee El has been completed, and the manager and supervisor teams are verifying that the above protocol is being followed consistently at all schools. Name: Manish Singh Title: Director, Food Services Division Telephone: (213) 241-2993
Condition: Nine (9) employee payroll expenditures were claimed at an hourly rate greater than that approved by ISBE. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, budgets will be mo...
Condition: Nine (9) employee payroll expenditures were claimed at an hourly rate greater than that approved by ISBE. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, budgets will be monitored and amended accordingly within the period performance of the grant. Responsible Person: Janiesa Owens, Chief School Business Official Anticipated Completion Date: June 30, 2026
Condition: Three (3) monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, und...
Condition: Three (3) monthly claims for reimbursement reported meal counts in excess of those supported by records of the District. Corrective Action Plan: Management will review its policies and procedures and implement changes to strengthen internal control over federal reporting. In addition, underlying claim support will undergo review before claims are submitted to the ISBE. Responsible Person: Janiesa Owens, Chief School Business Official Anticipated Completion Date: June 30, 2026
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective action will be taken: The University will review and revise policies and procedures related to reviewing and approving Research & Development ...
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective action will be taken: The University will review and revise policies and procedures related to reviewing and approving Research & Development grant scholarships prior to disbursement. The University will do the following:  Implement a review process to verify scholarships are reviewed and approved by Grant Administration prior to disbursement.  Provide training to relevant staff on proper documentation procedures to forward to Grant Administration to enhance compliance and accuracy.
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective actions have been taken: During the 2023-2024 academic year, EngageKY implemented a new process for recordkeeping related to the recruitment a...
Views of responsible officials and planned corrective actions: The University agrees with the auditors' finding and recommendations. The following corrective actions have been taken: During the 2023-2024 academic year, EngageKY implemented a new process for recordkeeping related to the recruitment and selection of Kentucky College Coaches. As part of the implementation, site supervisors and program staff began to use Salesforce to maintain notes from screening interviews and general interviews. The missing documentation referenced in this finding was for individuals hired prior to the new process. EngageKY will continue to use Salesforce to document the recruitment and selection of Kentucky College Coaches.
Finding 1170486 (2025-002)
Material Weakness 2025
Finding 2025-001 Budget Violations Name of contact person: Jen Waterhouse, Chief Financial Officer Corrective Action: Proposed completion date: Finding 2025-002 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date...
Finding 2025-001 Budget Violations Name of contact person: Jen Waterhouse, Chief Financial Officer Corrective Action: Proposed completion date: Finding 2025-002 Inaccurate Information Entry Name of contact person: Sabrina Magedanz, Medicaid Program Manager Corrective Action: Proposed completion date: Corrective Actions for Finding 2025-002 also apply to State Award Findings. Corrective Action Plan For the Year Ended June 30, 2025 Section II - Financial Statement Findings Training for understanding Subscription Based Information Technology Agreements (SBITA) is a priority and will be conducted immediately. In FY26, SBITA’s will be reviewed and recorded quarterly via a budgeting worksheet to capture payments throughout the year for GASB 96 agreements. In May, the list will be monitored closely, and Finance staff will follow up with departments to confirm anticipated expenditures falling under GASB 96 are taken into consideration. Reports will be reviewed by the Chief Financial Officer for correctness, and the budget amendment will be in place in the first Board of Commissioner’s meeting in June 2026. In addition to the Budget Amendment taking place in early June; staff will also reconcile debt book GASB 96 reports to ensure complete records and agreement with prior year balances are intact. 6/8/2026 Section III - Federal Award Findings and Questioned Costs Training will be conducted with staff specifically concerning the finding areas , ensuring all required request for information and electronic verification sources are used, ensuring all verified information is appropriately updated in NC FAST evidence and ensuring all timeframes are adhered to when processing actions. Second party reviews will be enhanced to ensure those conducting the review verify that proper procedures are being followed with regard to these policies. Section IV - State Award Findings and Questioned Costs 12/5/2025 􀀔􀀚􀀕
Finding 2025-001: During the year ended September 30, 2025, the Company loaned funds totaling $10,850 to two other Communities under common management and affiliated with the Sole Member of the Company to help fund operating shortfalls of the other Communities. Comments on the Finding and Each Recom...
Finding 2025-001: During the year ended September 30, 2025, the Company loaned funds totaling $10,850 to two other Communities under common management and affiliated with the Sole Member of the Company to help fund operating shortfalls of the other Communities. Comments on the Finding and Each Recommendation: Management and/or the Sole Member should reimburse the Company for the funds that were loaned to the two other Communities. If there are further operating shortfalls in the future, these should be funded by Management and/or the Sole Member and not borrowed from other Communities. Action(s) taken or planned on the finding: Management concurs with the finding and agrees with the recommendation. On November 7, 2025, Management deposited $10,850 into the Community's operating account. No further action is required.
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $5,119 from the operating account to the reserve for replacements account when there is cash avail...
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $5,119 from the operating account to the reserve for replacements account when there is cash available. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $5,119 into the replacement reserve on November 18, 2025, and will continue to make monthly deposits to the reserve as cash flow allows to ensure compliance.
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $3,535 from the operating account to the reserve for replacements account when there is cash avail...
Finding #2025-001: During the year ended September 30, 2025, the Corporation did not make the HUD required number of deposits to the reserve for replacements. Recommendation: Management should transfer $3,535 from the operating account to the reserve for replacements account when there is cash available. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management deposited $3,535 into the replacement reserve on November 7, 2025, and will continue to make monthly deposits to the reserve as cash flow allows to ensure compliance.
Finding No: 2025-004 Condition: The District receives Title I funding and determines eligibility for schoolwide programs based on attendance numbers derived from free and reduced lunch counts. During the audit, we noted that the district’s process for compiling these attendance numbers involves the ...
Finding No: 2025-004 Condition: The District receives Title I funding and determines eligibility for schoolwide programs based on attendance numbers derived from free and reduced lunch counts. During the audit, we noted that the district’s process for compiling these attendance numbers involves the grant manager obtaining a report from the Business Office, which is generated from the food service platform as of a specific day. However, the district was unable to reproduce the report used to complete the Title I application and supporting documentation for the reported figures was not available for review. Plan: The District will maintain all reports used to compile attendance figures for the Title I grant. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. Th...
Finding No: 2025-003 Condition: The District does not have an adequate review process in place for meal count claims prior to submission. Claims prepared by one individual are submitted without independent verification. As a result, the district reported an incorrect lunch count for January 2025. This error appears to be isolated to January; however, it would likely have been prevented if a review process were in place. Plan: The District will implement a system in which meal count claims will have secondary approval by the CSBO. Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Mark Orszula, CSBO
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: ...
U.S. Department of Agriculture Passed Through the North Dakota Department of Public Instruction and the Minnesota Department of Human Services Federal Financial Assistance Listing # 10.568 All Awards Federal Financial Assistance Listing # 10.569 All Awards Food Distribution Cluster Finding Summary: As part of the audit done by Eide Bailly LLP, a lack of internal controls were identified in eligibility determinations and reviews for The Emergency Food Assistance Programs. Responsible Individuals: Kate Molbert, COO David Stachon, CFO Corrective Action Plan: The GPFB will ensure all documents for TEFAP programs have proper signatures by necessary parties going forward. An electronic signature process has been implemented to make the dissemination, review and storage of this process easier. Also, additional staffing has been hired to manage this process in the form of a Programs and Operations Compliance Manager with substantial compliance experience. Anticipated Completion Date: Immediate
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses ...
Condition & Criteria: For three aviation program students, cost of attendance calculations were based on expected high-cost courses, but actual enrollment differed, resulting in overstated costs and excess aid disbursement. Auditor’s Recommendation: Adjust cost of attendance based on actual courses attended and fees incurred. Corrective Action: The Financial Aid Department now verifies actual course enrollment prior to disbursement for specialized programs, ensuring accuracy and compliance. Beginning Winter term 2026, mid-term audits for the aviation program have been implemented to strengthen oversight. Additionally, policy updates now require real-time cost of attendance adjustments for all individualized programs to maintain consistency and alignment with federal regulations. Responsible Person: Director of Financial Aid, with support from Aviation Program Director. Anticipated Completion Date: Begin implementation immediately and accomplish full implementation by Spring 2026; ongoing monitoring.
The District will review federal procurement requirements to ensure proper documentation and authorization procedures are followed
The District will review federal procurement requirements to ensure proper documentation and authorization procedures are followed
The District will review the work performed by the individual preparing the reports before submission
The District will review the work performed by the individual preparing the reports before submission
Corrective action taken or planned: Management concurs with the finding and the auditor's recommendation. The District will continue to provide targeted training and perform ongoing monitoring of staff responsible for the preparation and review of R2T4 calculations. In addition, the campus will crea...
Corrective action taken or planned: Management concurs with the finding and the auditor's recommendation. The District will continue to provide targeted training and perform ongoing monitoring of staff responsible for the preparation and review of R2T4 calculations. In addition, the campus will create internal procedures for the new FAFSA simplification calculations. District will strengthen internal controls over the R2T4 process by implementing an additional level of supervisory review and approval to ensure calculations are performed accurately and in accordance with applicable federal regulations. Anticipated completion date: June 30, 2026 Contact person responsible: Melissa Raby Vice President, Student Services Columbia College
The University initiated the following remedial actions upon self-identification of the items described in the finding. 1. Updated its policies to specifically prohibit any form of compensation (including payment of bonuses and other forms of incentive compensation) or promotions for admissions depa...
The University initiated the following remedial actions upon self-identification of the items described in the finding. 1. Updated its policies to specifically prohibit any form of compensation (including payment of bonuses and other forms of incentive compensation) or promotions for admissions department personnel to be based on the achievement of enrollment goals. 2. Discontinued the prior practice of awarding office-wide bonuses for undergraduate admissions personnel. 3. Engaged higher-education industry compliance experts to consult and assist the University with the development and implementation of stronger policies and procedures in the area of personnel compensation philosophy, including job levels and standardized promotional criteria. 4. Certain management-level employees responsible for oversight of enrollment recruitment and human resources departments within the University are no longer employed by the University. 5. Enhanced competencies of its internal compliance department and strengthened the program structure and operating model, supporting improved communication and oversight.
Federal Agency Name: United States Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program ...
Federal Agency Name: United States Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants Finding Summary: During our testing, there was no formal review separate from the preparer over the reserve fund reconciliation for the federal program and there was no formal review of the balance in comparison to the required minimum reserve balance. Due to there being no formal review of the balance in comparison to the required minimum reserve balance, the reserve balance was underfunded as of June 30, 2025 in the amount of $17,486. Corrective Action Plan: We will implement additional control processes to ensure a formal review over the reserve fund reconciliation and a formal review of the balance in comparison to the required minimum reserve balance is completed by staff separate from the preparer. On November 28, 2025, the minimum reserve balance was fully funded at $358,800. Responsible Individual: Mandy Robinson, Administrator Anticipated Completion Date: 11/28/2025
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER – ALN NOS. 84.027 AND 84.173 2025-001 Internal Control Over Compliance With Federal Allowable Costs Requirements Finding Summary 2 CF...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, SPECIAL EDUCATION CLUSTER – ALN NOS. 84.027 AND 84.173 2025-001 Internal Control Over Compliance With Federal Allowable Costs Requirements Finding Summary 2 CFR § 200.302(b)(3) requires Independent School District No. 911 (the District) to maintain records that adequately identify the source and application of funds for federally funded activities in accordance with 2 CFR 200 Subpart E – Cost Principles. The District did not have sufficient controls to assure adequate and timely documentation of time and effort was created and retained to support salary costs charged to federal programs and ensure compliance with this requirement. Corrective Action Plan Actions Planned – The District will review policies and procedures for maintaining time and effort documentation for its employees in its federal programs to ensure compliance with the Uniform Guidance in the future. Official Responsible – Director of Finance and Operations, Christopher Kampa. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Director of Finance and Operations, Christopher Kampa, will assure appropriate internal controls and procedures are updated and in place to ensure adequate time and effort documentation is maintained to support all employee salaries charged to federal programs in the future.
Views of Responsible Officials and Corrective Action: The District has added reconciling the accounts receivable balance from the billing software to the general ledger accounts receivable balance, to their monthly closing process.
Views of Responsible Officials and Corrective Action: The District has added reconciling the accounts receivable balance from the billing software to the general ledger accounts receivable balance, to their monthly closing process.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
Views of Responsible Officials and Corrective Action: The District will strive to segregate as many accounting functions as practical with the limited staff available.
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