Corrective Action Plans

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PDA, BFA has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. Upon identification of this finding, BFA directed our Field Representatives to immediately complete reviews of the 47 identified soup kitchens. As of 2/20/25, 18 of these soup kitc...
PDA, BFA has already or will put the following steps in place to address this deficiency and noncompliance finding. 1. Upon identification of this finding, BFA directed our Field Representatives to immediately complete reviews of the 47 identified soup kitchens. As of 2/20/25, 18 of these soup kitchen reviews have been completed and 8 of these reviews are in-process or pending final review approval. 2. BFA Field Representatives have been advised that Soup Kitchen reviews must be completed once every four years, just like other TEFAP agencies with which we have direct agreements. This requirement is also being added to the Field Representative work manual. Anticipated Completion Date: 06/30/2025 Contact Name: Caryn Long Earl, Director, Bureau of Food Assistance
View Audit 346904 Questioned Costs: $1
Finding Number: 2024‐003 Program Name/Assistance Listing Title: Indian School equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Renee Begay, Human Resource Technician Anticipated Completion Date: June 30, 20...
Finding Number: 2024‐003 Program Name/Assistance Listing Title: Indian School equalization; Title I Grants to Local Educational Agencies Assistance Listing Number: 15.042; 84.010 Contact Persons: Carmen Jodie, Principal; Renee Begay, Human Resource Technician Anticipated Completion Date: June 30, 2025 Planned Corrective Action: It is recommended that the School completes all the outstanding background checks. Secondly, the School will ensure that all background checks are fully completed with the appropriate documents for all newly hired and current employees. It is understood that all current and new employees must be reinvestigated every five years and performed in a timely manner (before “the expiration of the preceding investigation”). This is how the school will attempt to attain compliance.
Finding 528775 (2024-002)
Significant Deficiency 2024
AUDIT FINDINGS Finding Reference Number: Finding 2024-002 Description of Finding: Statement of Condition: The Financial Aid Office does not consistently report disbursement dates to COD correctly. Two (2) out of six (6) students tested had been incorrectly reported to COD. Statement of Concurrence o...
AUDIT FINDINGS Finding Reference Number: Finding 2024-002 Description of Finding: Statement of Condition: The Financial Aid Office does not consistently report disbursement dates to COD correctly. Two (2) out of six (6) students tested had been incorrectly reported to COD. Statement of Concurrence or Nonconcurrence: According to 34 CFR 668.164(a), Disbursing Funds, an institution makes a disbursement of Title IV, HEA funds on the date that the institution credits a student’s account at the institution or pays a student or parent directly with funds received from the Secretary; or institutional funds used in advance of receiving Title IV, HEA funds. Corrective Action: To ensure timely and accurate processing of financial aid disbursements, the Office of Accounting and the Office of Financial Aid will implement a Disbursement Memorandum outlining specific procedures. The Office of Accounting must upload disbursement files into PowerCampus on the same day they are received from the Office of Financial Aid. If disbursement files cannot be uploaded due to system issues, staff illness, or other delays, the Office of Accounting must immediately notify the Office of Financial Aid. In such cases, the Office of Financial Aid will update disbursement dates in COD as needed. The Office of Financial Aid already has a process in place to identify and correct mismatches between disbursement dates in PowerFAIDS and COD, and this process will continue as part of ongoing reconciliation efforts. The Office of Accounting will maintain awareness of the importance of same-day uploads and exercise diligence in ensuring compliance with this requirement. This corrective action plan will enhance coordination between offices, reduce discrepancies, and improve compliance with federal reporting requirements. Name of Contact Person: Keri Gilbert Associate Vice President of Financial Aid Analytics and Compliance (573) 876-7106 Projected Completion Date: 3/10/2025
Finding 2024-002: Matching Major Federal Program: Federal Transit Cluster Compliance Requirements: Allowable Costs and Cost Principles, Cash Management, Matching Response: Concur: An inaccurate reimbursement rate was applied causing overpayment of $613,075. Due to the inaccuracy of the percentage ra...
Finding 2024-002: Matching Major Federal Program: Federal Transit Cluster Compliance Requirements: Allowable Costs and Cost Principles, Cash Management, Matching Response: Concur: An inaccurate reimbursement rate was applied causing overpayment of $613,075. Due to the inaccuracy of the percentage rate applied in this drawdown, Trinity Metro will actively reinforce its internal control processes to ensure detailed reviews related to cost reimbursement rates are accurately identified monthly by those who are authorized to process drawdowns. Implementation will take place immediately. Steps that will be taken include: 􀁸 Dual-Approval Process for Reimbursement Requests: Both the Grants Department and Accounting will confirm the accuracy of the reimbursement rate before submission. 􀁸 Grant Agreement Review Process: Both the Grants Department and Accounting will jointly review grant agreements before submitting reimbursement requests to ensure that the correct rate if applied. Date of Completion: This action plan will go into effect immediately. Person Responsible to Ensure Completion: Contact Person: Greg Jordan, Chief Financial Officer Contact Person: Eva Williams, Director of Budget and Grants, Finance
View Audit 346790 Questioned Costs: $1
Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be ...
Corrective Actions Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Corrective Actions Manual processes will be reinforced regarding time and effort reporting (T/E) and Operations (Ops) will be instructed to hold each drawdown until all processes are completed and approved by the Grant Program Manager. Grant Program Manager will also conduct more frequent internal monitoring of completeness of records, and create an e-learning for all team members involved in the grant process regarding the steps that need to be followed. The Froedtert ThedaCare Health (FTCH) compliance team has created a proposal to implement a Grant Management Software solution. The software solution will have mechanisms for facilitating automated and streamlined processes to support time and effort documentation requirements. Specific actions to be taken include: Party Responsible Laurie Moore, Grant Program Manager Corrective Action Reinforce T/E and implement hold practice with each Ops owner expensing salaries Anticipated Completion Date April 1, 2025 Party Responsible Laurie Moore, Grant Program Manager Corrective Action Increase internal monitoring frequency for grants expensing salaries Anticipated Completion Date Beginning April 15, 2025 and ongoing thereafter Party Responsible Laurie Moore, Grant Program Manager Corrective Action Create e-learning Anticipated Completion Date Create Learning: May 1, 2025 Implementation: June 1, 2025 (If not able to do e-learn, will publish PowerPoint)
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Impact Aid Assistance Listing Number: 84.041 Contact Person: Michelle Quiroz, Director of Finance Anticipated Completion Date: April 1, 2025 Planned Corrective Action: The District will provide training for all relevant personn...
Finding Number: 2024‐001 Program Name/Assistance Listing Title: Impact Aid Assistance Listing Number: 84.041 Contact Person: Michelle Quiroz, Director of Finance Anticipated Completion Date: April 1, 2025 Planned Corrective Action: The District will provide training for all relevant personnel (procurement team members and project managers) on the need for certified payroll compliance and the consequences of non‐compliance; specifically emphasizing the requirements of the Davis‐Bacon Act and how to properly submit certified payroll documentation. The District will also implement a process to review contractors on federal projects, their compliance with certified payroll requirements, and their contracts to ensure the requirement for timely and accurate certified payroll submissions is included.
COVID-19 Coronavirus State and Local Fiscal Recovery Fund– Assistance Listing No. 21.027 Recommendation: The City should enhance or modify its internal controls over suspension and debarment, as necessary, to ensure compliance with suspension and debarment provisions. Explanation of disagreement wi...
COVID-19 Coronavirus State and Local Fiscal Recovery Fund– Assistance Listing No. 21.027 Recommendation: The City should enhance or modify its internal controls over suspension and debarment, as necessary, to ensure compliance with suspension and debarment provisions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We provided training to procurement staff about the suspension and debarment requirements of 2 CFR 200.214. Further, we expanded language in the City’s formal soliciation template regarding suspension and debarment and added a specifc step on our solitication timeline checklist to perform SAM checks. Name(s) of the contact person(s) responsible for corrective action Levi Gibson, Budget and Finance Director Planned completion date for corrective action plan: December 2024
Finding 528709 (2024-001)
Significant Deficiency 2024
Department of Education Bucknell University respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 01, 2023 - June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consisten...
Department of Education Bucknell University respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 01, 2023 - June 30, 2024 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS Department of Education 2024-001 Federal Pell Grant Program – Assistance Listing No. 84.063 Federal Direct Student Loans – Assistance Listing No. 84.268 Recommendation: We recommend the University review procedures around sending correct information to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Bucknell continues to review and refine its existing process of reporting student enrollment data to the NSLDS at both the campus level and program level. Name(s) of the contact person(s) responsible for corrective action: Tim Kracker, University Registrar and Erin Wolfe, Director, Financial Aid Planned completion date for corrective action plan: December 31, 2024 If the Department of Education has questions regarding this plan, please call Elizabeth D. Stewart, Associate Vice President, Treasurer & Controller at 570-577-3108.
2024-002 – Documentation of Tenant Eligibility Auditor Description of Condition and Effect: For 1 of 40 tenants tested, there was no evidence of income verification included in the tenant file. Because of this condition there was an increased risk that this tenant's Housing Assistance Payment (HAP...
2024-002 – Documentation of Tenant Eligibility Auditor Description of Condition and Effect: For 1 of 40 tenants tested, there was no evidence of income verification included in the tenant file. Because of this condition there was an increased risk that this tenant's Housing Assistance Payment (HAP) could be assessed inaccurately. Auditor Recommendation: The County should implement a policy requiring all tenants have a documented income verification prior to calculating or disbursing HAP. Management Assessment. Management concurs with the audit assessment regarding this matter. Planned Corrective Action. Management has reviewed its existing policy and will ensure income verification documentation is included in the tenant file. Please note this program ended December 31, 2024. No further HAP payments are being processed at this point in time. Responsible Party. Gustavo Perez, Community Action Director Date of Planned Corrective Action. March 2025
View Audit 346706 Questioned Costs: $1
2024-001 – Review and Approval of Housing Quality Standards (HQS) Inspections Auditor Description of Condition and Effect: HQS inspection reports reviewed during testing did not bear evidence of independent review and approval. Because of this condition there was an increased risk that inspection ...
2024-001 – Review and Approval of Housing Quality Standards (HQS) Inspections Auditor Description of Condition and Effect: HQS inspection reports reviewed during testing did not bear evidence of independent review and approval. Because of this condition there was an increased risk that inspection reports could be incomplete or contain inaccuracies. Auditor Recommendation: The County should implement a policy requiring all HQS inspection reports to have an independent review and that such review be sufficiently documented. Management Assessment. Management concurs with the audit assessment regarding this matter. Planned Corrective Action. Management has reviewed its existing policy and will ensure HQS inspection reports have independent reviews which are sufficiently documented. Please note this program ended December 31, 2024. Responsible Party. Gustavo Perez, Community Action Director Date of Planned Corrective Action. March 2025
Planned Response: The North Sweetwater Water and Sewer District (NSWSD) Board will prepare and adopt written policies and procedures by December 2025, to ensure that all Uniform Guidance regulations, relating to SAMS.gov debarment and suspension, are performed in accordance with federla regulations...
Planned Response: The North Sweetwater Water and Sewer District (NSWSD) Board will prepare and adopt written policies and procedures by December 2025, to ensure that all Uniform Guidance regulations, relating to SAMS.gov debarment and suspension, are performed in accordance with federla regulations and reviewed on a regular basis.
MANAGEMENT RESPONSE AND CORRECTIVE ACTION Management agrees with this finding. Corrective Actions: LHA has taken immediate action to correct this issue. LHA has reviewed the requirements with the third-party vendor and has implemented improved reporting requirements on the inspections reports for th...
MANAGEMENT RESPONSE AND CORRECTIVE ACTION Management agrees with this finding. Corrective Actions: LHA has taken immediate action to correct this issue. LHA has reviewed the requirements with the third-party vendor and has implemented improved reporting requirements on the inspections reports for their staff. LHA is conducting a retro-active QC effort to identify potential failures by the vendor and their reporting or adherence with LHA policy. LHA is implementing and drafting a QA process to ensure there are additional checks to inspection reports as they are provided to LHA. In addition, the LHA has posted a draft for public comment of the Administrative Plan that we anticipate will be implemented on 7/1/2025. The plan removes reference to adherence to state or local code as the LHA and its vendors are not the appropriate enforcement agency to address those requirements. We anticipate that there will be diminished issues effective immediately and full compliance with the current Administrative by 3/1/2025 and a new Administrative Plan implemented on 7/1/2025 removing the language related to local code enforcement. The responsible staff are the Administrative Clerk, Management Analyst and Executive Director.
Finding 2024-004 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Applicable Federal Award Number- Direct Loan and Guaranteed Loan Assistance Listing Number #10.766 Finding Summary: The Medical Center was not in compliance with the term...
Finding 2024-004 Federal Agency Name: U.S. Department of Agriculture Program Name: Community Facilities Loans and Grants Cluster Applicable Federal Award Number- Direct Loan and Guaranteed Loan Assistance Listing Number #10.766 Finding Summary: The Medical Center was not in compliance with the terms of the loan agreements related to the reservefunds. Responsible Individuals: Ron Harrington, CFO Corrective Action Plan: The CFO worked with the local bank in Concordia to establish the required reserve account equal to the 10% of the annual debt service requirement on the direct loan and the guaranteed loan for the entire year. The Hospital is now in compliance with the terms of the loan agreements related to the reserve funds as of August 31, 2024. The Hospital has access to the accounts set up at the Bank to run monthly reports and record the interest amounts to the proper GL accounts quarterly as the interest on the accounts set up at the bank accrue interest quarterly. This entry is to ensure the Gl accounts agree with the Bank statements on the Reserve funds. Anticipated Completion Date: August 2024
The City of Worcester, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the...
The City of Worcester, Massachusetts respectfully submits the following corrective action plan for the year ended June 30, 2024. Audit period: July 1, 2023 – June 30, 2024 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDING—FEDERAL AWARD PROGRAMS AUDIT U.S. Department of Housing and Urban Development 2024-001 Community Development Block Grant - Assistance Listing Number 14.218 Recommendation: We recommend procedures be strengthened to ensure all required subaward reports are filed with FSRS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The City of Worcester will strengthen its procedures to comply with the FSRS reporting requirements and ensure all subawards are appropriately reported in a timely manner. Name(s) of the contact person(s) responsible for corrective action: Alexis Delgado, Assistant Budget Director – Grants Planned completion date for corrective action plan: April 30, 2025
3.1.Ensure that the inventory expenses charged to the federal program are allowable within the period of performance. Responsible Official: Head of Operations, Supply Chain Managers, DRD Operations, SCM RTAs, Completion Date: September 30, 2025
3.1.Ensure that the inventory expenses charged to the federal program are allowable within the period of performance. Responsible Official: Head of Operations, Supply Chain Managers, DRD Operations, SCM RTAs, Completion Date: September 30, 2025
View Audit 346571 Questioned Costs: $1
2.1 Ensure timely reconciliation of inventory distributions in order to record the transactions in the correct accounting period. Responsible Official: Head of Operations, Supply Chain Managers, DRD Operations, SCM RTAs, Completion Date: September 30, 2025
2.1 Ensure timely reconciliation of inventory distributions in order to record the transactions in the correct accounting period. Responsible Official: Head of Operations, Supply Chain Managers, DRD Operations, SCM RTAs, Completion Date: September 30, 2025
Finding 528520 (2024-001)
Significant Deficiency 2024
Finding 2024-001 Personnel Responsible for Corrective Action: Director of Financial Aid, Kerry Hallahan Anticipated Completion Date: May 2024 Corrective Action Plan: The funds for the affected student have been retur
Finding 2024-001 Personnel Responsible for Corrective Action: Director of Financial Aid, Kerry Hallahan Anticipated Completion Date: May 2024 Corrective Action Plan: The funds for the affected student have been retur
View Audit 346554 Questioned Costs: $1
Finding Numbers: 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Jim Mosley, Superintendent Anticipated Completion Date: June 30, 2025 Planned Corrective Action: Improvement from the prior year was made in this ar...
Finding Numbers: 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Jim Mosley, Superintendent Anticipated Completion Date: June 30, 2025 Planned Corrective Action: Improvement from the prior year was made in this area and the Human Resources Manager has received additional training and is implementing new procedures and schedules to track the timing off renewing background checks in the future.
SINGLE AUDIT CORRECTIVE ACTION PLAN For the Fiscal Year Ended June 30, 2024 To Government Officials: SINGLE AUDIT FINDINGS: Finding 2024-001 Period of Performance Description of Finding Community Development Block Grant – Entitlement (ALN 14.218) funds must be expended by the end of the eighth fi...
SINGLE AUDIT CORRECTIVE ACTION PLAN For the Fiscal Year Ended June 30, 2024 To Government Officials: SINGLE AUDIT FINDINGS: Finding 2024-001 Period of Performance Description of Finding Community Development Block Grant – Entitlement (ALN 14.218) funds must be expended by the end of the eighth fiscal year after the fiscal year of appropriation the combined effect is to provide an expenditure period of eight fiscal years from the fiscal year of appropriation. For award B-17-MC-09-0007 (CDBG 2017), the eighth year after the year of appropriation ended on June 30, 2024. On this date, amount left unexpended after the end of the period of performance was $17,814. Statement of Concurrence or Nonconcurrence Management agrees with this finding. Corrective Action We recommend that the City review processes and controls related to timeliness of CDBG expenditures to ensure they comply with federal award requirements. Projected Completion Date June 30, 2025 Name of Contact Person Joseph Feest, Economic Development Director
Finding 528492 (2024-004)
Significant Deficiency 2024
Corrective Action: The Financial Aid Office notifies student of federal loan disbursements to their accounts, but was not aware that parent PLUS loan borrowers were required to be notified of PLUS loan disbursements. Beginning with the fall ’24 semester, the FAO has begun notifying PLUS loan borrowe...
Corrective Action: The Financial Aid Office notifies student of federal loan disbursements to their accounts, but was not aware that parent PLUS loan borrowers were required to be notified of PLUS loan disbursements. Beginning with the fall ’24 semester, the FAO has begun notifying PLUS loan borrowers of those disbursements to student accounts. Financial Aid is working with the internal IT department to assist with sending these notices in a timely manner. Proposed Completion Date: June 30, 2025
Finding 528491 (2024-003)
Significant Deficiency 2024
Corrective Action: We have used the last day of finals to be the last day in the payment period for any withdrawals in the 2024-2025 academic year. Proposed Completion Date: June 30, 2025
Corrective Action: We have used the last day of finals to be the last day in the payment period for any withdrawals in the 2024-2025 academic year. Proposed Completion Date: June 30, 2025
Finding 528490 (2024-002)
Significant Deficiency 2024
Corrective Action: The “Timely Reporting” issue resulted from a misunderstanding in the Registrar’s Office regarding the requirements of what had to be reported and by when. We have discussed this issue with that office’s personnel and established procedures designed to prevent it from happening in ...
Corrective Action: The “Timely Reporting” issue resulted from a misunderstanding in the Registrar’s Office regarding the requirements of what had to be reported and by when. We have discussed this issue with that office’s personnel and established procedures designed to prevent it from happening in the future. The “Funds Not Returned Timely” reflects continued improvements resulting from policies already established to enhance compliance with attendance reporting and tracking of those reports by the Registrar and Financial Aid Offices. The College will continue to reinforce compliance with the attendance monitoring and reporting policy, as well as refine procedures for active monitoring of those reports by these two offices. In particular, the process of evaluating whether students who are on the two-week absence report in any one class are in fact at risk of falling out of enrollment status overall. Proposed Completion Date: June 30, 2025
The 2023 FASS-PH report is now completed, and the 2024 FASS-PH is in progress of being completed. These reports have been added to our year-end checklist.  Include FASS-PH report to closing year-end reports schedule Financial reconciliations.  FASS-PH report preparation.  Management review & appr...
The 2023 FASS-PH report is now completed, and the 2024 FASS-PH is in progress of being completed. These reports have been added to our year-end checklist.  Include FASS-PH report to closing year-end reports schedule Financial reconciliations.  FASS-PH report preparation.  Management review & approval.  Assign responsible parties for each step in the process.  Conduct weekly check-ins during reporting periods to track progress. Name of contact person: Gary Donaldson 206
Item 2024-003 Delinquent Claim Filings Significant Deficiency Recommendation: Filing claims should be incorporated into the month-end close process. Management Views: Management agrees with the finding. Action Planned: Claim filing has been incorporated into the month-end closing process as of N...
Item 2024-003 Delinquent Claim Filings Significant Deficiency Recommendation: Filing claims should be incorporated into the month-end close process. Management Views: Management agrees with the finding. Action Planned: Claim filing has been incorporated into the month-end closing process as of November 2023. Anticipated Completion date: Complete Responsible Party: Karla Davis, Chief Financial Officer
Auditee’s Response and Planned Corrective Action The Authority has had staff and consultant turnover during the period under audit. Additionally, the eviction moratorium and lasting effects from the COVID-19 pandemic has resulted in delaying or receiving no responses from tenants regarding obtaining...
Auditee’s Response and Planned Corrective Action The Authority has had staff and consultant turnover during the period under audit. Additionally, the eviction moratorium and lasting effects from the COVID-19 pandemic has resulted in delaying or receiving no responses from tenants regarding obtaining the necessary documentation for eligibility requirements. The Authority has evidentiary documentation supporting their attempts to obtain the required documents from the tenants, such as certified letters, and courts suspension of evictions during the eviction process. Other documentation related to the moratorium that resulted from the COVID-19 pandemic, is available which includes evictions for nonpayment and noncompliance. The Authority has been working with legal counsel on these matters and continues to pursue this vigorously. The Authority has also hired new staff and consultants who has been diligently working to implement improvements. In most of the files the checklist cover pages were included but in some files reviewed the oversite cover page checklist was missing, however the required documentations were in place. A greater effort will be made immediately that all files will have completed the control check list cover pages in place with all appropriate signatures noted. Planned Implementation Date of Corrective Action: March 4, 2025 Person Responsible for Corrective Action: Keith Burrell, Executive Director
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