Corrective Action Plans

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National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with au...
National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review regulations to ensure that staff understands reporting requirements of the NSLDS. Name(s) of the contact person(s) responsible for corrective action: Financial Aid Director Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended Se...
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2025 Finding Reference Number: 2025-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of payroll expenditures to support activities allowed or unallowed and allowable costs/cost principles related to payroll expenditures reimbursed for the project worksheet. Corrective Action Plan: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late fiscal year 2022 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: revised the timekeeping policy to clarify employee and manager responsibilities, modified “failure to comply” provisions, deployed educational programs for both management and staff, reviewed/improved Kronos and UKG Pro Time and Attendance system automated notifications, and training resources have been available to management and staff via our Scripps intranet site. Leadership monitors policy compliance by individual employee and managers via systemwide reporting on a biweekly basis. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: Completed in fiscal year 2022. As the expenditures in the project worksheet were incurred from the beginning of the COVID-19 pandemic, the corrective action plan put in place during 2022 could not previously remediate the project; however, all payroll expenditures incurred after the end of fiscal year 2022 have these corrective actions in place.
Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We fou...
Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We found another instance of a student’s information not reported timely, however management did eventually detect and correct the error outside the required timeframe. Corrective Action planned: Management agrees and has implemented necessary procedures/controls to ensure the College is in compliance with enrollment requirements. Management has corrected the student’s change status not previously reported. Name(s) of Contact Person(s) Responsible for Corrective Action: {Jennifer Young, Director of Financial Aid and Edgewood Central, and Katelyn Peters, Student Service Specialist.} Anticipated Completion Date: Has already began as of the audit. Staff turnover occurred, have replaced the Student Service Specialist position - now have second point on NSC reporting.
Finding 1201454 (2025-002)
Material Weakness 2025
Finding: The change in student status for 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) timely when the student withdrew or changed status during the fiscal year. The change in student status for an additional 2 of 25 students tested was not reported to th...
Finding: The change in student status for 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) timely when the student withdrew or changed status during the fiscal year. The change in student status for an additional 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) accurately when the student graduated during the fiscal year. Explanation for Finding: The Registrar's data collection was not reviewed after submission to National Student Clearinghouse (NSC) by another responsible individual to ascertain the accuracy of graduate, withdrawal and status change dates of students being reported. The College received a response from NSC of no errors, therefore the withdrawn student in question was not reported in a timely manner. Corrective Actions Taken or Planned: The Registrar will run a report on the 15th of the month to verify any students that have exited the institution from the prior two submission periods (last two months) have valid exit dates in the National Student Loan Clearinghouse. The Assistant Registrar will review the work of the Registrar and verify any discrepancies between Coe’s records and those stored in the National Student Clearinghouse for correction. The Registrar will then ensure timely and accurate submission of student records from the Clearinghouse to NSLDS after all the data has been reviewed. When there are staffing changes in the future that impact a person on the staff in the Office of the Registrar who has been responsible for the verification and reporting of valid exit dates in the National Student Loan Clearinghouse, it is the responsibility of the Registrar, unless the Registrar has left, in which case it shall be the responsibility of the Assistant Registrar, to appoint another specific staff member in the Office of the Registrar to take the actions required by the written policy for the verification and reporting of this data. Persons Responsible and Completion Date: Registrar, Assistant Registrar. The actions outlined above has been added to the Withdrawal & Exit Procedure (NSC-NSLDS) as of 10/28/2025
Name of Contact Person: Amanda John, Executive Director. Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately.
Name of Contact Person: Amanda John, Executive Director. Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately.
Program: Congressionally Recommended Awards / HOME Investment Partnerships Program / Homeland Security Grant Program / Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 16.753 / 14.239 / 97.067 / 93.323 Federal Grantor: U.S. Department of Justic...
Program: Congressionally Recommended Awards / HOME Investment Partnerships Program / Homeland Security Grant Program / Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 16.753 / 14.239 / 97.067 / 93.323 Federal Grantor: U.S. Department of Justice / U.S. Department of Housing and Urban Development / U.S. Department of Homeland Security / U.S. Department of Health and Human Services Award No. and Year: Multiple Compliance Requirements: Other – Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of expenditures of Federal awards Type of Finding: Material Weakness in Internal Control Over Compliance Criteria: Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) states that the auditee (the County) must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements, which must include the total federal awards expended as determined in accordance with §200.502. §200.331 of the Uniform Guidance states the County is responsible for making case-by-case determinations to determine whether the entity receiving the Federal funds is a subrecipient. In addition, §200.303 of the Uniform Guidance states that the County must establish and maintain effective internal control over the federal awards, including controls over the accuracy of program information and expenditure amounts. Condition: During our audit procedures performed over the SEFA we noted the following: • The Sheriff-Coroner Department did not properly identify the amount expended for the Congressionally Recommended Awards, AL No. 16.753. The expenditures reported by the Department were overstated by $2,638,516. • The Orange County Community Resources Department did not properly identify the amount of Federal funding passed through to subrecipients for the HOME Investment Partnerships Program, AL No. 14.239. The amount passed through to subrecipients reported by the Department was overstated by $4,500,624. • The Sheriff-Coroner Department did not properly identify the amounts expended for the Homeland Security Grant Program, AL No. 97.067. The expenditures reported by the Department were overstated by $715,489. • The Orange County Health Care Agency (HCA) did not properly identify the amount expended for the Epidemiology and Laboratory Capacity for Infectious Disease program, AL No. 93.323. The expenditures reported by the Agency were overstated by $486,000. Cause: As a result, the County lacked adequate internal controls to ensure the SEFA is completely and accurately stated. Specifically, the County’s processes for recording and tracking expenditures of Federal awards are not designed so that expenditures are identified when incurred. In addition, the County’s processes for identifying and reporting subrecipients are not designed to ensure appropriate reporting on the SEFA. Effect: Adjustments to the SEFA were required. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures and amounts passed through to subrecipients were reconciled to the supporting records. Repeat Finding from Prior Years: No. Recommendation: The County, including all its reporting departments, should follow existing policies, procedures and internal controls to ensure all expenditures and amounts passed through to subrecipients are accurately tracked and reported on the SEFA. Personnel knowledgeable of federal expenditures should review amounts coded to federal programs for completeness and accuracy. The SEFA should be prepared and reviewed in a timely manner and reconciled to underlying records as well as the basic financial statements. Management Response and Corrective Action Plan: Health Care Agency: 1. Person Responsible: David Santalahti, HCA Claims & Financial Reporting Manager 2. Corrective action plan: HCA Accounting will review and enhance its procedures and training for analysis and tracking federal award expenditures to ensure expenditures are reported in the appropriate fiscal year period. 3. Anticipated Implementation date: June 30, 2026 Orange County Community Resources: 1. Person Responsible: Bill Malohn, OCCR Accounting Manager 2. Corrective action plan: Concur. OCCR has established policies and internal controls to ensure all expenditures and amounts passed through to subrecipients are accurately tracked and reported on the SEFA. Appropriate personnel review amounts coded to federal programs for completeness and accuracy. We prepare and review the SEFA in a timely manner and reconcile to underlying records as well as the basic financial statements. In this particular situation, we miscategorized one provider as a subrecipient and reported the related funding as such on the SEFA. This oversight had no impact on the total amount we reported on the SEFA. We will be sure to follow our policies and procedures to ensure accurate SEFA reporting. 3. Anticipated Implementation date: February 2, 2026 Sheriff-Coroner: 1. Person Responsible: Monique Vansuch, Fiscal Administrator 2. Corrective action plan: The Sheriff-Coroner Department acknowledges the finding and recognized federal grant expenditure incurred is defined as when expenditures are delivered and/or services are performed rather than when the expenditures are paid. We will strengthen the internal controls to ensure grant expenditures are reported per the Uniform Guidance. 3. Anticipated Implementation date: June 30, 2026
Program: Housing Voucher Cluster Federal Financial Assistance Listing Number: 14.871 / 14.879 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: Multiple Compliance Requirements: Special Tests and Provisions – HQS Enforcement Type of Finding: Significant Deficiency...
Program: Housing Voucher Cluster Federal Financial Assistance Listing Number: 14.871 / 14.879 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: Multiple Compliance Requirements: Special Tests and Provisions – HQS Enforcement Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: The 2025 OMB Compliance Supplement requires that for dwellings under Housing Assistance Payment (HAP) contracts that fail a Housing Quality Standards (HQS) inspection, the County must enforce HQS requirements. Specifically, upon notification that a unit has failed HQS, the County must inspect the unit within 15 days to confirm the deficiency and notify the owner if the deficiency is confirmed. Once notified, the owner is required to make the necessary repairs within the prescribed time frame. If the owner does not correct the cited HQS deficiencies within the specified correction period, the County must stop (abate) HAPs beginning no later than the first of the month following the specified correction period or must terminate the HAP contract. Condition: For one sample selected for testing, the County did not timely enforce HQS requirements. Cause: The cause of the finding was an administrative oversight that resulted in delays in issuing the final inspection notice following a missed inspection appointment. The County’s existing procedures did not adequately ensure timely follow-up and escalation when an inspection resulted in a noshow. Effect: Because the required inspection and notification were not completed timely, the County did not fully comply with the HQS enforcement requirements. This delay increased the risk that housing assistance payments could continue for a unit that did not meet HUD’s minimum housing quality standards, potentially affecting program compliance and participant health and safety. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of sixty (60) out of a total population of 1,029 instances of failed HQS were selected. The condition noted above was identified during our procedures related to special tests and provisions – HQS enforcement. Repeat Finding from Prior Years: No. Recommendation: We recommend the County strengthen its HQS enforcement procedures by implementing controls to ensure timely follow-up on failed inspections, including missed appointments. Such controls may include automated tracking of inspection deadlines, supervisory review of no-show appointments, and escalation procedures to ensure owners are notified within required time frames. Management Response and Corrective Action Plan: 1. Person Responsible: Linda Tarzjani, Leasing Manager 2. Corrective action plan: Concur. We will strengthen our HQS enforcement procedures by implementing controls to ensure timely follow-up on failed inspections, including missed appointments. In doing so we will consider automated tracking of inspection deadlines, supervisory review of noshow appointments, and escalation procedures to ensure owners are notified within required time frames. 3. Anticipated Implementation date: February 1, 2026
Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weaknes...
Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Instance of Noncompliance Criteria: CFR Appendix A to Part 170I(a)(2), Reporting Requirements, states the recipient must report each subaward to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was issued. Condition: During our testing of the County’s compliance with reporting requirements, we noted the County did not submit the required subaward data to FSRS. Cause: The department was unaware of this compliance requirement. Effect: Reports were not submitted to FSRS in accordance with the reporting requirements per Appendix A to Part 170I(a)(2). Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling : We identified that the FFATA reporting was not completed as required by 2 CFR Part 170 for the following instances: (Refer to Chart/Table to Finding 2025-003) Repeat Finding from Prior Years: No. Recommendation: We recommend that the County adhere to their policies and procedures in accordance with 2 CFR Appendix A to Part 170I(a)(2). Management Response and Corrective Action Plan: 1. Person Responsible: Francisco Padilla, Community Development Analyst 2. Corrective action plan: Concur. We will adhere to our policies and procedures to ensure reports are submitted to FSRS in accordance with 2 CFR Appendix A to Part 170I(a)(2). 3. Anticipated Implementation date: April 30, 2026
The City has commenced the preparation of the FFATA report and is working toward full compliance with reporting requirements. The corrective action is expected to be fully implemented by Fiscal Year 2025/2026. The contact persons for this corrective action are Sabrina Chavez, Director of Public Serv...
The City has commenced the preparation of the FFATA report and is working toward full compliance with reporting requirements. The corrective action is expected to be fully implemented by Fiscal Year 2025/2026. The contact persons for this corrective action are Sabrina Chavez, Director of Public Services, and Martin E. Martinez, Principal Management Analyst, of the City of Perris.
Finding: 2025-005 Name of Contact Person: Linda Higuet, Interim Finance Director Corrective Action: Management will make organizational changes as needed to ensure that each program is self-sustaining. Upper level management will obtain training for allowable costs/cost principles and activities all...
Finding: 2025-005 Name of Contact Person: Linda Higuet, Interim Finance Director Corrective Action: Management will make organizational changes as needed to ensure that each program is self-sustaining. Upper level management will obtain training for allowable costs/cost principles and activities allowed/unallowed under the Uniform Guidance and specific program regulations. Additionally, all upper level management will obtain training for financial and program specific reporting. Financial reports will be reviewed monthly by program directors, and program specific reporting will undergo monthly review by program directors. Proposed Completion Date: As soon as possible.
Corrective Action Plan – Management concurs with this finding. The exceptions resulted from two distinct scenarios: 1) An official withdrawal processed manually outside the standardized workflow. 2) An unofficial withdrawal triggered by a grade change submitted after the final grade deadline. In Fal...
Corrective Action Plan – Management concurs with this finding. The exceptions resulted from two distinct scenarios: 1) An official withdrawal processed manually outside the standardized workflow. 2) An unofficial withdrawal triggered by a grade change submitted after the final grade deadline. In Fall 2024, an undergraduate student’s official withdrawal was completed late in the semester. The Dean requested a Torero Hub Counselor to manually remove the course, bypassing the standardized workflow. While the Counselor notified the Registrar’s Office, the Office of Financial Aid was not included in the communication chain. To address this gap, the Office of Financial Aid will implement a biweekly report to monitor and verify any changes to student withdrawal statuses that fall outside the automated workflow. Management believes this enhancement will effectively prevent similar errors in the future. The second exception involved a Professional and Continuing Education (PCE) student. After the final grade submission deadline, the instructor updated the student’s grade to an ‘F’, which retroactively classified the student as an unofficial withdrawal. This change occurred after the Office of Financial Aid had already run the final Fall 2024 unofficial withdrawal report. PCE has been notified that grade changes are not permitted after the final grade deadline. Additionally, the Office of Financial Aid will now run the unofficial withdrawal report biweekly beyond the final grade due date to identify and verify any late changes to student withdrawal statuses. Management believes these measures will mitigate the risk of future occurrences. Completion date: September 2025 Persons responsible: Kellie Nehring, Director of Financial Aid and Diana Hannasch-Haag, Director of Retention – Online Degree Programs
Finding No. 2025-007 ALN No. 11.419 Program Title: Hawaii Coastal Zone Management Program Grant Award No.: NA22NOS4190022 NA23NOS4190139 NA24NOSX419C0023 NA22NOS4190065 Condition Accuity noted that the State did not submit FFATA reports for most of the active grant agreements open for the program. C...
Finding No. 2025-007 ALN No. 11.419 Program Title: Hawaii Coastal Zone Management Program Grant Award No.: NA22NOS4190022 NA23NOS4190139 NA24NOSX419C0023 NA22NOS4190065 Condition Accuity noted that the State did not submit FFATA reports for most of the active grant agreements open for the program. Corrective Action Plan DBEDT OPSD will strengthen internal controls over subaward identification and reporting. This will include hiring and training staff to support federal grant administration and management-level review of all subawards to ensure FFATA reporting is complete and timely. Person Responsible Mary Alice Evans, Director of Office of Planning and Sustainable Development Anticipated Date of Completion April 1, 2026
Condition: Northeastern Illinois University (University) did not report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for the Higher Education Institutional Aid grants. Planned Corrective Action: The University wil...
Condition: Northeastern Illinois University (University) did not report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) for the Higher Education Institutional Aid grants. Planned Corrective Action: The University will review applicable guidelines and assign the responsibility to the appropriate office. Contact person responsible for corrective action: Jannica Henry, Controller’s Office Anticipated Completion Date: 6/30/2026
Condition: Northeastern Illinois University (University) did not pay reimbursements within 30 days for certain subrecipients in the Research and Development Cluster. Planned Corrective Action: The University will explore procedures to address this issue. Contact person responsible for corrective act...
Condition: Northeastern Illinois University (University) did not pay reimbursements within 30 days for certain subrecipients in the Research and Development Cluster. Planned Corrective Action: The University will explore procedures to address this issue. Contact person responsible for corrective action: Jannica Henry, Controller’s Office Anticipated Completion Date: 6/30/2026
Management agrees with the finding. Although reports were submitted timely, certain required programmatic data (units completed) was not included, resulting in unsupported expenditures and disallowed costs. This reflects a breakdown in coordination between program and finance, and the absence of a s...
Management agrees with the finding. Although reports were submitted timely, certain required programmatic data (units completed) was not included, resulting in unsupported expenditures and disallowed costs. This reflects a breakdown in coordination between program and finance, and the absence of a structured process to ensure complete and accurate reporting prior to submission. The root cause is lack of defined roles, standardized workflows, and formal review controls governing integration of programmatic and financial reporting. The corrective actions are: (1) Define roles and responsibilities across program, finance, and Controller; (2) Implement standardized reporting checklists by program; (3) Establish pre-submission review and signoff process with cross-functional validation; (4) Formalize handoffs between program and finance, including timelines and escalation protocols; and (5) Provide training on grant reporting requirements and compliance. The parties responsible are the CFAO, Director of Finance, and Program Leadership. We expect to complete initial implementation in 30 days and full implementation in 120 days.
Management Response and Corrective Action Plan City’s Response: The City concurs with the recommendation. Corrective Action Plan: The City’s finance department has taken over reporting duties and has ensured all reporting related to CSLFRF is done on a timely basis. Planned Implementation Date: Reso...
Management Response and Corrective Action Plan City’s Response: The City concurs with the recommendation. Corrective Action Plan: The City’s finance department has taken over reporting duties and has ensured all reporting related to CSLFRF is done on a timely basis. Planned Implementation Date: Resolved, implemented in December of 2024. Responsible Person: Director of Finance
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of do...
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of documentation supporting grant deliverables and required progress reports. The procedures will include, at a minimum, the following: • Define required documentation, storage location, staff responsibilities, and retention requirements. • Require all supporting documentation to be maintained in a designated centralized repository and ensure documentation is complete, organized, and readily accessible for review. • Detail the steps during staff transitions that new staff must follow to access, maintain, and update grant-related documentation, ensuring consistency and completeness of records. VPDCP will perform periodic reviews of the centralized repository and formally document and sign-off on the reviews to verify that required documentation is maintained. 3. Anticipated implementation date: June 19, 2026
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement p...
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement procedures for review and reconciliation of lunch count data with claims reports in accordance with the Uniform Guidance.
Condition: The Organization paid out management fees in excess of allowable amount per the Management Agent’s Certification agreement. Planned Corrective Action: The excess management fees will be reversed out of the Corporation for the year ended December 31, 2026, thus adjusting the fees to the al...
Condition: The Organization paid out management fees in excess of allowable amount per the Management Agent’s Certification agreement. Planned Corrective Action: The excess management fees will be reversed out of the Corporation for the year ended December 31, 2026, thus adjusting the fees to the allowable amount. Management acknowledges noncompliance in the current year and is currently reviewing internal controls related to management fees going forward. Contact person responsible for corrective action: Michael McMillan, Director of Finance / President Anticipated Completion Date: 12/31/2026
Response to Finding 2025-001 Timely Filing of SF-425, Federal Financial Report (FFR) (Federal Award Finding) An SF-425 annual report, covering the period ending September 30th, is due within 90 days of the reporting period for each open Airport Improvement Program (AIP) that receives funding from th...
Response to Finding 2025-001 Timely Filing of SF-425, Federal Financial Report (FFR) (Federal Award Finding) An SF-425 annual report, covering the period ending September 30th, is due within 90 days of the reporting period for each open Airport Improvement Program (AIP) that receives funding from the Federal Aviation Administration (FAA). Prior to submission, Talbot County ensures the accuracy of each financial report by reconciling amounts between various sources, including vendor invoices, SF-271 forms, Talbot County’s ERP/accounting system, and the FAA’s web-based electronic invoicing and grant payment portal system (Delphi). While this multi-step verification process supports the accuracy of financial reports, it remains highly manual and is constrained by increasing workloads, limited resources, and a lean workforce. This challenge has intensified and become more apparent over the last few years due to the recent surge in the number of open and active AIPs. Further compounding the issue were delayed responses from the FAA and the Federal government shutdown that occurred from October 1, 2025 to November 12, 2025. During this 43-day period, Talbot County staff were unable to effectively communicate with the FAA to verify essential financial data necessary to complete the SF-425 reports. Auditee’s Corrective Action Plan: Talbot County’s corrective action plan focuses on evaluating the current workflow to identify bottlenecks (points of constraint) and opportunities to leverage technology and improve efficiency. Ultimately, a clearly defined grant process will be implemented that establishes roles, responsibilities, and expectations for staff. Increasing the frequency of grant tracking and reconciliation activities throughout the year will be a key component, as this will mitigate the potential for reporting delays and minimize the burden on staff when SF- 425 reports are due subsequent to the Federal fiscal year ending each September 30th. The improved grant procedures will expand the role of Talbot County’s Finance Office and allow for the consistent timely filing of SF-425 reports. This is an evolving process that will show marked improvement for the 2026 Single Audit. Sincerely, Martha Darling Sparks Finance Director
Finding 1191734 (2025-003)
Material Weakness 2025
Finding 2025-003 Significant Deficiency Medical Billing Revenue Recognition Internal Controls Finding Summary: Regular reconciliation between the medical billing system and the accounting system was not conducted throughout the year, leading to a significant discrepancy between the end of year trail...
Finding 2025-003 Significant Deficiency Medical Billing Revenue Recognition Internal Controls Finding Summary: Regular reconciliation between the medical billing system and the accounting system was not conducted throughout the year, leading to a significant discrepancy between the end of year trail balance and the billing software report. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We are developing formal procedures to include monthly reconciliation between accounting and billing systems. Anticipated Completion Date: March 31, 2026
Finding 1191716 (2025-002)
Material Weakness 2025
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting ...
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting workpapers. Therefore, the CECL adjustment was not recorded at the beginning of the audit and required multiple attempts before a reasonable estimate was determined and recorded. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We will capture detailed documentation of the CECL calculation process, including training and detailed written procedures. Anticipated Completion Date: January 1, 2026
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and document...
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and documenting submission. Management expects these procedures to be implemented beginning in the next reporting cycle. Management has subsequently completed and submitted all of the required performance reports to remedy the identified deficiency.
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvement...
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2026
Condition: Of the 40 students selected for enrollment reporting, the College did not update the student enrollment information for 3 students accurately. Planned Corrective Action: The College will modify its process and update its documented procedures to include periodically running an Enrollment ...
Condition: Of the 40 students selected for enrollment reporting, the College did not update the student enrollment information for 3 students accurately. Planned Corrective Action: The College will modify its process and update its documented procedures to include periodically running an Enrollment Reporting Graduated/Withdrawn Report from NLSDS and review for accuracy and make timely corrections, if necessary. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: June 30, 2026
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