Corrective Action Plans

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The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
The Organization acknowledges its responsibility to complete required audits and will do so in a timely manner.
Name of Contact Person: Meagan O’Neal Management Response: As covered in 2025-001, several years of late audits have inevitably created a lag. With the challenges of a new finance director, Hurricane Helene, 600+ acres of wildfire due to blowdown from Helene, County staff across all departments have...
Name of Contact Person: Meagan O’Neal Management Response: As covered in 2025-001, several years of late audits have inevitably created a lag. With the challenges of a new finance director, Hurricane Helene, 600+ acres of wildfire due to blowdown from Helene, County staff across all departments have been maxed out, including Finance staff trying to balance regular duties, audit fieldwork and disaster related responsibilities. 180 Corrective Action Plan (continued) We completed the FY24 audit at the end of September 2025 and immediately began the FY25 process. With systems implemented over the last two years, we were able to complete all year-end reconciliations and FY25 audit fieldwork in approximately seven months. This has been the most efficient completion of an audit for Transylvania since FY19, reflecting the effectiveness of these changes. Procedures to reconcile subsidiary ledgers monthly have been implemented as an ongoing responsibility of the Finance Director and Accountant to minimize year-end adjustments. The Finance Director has also completed over 50 hours of CPE through the School of Government to support continued process improvement. Communication between the auditor and the County has remained open throughout this period of transition and disaster management. Proposed Completion Date: Immediately.
2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to ena...
2025-002 – Reporting Requirements Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. Action Taken: We have reviewed our project set up process and modified it to capture all federal projects upon initiation to enable accurate monitoring and tracking of accumulated expenditures on a fiscal year basis so we can timely determine if the Organization meets the threshold for a Single Audit.
2025-001 – Insufficient Documentation Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. The Organization should ensure it maintains documentation of its controls over allowable costs and reporting. Throughout the...
2025-001 – Insufficient Documentation Recommendation: The Organization should develop internal controls over reporting to ensure that it is meeting its reporting requirements. The Organization should ensure it maintains documentation of its controls over allowable costs and reporting. Throughout the year, the Organization should retain records of these operating effectively. Action Taken: We have reviewed our required documentation submission process and updated it to require capture of proof of documentation submission.
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-a...
Name of Contact Person: Brent Boren, Superintendent. Recommendation: We recommend that the District complete the required semi-annual certifications or time and effort logs for each employee who has time allocated to a grant. Corrective Action: The District will begin completing the necessary semi-annual certifications of time and effort distribution records. Proposed Completion Date: Fiscal year 2026.
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recogni...
2025-001: Internal Controls Over Disbursement Approvals Action Taken/Planned: The University acknowledges the control deficiencies identified related to disbursement approval documentation for federal awards. While policies requiring multi-level approvals are formally established, management recognizes that consistent execution and documentation of these controls were not fully adhered to in all instances. Management will formally re-communicate federal disbursement approval requirements to all relevant personnel, i ncluding principal investigators, department heads, and finance staff. This will include mandatory training sessions on federal compliance and approval protocols and distribution of updated written procedures outlining required approval l evels and documentation standards. To reduce reliance on manual processes, the University will configure the financial system/workilow to require multiple l evels of electronic approval prior to payment processing and restrict disbursement processing until all required a pprovals are completed and documented within the system. Management will implement ongoing monitoring procedures to ensure compliance, including monthly reviews of a sample of federal disbursements by the Controller's Office or Grants Accounting, quarterly compliance reporting to the CFO and senior leadership, and documentation of review results and corrective follow-up actions. Anticipated Completion Date/Date Completed: This will be implemented immediately with an anticipated completion date of June 30, 2026
Finding Number: 2025-001 Condition: While the System had controls over accumulating the data for inputs into the portal, it did not have an adequate control in place to ensure transactions subject to FFATA reporting were reviewed for completeness and accuracy upon submission. Planned Corrective Acti...
Finding Number: 2025-001 Condition: While the System had controls over accumulating the data for inputs into the portal, it did not have an adequate control in place to ensure transactions subject to FFATA reporting were reviewed for completeness and accuracy upon submission. Planned Corrective Action: Management concurs with this recommendation. MetroHealth will establish and maintain a log documenting FFATA report submission, with internal reviews of disclosures prior to submission Contact person responsible for corrective action: Michele Benos, Manager, Grants Accounting and Brynna Baird, Manager, Sponsored Programs Anticipated Completion Date: 05/31/2026
Finding 1224390 (2025-001)
Material Weakness 2025
Fraser
MN
Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: During testing instances were identified where statistical information submitted via the required annual reports were inaccurate. In addition, there was no documented review of the reports prior to submission. Resp...
Reporting Significant Deficiency in Internal Control over Compliance Finding Summary: During testing instances were identified where statistical information submitted via the required annual reports were inaccurate. In addition, there was no documented review of the reports prior to submission. Responsible Individuals: Lucas Kunach, Miranda Gilmore, Jim Olson Corrective Action Plan: We have designated a member of management to review the reporting materials prior to submission for accuracy and tie to detail support. Anticipated Completion Date: Already in place
Finding No. 2025-001 Significant Deficiency in Internal Control over Compliance, Other Matters Condition The Organization had revisions to the SEFA and management’s review and approval process did not detect the following errors that were identified during the audit procedures performed: - An incorr...
Finding No. 2025-001 Significant Deficiency in Internal Control over Compliance, Other Matters Condition The Organization had revisions to the SEFA and management’s review and approval process did not detect the following errors that were identified during the audit procedures performed: - An incorrect de minimis indirect cost rate was used and charged to a federal award. - Approximately $65,000 of federal expenditures were omitted from the initial SEFA. - Subrecipient costs from the prior year were charged to the current year due to incomplete accruals in the prior year. As a result, the SEFA was not complete or accurate prior to submission for audit. Planned Corrective Action: Management concurs with the findings and related recommendations. While the Organization completed its federal award activity in May 2025 and does not currently anticipate additional federal award activity, it recognizes the importance of compliance with grant reporting requirements, including the accurate preparation of the Schedule of Expenditures of Federal Awards (SEFA). In response to this finding, the Organization has taken the following corrective actions: Indirect Cost Rate: Updated our grant setup checklist to ensure the correct de minimis indirect cost rate is applied. The Organization has initiated and is currently processing the repayment of the overcharged indirect costs to the primary awardee. SEFA Completeness & Year-End Cutoff: Implemented a formal year-end SEFA reconciliation procedure. This includes a secondary review by the Director, Accounting to cross-reference general ledger federal expenditures against grant award agreements and to verify that all subrecipient accruals are recorded in the proper fiscal period. These improvements in our review and approval functions are designed to prevent future reporting omissions and ensure timely, accurate SEFA preparation should the Organization be subject to Single Audit requirements in the future. Anticipated Completion Date: July 31, 2026 Name of Contact Person: Melinda O’Leary, Chief Financial Officer & Vice President If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call Melinda O’Leary, Chief Financial Officer & Vice President at 571-483-1324.
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in Decem...
After the audit report of 2023-2024 the Platte County Treasurer has developed a procedure to record the federal awards by project and by department. The spreadsheet shall provide the reporting information of federal awards received and the expenditures processed. Procedures were implemented in December 2025.
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit ...
Medical Assistance – Assistance Listing No. 93.778 Type of Finding: Significant Deficiency Recommendation: We recommend the County design controls to ensure an adequate review process is in place to ensure all verification procedures are accurately documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will work with program managers to improve eligibility verification documentation. Name of the contact person responsible for corrective action: Heather Goodwin Planned completion date for corrective action plan: December 31, 2026
The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the ...
The City recently went through implementation of a new financial software, which has allowed for development of some documentation and assignment of roles and responsibilities with the new system. Staff will make efforts to enhance and update this documentation to provide specific details about the annual financial reporting. The City has also struggled with vacancies in key positions, as well as challenges in completing successful recruitments to fill the positions; staff are exploring options for third party assistance with financial reporting functions.
Management concurs with this finding and appreciates the opportunity to provide additional context regarding the circumstances that contributed to the delayed audit reporting. During the audit period, Ability1st experienced an unprecedented transition in its financial management infrastructure. The ...
Management concurs with this finding and appreciates the opportunity to provide additional context regarding the circumstances that contributed to the delayed audit reporting. During the audit period, Ability1st experienced an unprecedented transition in its financial management infrastructure. The Organization unexpectedly lost its long-term accounting support, engaged multiple accounting providers during the transition period, and ultimately retained a new accounting firm while simultaneously completing two fiscal years of audit activity. Despite these significant administrative challenges, the Organization continued uninterrupted delivery of critical independent living, housing, mental health, disaster recovery, youth transition, and accessibility services throughout its seven-county service area. Staff remained focused on meeting contractual obligations and serving individuals with disabilities while rebuilding financial systems. Since that time, Ability1st has implemented substantial improvements, including: • engaging a permanent external accounting firm; • strengthening month-end closing procedures; • improving reconciliations and financial reporting; • establishing regular fiscal monitoring meetings; • improving coordination among management, accounting personnel, and auditors; • developing standardized financial schedules for grant reporting; • improving documentation supporting accounting transactions; and • implementing earlier audit preparation timelines. Management believes these improvements have significantly strengthened the Organization's financial reporting process and will greatly improve future compliance with federal reporting deadlines. Responsible Official: Executive Director Implementation Date: Substantially complete; ongoing monitoring throughout FY2026 and beyond.
Finding type: Significant deficiency. Federal award: 21.027 Coronavirus State and Local Fiscal Recovery Funds and 14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants. Passthrough organization: 21.027 (Vermont Agency of Commerce and Community Development, Town ...
Finding type: Significant deficiency. Federal award: 21.027 Coronavirus State and Local Fiscal Recovery Funds and 14.251 Economic Development Initiative, Community Project Funding, and Miscellaneous Grants. Passthrough organization: 21.027 (Vermont Agency of Commerce and Community Development, Town of Windsor, and Vermont Housing & Conservation Board); 14.251 (Vermont Housing & Conservation Board). Condition: Organization's draft schedule of expendiures of federal awards was missing certain awards. Management concurrence: Management concurs with this finding. Corrective action plan: The proper recording of all grants passed through WWHT will be identified upon the signing of the grant agreement to ensure which party is responsible for reporting of Federal funds. The SEFA will be created after confirmation that all Federal grants have been recorded. Name of contact person: Sandy Garland, Finance Director. Projected completion date: December 31, 2026.
Corrective Action Plan Finding No: 2025-001 Condition: During the audit, our procedures indicated that capital expenditures were primarily reviewed at an individual invoice level to determine whether they exceeded the capitalization threshold. We also noted that communication between the City’s fina...
Corrective Action Plan Finding No: 2025-001 Condition: During the audit, our procedures indicated that capital expenditures were primarily reviewed at an individual invoice level to determine whether they exceeded the capitalization threshold. We also noted that communication between the City’s finance department and engineers or other City staff responsible for managing grants and capital projects is not consistently formalized. Management’s Plan: Management is committed to strengthening coordination and oversight of the City’s grant-funded capital projects through centralizing project tracking via grant/project management software, implementing rigorous compliance monitoring, and improving intradepartmental communication. By centralizing our grants through the course of their lifespans, we intend to better track the progress of our grant projects and budgets and with the inclusion of grant document storage, to enhance compliance across departments. We will also designate coordination teams consisting of liaisons across administration, finance, engineering, public works, and grant writers to ensure internal alignment. Anticipated Date of Completion: 4/30/2027 Name of Contact Person: Cheri Grieco, Finance Director
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating...
Finding 2025-001 – Internal control deficiency over Activities Allowed or Unallowed, Allowable Costs/Cost Principles, Period of Performance, Reporting, and Special Tests and Provisions. Condition: Management did not design effective internal controls to retain documentation to evidence the operating effectiveness of the internal controls over the project and related expenses submitted to FEMA for reimbursement. Resolution: Management will develop and implement additional internal controls to ensure that adequate documentation is retained to evidence the design and operating effectiveness of controls over FEMA-related expenditures. These internal controls will be designed to ensure that expenses included in FEMA grant applications are complete, accurate, and allowable in accordance with program requirements. Specifically, management will implement a reconciliation process comparing detailed application expenses to the corresponding final paid invoices or payroll expenditures. As part of this process, each expense will be reviewed and annotated to confirm its allowability under FEMA guidelines. The reconciliation will be subject to review and approval by the Cottage Health Vice President of Finance prior to submission of the FEMA application. Evidence of this review and approval will be formally documented and retained. Contact Person: Lawrence Thomas, Vice President of Finance Anticipated Completion Date: December 31, 2026 (The entity has not incurred expenditures under the FEMA program subsequent to the period under audit. Accordingly, the corrective actions described above will be implemented on a prospective basis, contingent upon the entity incurring future FEMA-related expenditures).
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP progr...
Current policy and precedure in place will be followed. The Executive Director of Nutrition Services and the Food Compliance Officer will review Summer Food Service Program sited and serving windows prior to the start of the program as well as reinbursements prior to the completion of the SFSP program period each year.
View of Responsible Officials and Planned Corrective Actions: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner moving forward.
View of Responsible Officials and Planned Corrective Actions: We plan on verifying that the submission to the Federal Audit Clearinghouse is completed in a timely manner moving forward.
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations re...
Allegations of Fraud Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action HealthXP manages fraud risk through a combination of preventative, detective, and monitoring controls, and reinforces its expectations regarding ethical behavior through training and communications. HealthXP proactively reports and investigates allegations of fraud and raises awareness of the actions to be taken when fraud is suspected. The HealthXP Global Internal Audit and Investigations team shares lessons learned from its work. Given the challenging operating environments in which HealthXP implements its programs, fraud remains an ongoing risk that HealthXP actively monitors, investigates, and mitigates.
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit wil...
Internal Control over Compliance and Compliance with Activities Allowed or Unallowed and Allowable Costs and Cost Principles Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appropriate staff and reiterated in training to ensure that adequate attention and guidance is provided on recording expenses within the correct accounting period. HealthXP delivers in person training to its global finance and program staff and will continue to offer training during 2026 to address such issues.
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporti...
Action To Be Taken: To ensure federal compliance for the Corona virus Relief Fund (ALN 21.019), the organization will implement a secondary review process. After the Executive Director prepares the federal financial reports, a designated member of the Board Finance Committee will review the supporting documentation (General Ledger and invoices) for accuracy before the report is submitted to the granting agency.•Responsible Party: Executive Director and Board Finance Committee. Anticipated Completion Date: February 28, 2026.
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management ...
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management review. In addition, the Authority should train relevant personnel on these policies and perform ongoing monitoring to confirm that federal expenditures are reviewed and documented in accordance with applicable grant requirements. Management’s Response: Management acknowledges the recommendation. The Authority will evaluate its existing processes and controls over the use of federal funds and consider whether additional written guidance and/or enhancements to current procedures are warranted to address, as applicable, cost allowability, procurement requirements, approval responsibilities, documentation and record retention, subrecipient or vendor oversight, reimbursement request preparation and review, and periodic management review of federal expenditures. Based on the results of this evaluation, the Authority will communicate any clarifications, reminders, and/or targeted training to relevant personnel involved in administering, approving, recording, or requesting reimbursement for federal expenditures, as deemed necessary. Management will also consider whether additional monitoring activities are warranted to help confirm that federal expenditures are reviewed, approved, and supported by appropriate documentation in accordance with applicable grant requirements.
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S Department of Health and Human Services 2025-001 Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: We recommend that there is an appropriate reviewer of the WIMCR cost report and CLTS annual reconciliation. Explanation of disagreement with au...
FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S Department of Health and Human Services 2025-001 Medicaid Cluster – Assistance Listing No. 93.778 Recommendation: We recommend that there is an appropriate reviewer of the WIMCR cost report and CLTS annual reconciliation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will evaluate their current processes and procedures during staffing transitions in fiscal year 2025 to ensure that proper review of the WIMCR cost report and the CLTS annual reconciliation. Name(s) of the contact person(s) responsible for corrective action: Hollie Viestenz and Tim Marzu Planned completion date for corrective action plan: December 31, 2026 If the State of Wisconsin has questions regarding this plan, please call Hollie Viestenz at (715) 732-7422.
Finding 2025-001 Capital Asset Accounting and Reporting-The town has a fixed asset file where we have researched recent fixed asset purchases. The cost benefit of researching costs as far back as 1913 is cost effective for all capital purchases. We will continue to work on updating the file for new ...
Finding 2025-001 Capital Asset Accounting and Reporting-The town has a fixed asset file where we have researched recent fixed asset purchases. The cost benefit of researching costs as far back as 1913 is cost effective for all capital purchases. We will continue to work on updating the file for new purchases so that the fixed asset value can be confirmed in the future.
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsib...
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Hospital will establish an annual audit readiness timeline working backward from the Uniform Guidance submission deadline (the earlier of thirty (30) calendar days after receipt of the auditors’ reports or nine months after the end of the audit period, June 30). The timeline will include target dates for the completion of year-end closing procedures, the delivery of auditor-requested schedules and supporting documentation, audit fieldwork, review of the draft report, and submission of the reporting package and Data Collection Form to the Federal Audit Clearinghouse in advance of the deadline. 2. Monthly closing discipline will be maintained throughout the fiscal year so that year-end balances, account reconciliations (including patient accounts receivable aging, the allowance for credit losses, and grants receivable), and audit support schedules are substantially complete at year end and available for timely delivery to the auditors. 3. The Chief Financial Officer will monitor the status of the audit timeline monthly beginning in October of each fiscal year, and any delay against the established milestones will require a documented recovery plan to return the process to schedule. 4. The Single Audit Reporting Package and Data Collection Form for the year ended September 30, 2025 will be submitted to the Federal Audit Clearinghouse immediately upon issuance of the final audit report. Anticipated Completion Date October 31, 2026
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