Corrective Action Plans

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Description: Significant deficiency in internal control over compliance related to reporting. Cause: Though the Organization has established internal controls for submitting covered subawards as required by the Transparency Act, the Organization made an incorrect determination that the covered subaw...
Description: Significant deficiency in internal control over compliance related to reporting. Cause: Though the Organization has established internal controls for submitting covered subawards as required by the Transparency Act, the Organization made an incorrect determination that the covered subaward was under the required reporting limit. Effect: The Organization did not comply with the subaward reporting requirements as specified in 2 CFR 170. Corrective Action: • The Organization’s management and Board of Directors understand the requirement and importance of complying with the Federal Funding Accountability and Transparency Act. Our Accounting & Finance Policy and Subrecipient Monitoring Policy have both been updated to clearly assign the responsibility for timely reporting of subawards. The covered subaward that was not reported in FY25 was reported promptly as soon as this issue was raised as part of the audit. Contact Person: Daniel Pulse, CFO Anticipated completion date: November 2025, Corrective action has been completed.
Finding 2025-003 Lack of Internal Controls over Reporting Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: The District will save copies and related supporting documentation of required reports submitted to granting agencies in a file accessible to appropriate indivi...
Finding 2025-003 Lack of Internal Controls over Reporting Name of Contact Person: Elena Begojevic, Business Manager Corrective Action Plan: The District will save copies and related supporting documentation of required reports submitted to granting agencies in a file accessible to appropriate individuals to ensure information is available to more than one District employee. This will mitigate issues in obtaining compliance documents when requested. Proposed Completion Date: December 2025.
Finding No. Corrective Action Plan 2025-002 Segregation of Duties – Monthly claims Recommendation: We recommend the District designate an individual to review monthly claims prior to submitting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action p...
Finding No. Corrective Action Plan 2025-002 Segregation of Duties – Monthly claims Recommendation: We recommend the District designate an individual to review monthly claims prior to submitting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: Management will review and approve monthly claims prior to submitting. Name of responsible official: Jesse Brinkmann, Superintendent Expected Completion Date: 06/30/2026
Management will monitor utility allowances on a monthly basis to ensure they are applied to tenants correctly.
Management will monitor utility allowances on a monthly basis to ensure they are applied to tenants correctly.
The tenant recertifications will be monitored by the owner to ensure they are being completed in a timely manner.
The tenant recertifications will be monitored by the owner to ensure they are being completed in a timely manner.
Processes have been implemented to improve and maintain documentation for grant reimbursement requests so overclaiming federal funds does not occur.
Processes have been implemented to improve and maintain documentation for grant reimbursement requests so overclaiming federal funds does not occur.
Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Number: 14.871 & 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material weakness in Int...
Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Number: 14.871 & 14.EHV Noncompliance – E. Eligibility - Tenant Files Non Compliance Material to the Financial Statements: Yes Material weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). Finding 2025-001 (continued) Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit and the Authority included income that was miscalculated during the annual recertification. Context: Of a sample size of thirty-seven (37) tenant files, the following information was unavailable for examination at the time of audit: • Original application was missing in one (1) file • Citizenship declaration was missing in one (1) file • Signed lease was missing in one (1) file • Verification of income was missing in four (4) files • HUD form 50058 was not timely filed for one (1) file In addition, three (3) tenants' annual recertifications (HUD-50058 form) included income that was miscalculated. Our sample size is statistically valid. Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered and designed a system of internal controls that reasonably assures the program is in compliance. Effect: The Housing Voucher Cluster program is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will reasonably assure eligibility compliance with the Uniform Guidance and the compliance supplement. Authority Response: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Housing Voucher Cluster Program to ensure that established internal control policies are being followed on a timely basis. Views of responsible officials and planned corrective action: Ms. Irma Gorham, Executive Director is responsible to remedy the deficiency by March 31, 2026.
The Authority will consider implementing the recommendation. The Authority is actively working on rectifying the finding.
The Authority will consider implementing the recommendation. The Authority is actively working on rectifying the finding.
Wheeler Clinic, Inc. has reviewed the current approval processes. As of October 9, 2025, Wheeler Clinic, Inc. has formally implemented a process change removing any universal approval practices effective immediately. Wheeler Clinic, Inc. has also implemented a process that requires all managers/supe...
Wheeler Clinic, Inc. has reviewed the current approval processes. As of October 9, 2025, Wheeler Clinic, Inc. has formally implemented a process change removing any universal approval practices effective immediately. Wheeler Clinic, Inc. has also implemented a process that requires all managers/supervisors to authorize timesheets by a designated time on the subsequent Monday of the payroll cycle prior to payroll processing in order for payroll to be processed.
Finding 2025-002 – Maintenance of Effort Significant Deficiency | Federal Program: Title I, Part A (84.010) Response Steel City Academy recognizes that Maintenance of Effort (MOE) calculations rely on accurate cash-basis expense data reported on the Form 9 and that prior inaccuracies could impact ID...
Finding 2025-002 – Maintenance of Effort Significant Deficiency | Federal Program: Title I, Part A (84.010) Response Steel City Academy recognizes that Maintenance of Effort (MOE) calculations rely on accurate cash-basis expense data reported on the Form 9 and that prior inaccuracies could impact IDOE’s calculations. 24 Beginning July 1, 2025, the School implemented comprehensive corrective actions to improve Form 9 reporting, fund balance accuracy, and expense classification by consolidating all financial activity into QuickBooks Online. All expenses are now recorded by the Finance Coordinator using fund, program, and object codes aligned with IDOE reporting guidelines, ensuring Form 9 expenses are fully supported by underlying financial records. To ensure accurate fund balances, audited reconciliation worksheets are used to validate beginning-of-year balances prior to Form 9 submission. Grant expenditures and remaining balances are reviewed monthly to ensure proper classification and alignment between expenses and recognized revenue. The School has also engaged directly with the IDOE Form 9 team for technical guidance. The Executive Director provides direct oversight and performs a final review of Form 9 submissions to ensure compliance with reporting guidelines. These corrective actions are designed to ensure accurate, reliable Form 9 reporting and to prevent recurrence of this deficiency in future reporting periods.
Condition: The Organization did not review period end reimbursement requests for costs that had been expended and requested in prior months. The lack of proper review resulted in the Organization charging duplicate costs of $95,294. Planned Corrective Action: The CFO maintains a payout tracker which...
Condition: The Organization did not review period end reimbursement requests for costs that had been expended and requested in prior months. The lack of proper review resulted in the Organization charging duplicate costs of $95,294. Planned Corrective Action: The CFO maintains a payout tracker which is updated every time a vendor payout is made and tracks that payment to the reimbursement request and the final payment by the pass-through agency. This process ensures that a payout is not included in a payout request multiple times. The Staff Accountant also maintains a tracker of all reimbursement requests to track with the program budgets and for inclusion in the MIP accounting system. In addition, new personnel are involved in the process with a more formal approval and authorization process implemented. The Organization’s staff has communicated these duplicate requests to the appropriate personnel at the granting agency and are coordinating the repayment of the excess funds as determined by the granting agency. Contact person responsible for corrective action: Tom Sakos, Chief Financial Officer, and Jenny Cuitiva, Accounting Manager Anticipated Completion Date: May 1, 2025 for implementing controls and November 30, 2025 for communicating with the granting agency.
Condition: YWCA Evanston/North Shore did not submit its fiscal year 2024 Data Collection Form and single audit reporting package to the Federal Audit Clearinghouse within the earlier of nine months following its fiscal year end, or 30 days after receipt of the auditors' report. Corrective Action Tak...
Condition: YWCA Evanston/North Shore did not submit its fiscal year 2024 Data Collection Form and single audit reporting package to the Federal Audit Clearinghouse within the earlier of nine months following its fiscal year end, or 30 days after receipt of the auditors' report. Corrective Action Taken or Planned: Management concurs and plans to submit the June 30, 2024 data collection form and single audit reporting package on or before December 31, 2025. Anticipated Date of Completion: December 31, 2025 Name of Contact Person: Laura Moorehead, Vice President of Finance and Operations Management Response: Management concurs with the finding.
Recommendation: We recommend the District have someone reviewing all Clics reports before they are submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensure the Clics...
Recommendation: We recommend the District have someone reviewing all Clics reports before they are submitted. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will implement policies to ensure the Clics reports are reviewed before submission. Name of the contact person responsible for corrective action: Lauren Syrup, Business Manager Planned completion date for corrective action plan: June 30, 2026
2025-001 - Non-Compliance with Timely Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Grantor: U.S. Department of Education Cluster Name: Student Financial Assistance Cluster Award Name: Federal Direct Loan Program Award Year: 6/1/2024- 5/31/2025 Award Number: ...
2025-001 - Non-Compliance with Timely Student Enrollment Change Submissions to the National Student Loan Data System (NSLDS) Grantor: U.S. Department of Education Cluster Name: Student Financial Assistance Cluster Award Name: Federal Direct Loan Program Award Year: 6/1/2024- 5/31/2025 Award Number: Not applicable Assistance Listing Number: 84.268 Corrective Action Plan The University acknowledges that the graduation reporting date was not adjusted to reflect changes in the academic calendar. This resulted in a compressed timeframe for both the NSC and the University to process and correct student records as needed. To address this, the University will revise its reporting schedule beginning with the Fall 2025 graduation date to ensure that status changes related to graduation are reported promptly. This adjustment will allow the NSC to verify data with the NSLDS and provide the University sufficient time to resolve any discrepancies. Additionally, the University will explore further options to enhance the timeliness of reporting student status changes and will strengthen its reconciliation process to ensure accurate and efficient communication of all status updates. Contact Person: Aida Shadfan, Vice President of Finance and University Controller Aida.shadfan@lmu.edu
Immediate Corrective Action Taken: • Fiscal Services reviewed the Title I allocations to confirm that no improper fiscal impact occurred as a result of the reporting discrepancy. • The district documented the finding and communicated the error internally to Fiscal Services and Educational Services s...
Immediate Corrective Action Taken: • Fiscal Services reviewed the Title I allocations to confirm that no improper fiscal impact occurred as a result of the reporting discrepancy. • The district documented the finding and communicated the error internally to Fiscal Services and Educational Services staff. • Roles and responsibilities for ConApp enrollment data review have been clarified to prevent future manual errors. Preventive Measures to Avoid Recurrence: 1. Dual Verification of ConApp Enrollment Data • The Accountant in Fiscal Services will now compare and confirm the ConApp enrollment counts to certified CALPADS Fall 1 data before submission and certification. • A second-level review by the Coordinator of Teaching and Learning Department certifying the ConApp. 2. Documentation & Recordkeeping • Any adjustments to pre-populated enrollment numbers will require written justification and supporting documentation (e.g., CALPADS reports, email confirmations). Responsible Parties: • Fiscal Services Accountant – Responsible for matching the ConApp enrollment counts to CALPADS Fall 1 and maintaining backup documentation. • Coordinator, Teaching and Learning Department – Support in verifying site-level data. Completion Date: • Immediate clarification and assignment of review responsibilities were completed in October 2025.
1. Finding 2025-001: a. We concur that material audit adjustments related to accounts receivable, revenue, prepaid assets, fixed assets, accounts payable and other current liabilities, and expenses were needed in order to present the financial statements in accordance with generally accepted account...
1. Finding 2025-001: a. We concur that material audit adjustments related to accounts receivable, revenue, prepaid assets, fixed assets, accounts payable and other current liabilities, and expenses were needed in order to present the financial statements in accordance with generally accepted accounting principles, and are in agreement with the recommendations to implement staff training on monthly and annual procedures over financial close and reporting. b. Action(s) Taken on the Finding: We have posted the adjustments recommended by the auditors. Management will conduct staff training on monthly and annual procedures over financial close and reporting by December 31, 2025.
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim used incomplete Z-Reports which resulted in the meal claim being submitted for less than it should have been. Not al...
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim used incomplete Z-Reports which resulted in the meal claim being submitted for less than it should have been. Not all dining locations had their final meal counts completed before the meal claim was submitted. The persons responsible for the corrective action are Aaron Burnett, the Food Service Director and Emily Kearney, the Business Manager. The anticipated completion date of the corrective action plan is immediate. The plan for monitoring adherence is the Food Service Director will ensure that all meal counts are final on the Z-Report before the claim requests are made.
Management agrees with the finding and will establish the recommended procedure outlined in the Schedule of Findings and Questioned Costs.
Management agrees with the finding and will establish the recommended procedure outlined in the Schedule of Findings and Questioned Costs.
Finding 2025-001: Education Stabilization Fund Special Reporting Procedures U.S. Department of Education Type of Finding: Control Pass-through agency: Michigan Department of Education Assistance Listing Numbers: 84.425U and 84.425V Award numbers: COVID-19 213713 2122 and COVID-19 221037 2324 Award y...
Finding 2025-001: Education Stabilization Fund Special Reporting Procedures U.S. Department of Education Type of Finding: Control Pass-through agency: Michigan Department of Education Assistance Listing Numbers: 84.425U and 84.425V Award numbers: COVID-19 213713 2122 and COVID-19 221037 2324 Award year end: September 30, 2024 Recommendation: The School District should create a process for gathering all requirements for special reporting under Uniform Guidance and the School District should prepare and submit the necessary special reports. Action taken: The Finance Director has created a process for gathering all requirements for special reporting under Uniform Guidance and for preparing and submitting the necessary special reports. Responsible Person and Anticipated Completion Date: Finance Director, January 2026. If the Michigan Department of Education has questions regarding this plan, please call Todd Hronek at (231) 788-7109.
Identifying Number: 2025-002 Audit Finding: Per the U.S. Department of Agriculture at 7 CFR 226.16(d)(4) and the Missouri Department of Health and Human Services, sponsoring organizations must conduct three monitoring review visits for each of their facilities and no more than six months may lapse b...
Identifying Number: 2025-002 Audit Finding: Per the U.S. Department of Agriculture at 7 CFR 226.16(d)(4) and the Missouri Department of Health and Human Services, sponsoring organizations must conduct three monitoring review visits for each of their facilities and no more than six months may lapse between monitoring visits for CACFP compliance. At least two of the three reviews must be unannounced. If a violation occurs during the visit, the sponsor must follow up with the facilities noted as having problems, and the follow-up visit must be conducted no less than one week after the initial finding, and the visit must be documented. Kansas City Public Schools did not perform the required three site visits per year within a six-month timeframe for five of the samples, and the supporting documentation provided for all six samples did not contain the total of participants in attendance during the meal service and the total number of meals claimed during the five consecutive days. Corrective Actions Taken or Planned: The District agrees with the finding. The District will implement and strengthen the following internal controls to ensure that all three required visits are accurately documented using the DHSS Site Visit Report by June 30, 2026: a. Training: Child Nutrition Services (CNS) will review and provide training to all supervisors and department leaders on DHSS Sponsor Review requirements. Person responsible for implementation: Katlyn Lanoue, Officer of Nutrition & Compliance b. SOP: CNS will utilize a central repository [CNSReporting@kcpublicschools.org] to streamline and time-stamp audit submissions. The original copy will be stored in a designated binder, and a digital copy will be retained in the CNS shared drive. Person responsible for implementation: Katlyn Lanoue, Officer of Nutrition & Compliance c. Monitoring: C CNS leaders, as designated by the Officer of Nutrition & Compliance, will conduct Supper audits during SY 2025–2026 in September, December, and March. Snack audits will be conducted in November, February, and April. Additional audits will be scheduled as necessary to ensure compliance with program requirements. Person responsible for implementation: Katlyn Lanoue, Officer of Nutrition & Compliance d. Reporting: As part of progress monitoring, at the end of each monitoring month, each applicable site will be reviewed to confirm completion & accuracy of a Sponsor Review. Person responsible for implementation: Katlyn Lanoue, Officer of Nutrition & Compliance
Identifying Number: 2005-003 Audit Finding: The District must demonstrate that costs incurred are allowable and internal controls are in place to record hours worked and required educational credentials for staffing levels. Hours per timesheet did not reconcile to hours per payroll system for servic...
Identifying Number: 2005-003 Audit Finding: The District must demonstrate that costs incurred are allowable and internal controls are in place to record hours worked and required educational credentials for staffing levels. Hours per timesheet did not reconcile to hours per payroll system for services rendered for four samples and one sample did not hold the required educator credentials for their staffing level. Corrective Actions Taken or Planned (Timesheets): The District agrees with the finding. The District will implement and strengthen the following internal controls to ensure that hours paid agree with time reported by June 30, 2026. a. Training – The District has fully implemented an electronic time keeping system for hourly employees. Training has been provided to all hourly staff, and supervisors responsible to review and approve time reported. Person responsible for implementation: Erin Thompson, Chief Finance Officer b. SOP: Business & Finance will continue training of employees and supervisors who review and approve time worked. Person responsible for implementation: Erin Thompson, Chief Finance Officer c. MonitoringLeadership will periodically meet with the Department Director to verify compliance. Person responsible for implementation: Dr. Latanya Franklin Chief Academic & Accountability Officer d. Reporting: On a district-wide basis, the Payroll Department will provide to management when adherence to procedures is not followed. Person responsible for implementation: Erin Thompson, Chief Finance Officer Corrective Actions Taken or Planned (Credentials): The District agrees with the funding. The District will implement and strengthen the following internal controls to ensure staff have the required educational credentials. a. SOP: Human Resources maintain a central repository documenting certification-related notifications Person responsible for implementation: Micah Enders, Executive Director Human Recourses b. Monitoring: On a quarterly basis, reviews will be conducted to track and update certification status. Person responsible for implementation: Micah Enders, Executive Director Human Recourses c. Reporting: As part of the quarterly monitoring, a quarterly compliance report will be submitted to management. Person responsible for implementation: Micah Enders, Executive Director Human Recourses
Assign supervisors responsibility for ,specific program related timeliness and compliance reports to improve accountability and avoid duplicative monitoring. Require supervisors to conduct and document monthly review of assigned reports and take corrective action as needed. Upon filling the vacant m...
Assign supervisors responsibility for ,specific program related timeliness and compliance reports to improve accountability and avoid duplicative monitoring. Require supervisors to conduct and document monthly review of assigned reports and take corrective action as needed. Upon filling the vacant manager position, require agency-wide review of supervisory reports. Incorporate handson exposure to Medical Assistance screens in VACMS during SNAP processing for new staff. Reinforce expectations for simultaneous processing of SNAP and Medical Assistance combination cases.
FINDING 2025-002: LATE RETURN OF TITLE IV FUNDS We concur with the finding and will implement procedures to ensure that, in the future, Title IV refunds are made in accordance with the federal regulations. The institution has implemented the following corrective measures: • A strengthened reconcilia...
FINDING 2025-002: LATE RETURN OF TITLE IV FUNDS We concur with the finding and will implement procedures to ensure that, in the future, Title IV refunds are made in accordance with the federal regulations. The institution has implemented the following corrective measures: • A strengthened reconciliation process has been established between the Student Accounts, Financial Services, and the Registrar’s departments. This process ensures that student enrollment changes are communicated in real time and that Title IV funds are returned promptly upon the institution’s determination of a withdrawal or cancellation. • Formalized timelines and internal monitoring controls have been created to ensure returns are completed within the regulatory timeframes. • Staff cross-training has been implemented to minimize the impact of personnel changes on the execution of Title IV responsibilities. • Periodic reviews will be conducted each term to verify timely processing of R2T4 calculations and returns.
Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: The auditors recommend that the District review its internal controls and implement a procedure to ensure all reports required under the grant have a designated reviewer that is different from the individual responsib...
Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: The auditors recommend that the District review its internal controls and implement a procedure to ensure all reports required under the grant have a designated reviewer that is different from the individual responsible for preparing, even when there are gaps of coverage in preparer and reviewer positions, and that the review and approval happens prior to submitting the reports to the granting agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District acknowledges the oversight in the separation of duties for preparation and reviewing of reports. Corrective measures have been implemented to require assignment of a preparer different from the approver before finalizing the report. The procedures for submitting monthly claims have been updated to include submitting the report to the Finance Director for review and approval prior to submission. The Finance Director has added a monthly calendar reminder to review claim submission reports as part of the internal control process. Name(s) of the contact person(s) responsible for corrective action: Steven Van Wyhe Planned completion date for corrective action plan: Immediately
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim had an incorrect subtotal of meals disbursed which resulted in the meal claim being submitted for less than it shoul...
This finding is due to the District not having the proper controls in place to prevent, detect, or correct an incorrect monthly meal claim. The month that had the incorrect meal claim had an incorrect subtotal of meals disbursed which resulted in the meal claim being submitted for less than it should have been. There is a chance that the claim was done for the correct amount, but the supporting documentation shows that the District claimed less than they were allowed to. The District is going to ensure that all totals are subtotaled correctly in the future and double checked before the claim request is made. The persons responsible for the corrective action are Jack Ledford, the Food Service Director and Katrina Bontekoe, the Business Manager. The anticipated completion date of the corrective action plan is immediate. The plan for monitoring adherence is the Food Service Director will ensure that funds requested for meal reimbursements agree to total meals served.
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