Corrective Action Plans

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Finding Number: 2025-004 Condition: All disbursements need either an approved invoice or credit card receipt for the amount charged to the grant. Planned Corrective Action: Imagine! will send out a communication to all employees reviewing the current internal control process that requires receipts a...
Finding Number: 2025-004 Condition: All disbursements need either an approved invoice or credit card receipt for the amount charged to the grant. Planned Corrective Action: Imagine! will send out a communication to all employees reviewing the current internal control process that requires receipts and / or invoices from vendors to be attached to credit card disbursements. Employees who do not abide by the process are subject to losing credit card privileges. Contact person responsible for corrective action: Melody Kim Anticipated Completion Date: 7/31/2026
Effective immediately, all federal financial reports (SF-425s) will require the preparer to attach approval from the Financial Controller confirming the report has been reviewed before submission. The Vice President of Finance and Administration will communicate this policy to the grants management ...
Effective immediately, all federal financial reports (SF-425s) will require the preparer to attach approval from the Financial Controller confirming the report has been reviewed before submission. The Vice President of Finance and Administration will communicate this policy to the grants management and finance teams.
Wild Salmon Center management will require all program staff with federal grant responsibilities or with credit card expense and timesheet approval responsibilities to attend an internal training session which will include training regarding what documentation and approvals are required under govern...
Wild Salmon Center management will require all program staff with federal grant responsibilities or with credit card expense and timesheet approval responsibilities to attend an internal training session which will include training regarding what documentation and approvals are required under government grant guidelines. The Financial Controller will conduct a review of credit card expenses before charging expenses to a government grant and will review that all timesheets have been approved before submission.
We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31 federal requirement.
We will improve our internal control procedures related to record keeping and adjustments in order to ensure compliance with the March 31 federal requirement.
Corrective Action Plan: Zero to Five Montana (ZtF) has implemented updated policies and procedures governing program expenditures to strengthen internal controls. Employees in managerial or director roles are no longer permitted to approve their own submitted expenditures. All expenditures, includin...
Corrective Action Plan: Zero to Five Montana (ZtF) has implemented updated policies and procedures governing program expenditures to strengthen internal controls. Employees in managerial or director roles are no longer permitted to approve their own submitted expenditures. All expenditures, including purchase orders, must be approved by the next level of managerial authority. Similarly, employee timecards cannot be self-approved by individuals in managerial roles who have system access to approve time entries. The expense management and timekeeping systems have been reconfigured to prevent approvals when the approver and requestor are the same individual. Contact Person Responsible for Corrective Action: • Caitlin Jensen, Executive Director Anticipated Completion Date: May 15, 2026
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater ...
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater error rate are receiving focused retraining and ongoing monitoring, with audit results shared with leadership to promote accountability. Two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant program implementation. Persons Responsible: Steven Hansen, President & CEO; Pearl Lujan, Central Billing Office Director Estimated Completion Date: December 31, 2026
FINDING 2025-002 – SIGNIFICANT DEFICIENCY- REPORTING - INTERNAL CONTROL OVER COMPLIANCE Description of Finding: The Town is required to submit an annual Project and Expenditure report within 30-days of after the close of the reporting period. Statement of Concurrence or Nonconcurrence: The Town agre...
FINDING 2025-002 – SIGNIFICANT DEFICIENCY- REPORTING - INTERNAL CONTROL OVER COMPLIANCE Description of Finding: The Town is required to submit an annual Project and Expenditure report within 30-days of after the close of the reporting period. Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure the reports are filed on time and accurately. Name of Contact Person: Shelley Cates, Finance Director, (860) 779-3411 x133. Projected Completion Date: June 30, 2026.
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversig...
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversight of financial reporting and internal controls. This role will be responsible for ensuring timely and accurate financial close processes and supporting audit readiness. 2. Health Projects Center will implement a more structured and timely year-end close process, with the goal of completing the fiscal year close within the first quarter following year-end. With the improved close timeline, Health Projects Center aims to complete the annual audit by the end of the second quarter. Person Responsible for Corrective Action Plan: John Beleutz, Executive Director Anticipated Date of Completion: June 30, 2026 fiscal year-end
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will...
Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
Plan: Management acknowledges the finding regarding non-property related expenses that were inadvertently paid by the property. Prior to the audit, management identified the error internally and corrective action was already completed. Upon discovery, the amounts were immediately reviewed, reclassif...
Plan: Management acknowledges the finding regarding non-property related expenses that were inadvertently paid by the property. Prior to the audit, management identified the error internally and corrective action was already completed. Upon discovery, the amounts were immediately reviewed, reclassified, and recorded from the related entity. Although the expense was not identified within the desired timeframe, management’s internal review process ultimately detected the issue before the audit process began, demonstrating that management understands that project funds must only be used for property-related expenses and that these types of transactions are not permissible. Management has since reinforced internal review procedures to ensure expenses are properly allocated to the correct entity in a more timely manner going forward. Management believes the corrective actions already taken adequately address this matter and will help prevent similar occurrences in the future. Completion Date: 1/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Opera...
Finding 2025-003 Plan: The Director of Affordable Housing will ensure that her staff submit allocation sheets each pay period. The Director will review the allocation sheets for accuracy, and the Director will approve the allocation sheets before submitting to Payroll for processing. The Chief Operating Officer will ensure that the Director of Affordable Housing submits an allocation sheet each pay period. The COO will check the allocation sheet for accuracy before approving the allocation sheet and submitting to Payroll for processing. The allocation sheet submitted will include detailed information on the job duties performed during that pay period by the staff member submitting the allocation sheet. Additionally, the Director of Affordable Housing will document job duties for each position in the department. Anticipated Completion Date: 7/1/2026 Contact: Jill Lesmerises, CFO
As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended August 31, 2025. Finding 2025-001: Allowable Costs – Significant Deficiency in Internal Control Over Compliance...
As required by the OMB Uniform Guidance, we have provided our response and corrective action plan addressing the finding in the Schedule of Findings and Questioned Costs for the year ended August 31, 2025. Finding 2025-001: Allowable Costs – Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Management’s Views – Management agrees with the finding. LAJH acknowledges that payroll reimbursement calculations submitted under the federal program were prepared using subsequent employee pay rates rather than the contemporaneous pay rates applicable during the grant performance period and that certain duplicative expenditures were included in error. Management recognizes that these errors resulted in overstated costs totaling $79,825. Corrective Action Plan – LAJH will implement enhanced internal control procedures over the preparation and review of payroll costs charged to federal awards. Specifically, management will require all payroll reimbursement calculations to be supported by contemporaneous payroll registers and employee pay rate documentation applicable to the period during which services were performed. Person Responsible for Corrective Action: Robin Ray, Corporate Controller Anticipated Completion Date: May 31, 2026
Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) respon...
Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned completion date for corrective action plan: 05/28/2026
Action taken in response to finding: The Club will utilize expenditures report directly from the accounting system when preparing progress reports to ensure all activity is accurately captured and reported. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned co...
Action taken in response to finding: The Club will utilize expenditures report directly from the accounting system when preparing progress reports to ensure all activity is accurately captured and reported. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned completion date for corrective action plan: 05/28/2026
Finding 2025-005 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications to return Title IV funds within the required timeframe as outlined in the Federal Direct Student Loans Program. Anticipated Complet...
Finding 2025-005 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications to return Title IV funds within the required timeframe as outlined in the Federal Direct Student Loans Program. Anticipated Completion Date The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar
Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direc...
Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direct Student Loans Program. The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar
April 30, 2026 Finding Number: 2025-002: Significant Deficiency in Internal Control / Immaterial Noncompliance – Reporting Finding Condition: Quarterly reports selected for testing for WIOA Cluster and Temporary Assistance for Needy Families Cluster were submitted after the deadline. Planned Correct...
April 30, 2026 Finding Number: 2025-002: Significant Deficiency in Internal Control / Immaterial Noncompliance – Reporting Finding Condition: Quarterly reports selected for testing for WIOA Cluster and Temporary Assistance for Needy Families Cluster were submitted after the deadline. Planned Corrective Action: We have changed our timeline for quarterly reports so that all entries, posting, and certifications will occur prior on or before the reporting deadlines. Responsible Contact Person: Shamar Herron (Executive Director) Sherron@mwse.org Anticipated Completion Date: Effective Immediately Respectfully, Shamar Herron
Finding 2025-002 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Healthcare Services Program Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Period of Performance Finding...
Finding 2025-002 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Healthcare Services Program Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles and Period of Performance Finding Summary: BHD, LLC did not retain documentation of the review and approval of all direct expenditures allocated to the program. Responsible Individuals: Valarie Howard, CFO Corrective Action Plan: We have begun generating a report each pay period identifying any timecards that remain unapproved at the processing deadline. Payroll will proactively follow up with the responsible managers to obtain approval for any outstanding timecards identified in the report. Payroll will disburse a document to the responsible managers who must document why the approval was not made by the payroll deadline and that they approve the time that was presented on the timecard and paid out. Anticipated Completion Date: Action plan has been implemented immediately after finding was communicated to management (May 2026).
Finding 2025-001 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Healthcare Services Program Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: For a portion of...
Finding 2025-001 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Healthcare Services Program Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: For a portion of the year, BHD, LLC calculated their indirect cost rate based on the total grant budget and took an equal amount of that per month instead of calculating the indirect cost rate per direct expenditures for each month. When they started to calculate the indirect cost rate per direct expenditures for each month, they used the wrong cost pool per the budget and award. Responsible Individuals: Valarie Howard, CFO Corrective Action Plan: Historically, the indirect cost received by this grant has not been dependent of the direct expenditures. Based on verbal conversations with the HRSA grant project manager, requesting reimbursement for the indirect costs evenly over the year based on the budget submitted was acceptable. Therefore, the accounting treatment has been reflective of that. However, management agrees that recording the indirect cost based on the direct cost expenditures monthly is reasonable and appropriate and will make the change accordingly. The action plan was implemented immediately upon communication of the finding. Due to the timing of the prior year audit and communication of findings, the implementation of the action plan was mid- year during the current fiscal year resulting in a repetitive finding. Anticipated Completion Date: Action plan was implemented directly after issuance of prior year audit and communication of finding to management (March 2025).
Audit Finding Reference: 2025-002 Document Policies and Procedures Over Federal Awards Planned Corrective Action: - Perform a comprehensive review of existing federal award policies and procedures - Develop and formally document policies covering federal award administration, allowable costs, procur...
Audit Finding Reference: 2025-002 Document Policies and Procedures Over Federal Awards Planned Corrective Action: - Perform a comprehensive review of existing federal award policies and procedures - Develop and formally document policies covering federal award administration, allowable costs, procurement, cash management, subrecipient monitoring, reporting, and record retention Planned Implementation Date of Corrective Action: 1/1/2026 Person Resposible for Corrective Action: Finance Director/Senior Accountant Grant Administrator
Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit find...
Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend the College evaluate its procedures and policies around reporting enrollment changes to NSLDS to ensure that student information is reported accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Augustana intends to modify the NSC/NSLDS monthly data file to ensure that campus and program enrollment dates are pulled from the appropriate data fields in the student information system. Additionally, Augustana intends to implement a step in the withdrawal process to ensure the change in status is reported accurately and timely. Name of the contact person responsible for corrective action: John Cage at johncage@augustana.edu Planned completion date for corrective action plan: January 30, 2026
Management agrees with the finding. The Agency’s current approach was designed to balance compliance needs with limited resources. Management will assess feasible improvements to its documentation practices to enhance support for payroll allocations to federal awards while remaining mindful of fundi...
Management agrees with the finding. The Agency’s current approach was designed to balance compliance needs with limited resources. Management will assess feasible improvements to its documentation practices to enhance support for payroll allocations to federal awards while remaining mindful of funding and staffing constraints.
The district will implement a process to create and maintain documentation for supplemental contracts and substitute employees serving in vacant positions that clearly identifies the applicable cost objectives and includes employee signatures. These records will be retained and maintained for audit ...
The district will implement a process to create and maintain documentation for supplemental contracts and substitute employees serving in vacant positions that clearly identifies the applicable cost objectives and includes employee signatures. These records will be retained and maintained for audit purposes.
Finding No. 2025-001 – Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The discrepancies identified during the current audit were determined to be timing-related issues associated with the transition and implementation of revised disbursement reporting an...
Finding No. 2025-001 – Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The discrepancies identified during the current audit were determined to be timing-related issues associated with the transition and implementation of revised disbursement reporting and reconciliation procedures in order to address a similar compliance finding that was identified in the 2024 Single Audit. These discrepancies occurred while updated controls and monitoring processes were being fully integrated into daily operations. During the prior audit conducted on April 6, 2025, auditors identified discrepancies between institutional disbursement dates and the dates reflected in the Common Origination and Disbursement (COD) system for the 2023-2024 award year. Immediately upon identification of the issue in the 2024 Single Audit, the institution implemented corrective measures to ensure that institutional disbursement dates matched Common Origination and Disbursement (COD) reporting. Since May 2025, the following corrective actions have already been fully implemented: 1. Revised and strengthened reconciliation procedures between the Student Information System and COD to ensure accurate disbursement date reporting. 2. Implemented secondary review controls prior to transmitting disbursement records to COD. 3. Established ongoing internal monitoring and periodic reconciliation reviews to identify and resolve discrepancies promptly. 4. Conducted additional staff training regarding Title IV disbursement reporting requirements and COD reconciliation procedures. 5. Assigned designated personnel responsibility for continuous oversight and verification of disbursement date accuracy. 6. Corrected disbursement reporting processes to ensure institutional records align with COD reporting requirements moving forward. Anticipated Completion Date: Since May 2025, the institution has taken all necessary measures to address and correct the identified issues on a prospective basis. All corrective actions outlined above are currently in place and operational. The institution continues to monitor disbursement reporting and reconciliation processes to ensure ongoing compliance with federal Title IV regulations and accurate reporting to COD. Person(s) Responsible for Corrective Action: Beatriz Novoa-Cruz Associate Vice President of Enrollment 718-429-6600 ext. 114
Finding #2025-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: U.S. Department of Health and Human Services, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Recovery Support Services, Contract Number: HHS00013050...
Finding #2025-004 – Reporting – Significant Deficiency and Other Noncompliance. Applicable federal programs: U.S. Department of Health and Human Services, Assistance Listing #93.959, Block Grants for Prevention and Treatment of Substance Abuse, Recovery Support Services, Contract Number: HHS000130500013, Contract Year: 09/01/24-08/31/25; Prevention and Behavioral Health Promotion Youth Prevention Services, Contract Number: HHS001344700032, Contract Year: 09/01/24-08/31/25. Condition and context: During our testing of the Federal Financial Reports, we noted that the final financial status reports were submitted late and the reports did not have evidence of review and approval. Additionally, a recoupment of $33,541 was required by the funder upon review of the closeout report for contract number HHS000130500013. Recommendation: Re-emphasize policies and procedures to meet the grant reporting requirements and ensure that all reports are independently reviewed prior to submission. Planned corrective action: Management will maintain a grant reporting deliverables calendar covering all federal and state reporting requirements, with internal due dates set in advance of funder deadlines and assigned to a specific grant manager. No Federal Financial Report or closeout report will be submitted without documented independent review and approval by the Controller, with preparer, reviewer, and approver sign-off retained in the grant file alongside the supporting reconciliation to the CYMA general ledger. Responsible officer: Michael McIntyre, Chief Administrative Officer. Estimated completion date: August 31, 2026.
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