Corrective Action Plans

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Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the College evaluate its policies and procedures around reporting to the COD to ensure that information is reported accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit fin...
Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the College evaluate its policies and procedures around reporting to the COD to ensure that information is reported accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: A PELL reconciliation report will be pulled monthly to check that the disbursement dates/amounts on COD match the disbursement dates/amounts on PowerFAIDS and Bionic. Name of the contact person responsible for corrective action: Shannon Braccili, Associate Director of Financial Aid Planned completion date for corrective action plan: Effective starting August 2025 with the first Fall 2025 PELL disbursement and continuing through the end of the academic year. This procedure will continue to be followed in subsequent academic years.
U.S. Department of Education National Student Loan Data Systems (NSLDS) Enrollment Reporting - Federal Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review its policies and procedures on reporting of enrollment status changes to NSLDS to ensure that a...
U.S. Department of Education National Student Loan Data Systems (NSLDS) Enrollment Reporting - Federal Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review its policies and procedures on reporting of enrollment status changes to NSLDS to ensure that all status changes are being reported accurately to be in compliance with regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: An investigation that uncovered a National Student Clearinghouse enrollment transmission proofing error related to program-level effective date for graduated students. Name of the contact person responsible for corrective action: James Keane, Registrar Planned Corrective Action Plan: The Registrar's Office will ensure that the program level effective date for graduates is accurate prior to submission. The Registrar will also partner with IITS to ensure that the program-level effective date for graduates is generated in the submission file as expected. Planned completion date for corrective action plan: May 2026, prior to the June 2026 submission date.
Finding Reference Number: Finding 2025-004: Significant Deficiency in Internal Control and Compliance over Reporting – Medicaid Cluster Corrective Action: The District submitted corrected versions of the Quarterly Financial Summaries to SBS after audit fieldwork. The District plans for the Finance D...
Finding Reference Number: Finding 2025-004: Significant Deficiency in Internal Control and Compliance over Reporting – Medicaid Cluster Corrective Action: The District submitted corrected versions of the Quarterly Financial Summaries to SBS after audit fieldwork. The District plans for the Finance Director to review Quarterly Financial Summaries and Annual Cost reports and document this review before submitting to SBS. The payroll coordinator will prepare the quarterly financial summaries and they will be reviewed by the Business Manager prior to submission to ensure accuracy. Responsible Person: Shannon Grindell, Sharon Weise Anticipated Completion Date: Ongoing
Recommendation: The University should review its policies and procedures on determining student's withdrawals and timely communication among departments to ensure timely returns of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action...
Recommendation: The University should review its policies and procedures on determining student's withdrawals and timely communication among departments to ensure timely returns of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University automated the process of communicating withdrawals between departments a few years ago. Unfortunately, an individual responsible for communicating withdrawals failed to use the system in that instance. When the delay in process was discovered, the offices of Student Support, Registrar, Financial Aid, and Bursar met to review communication and documentation processes. Meetings occurred in Summer 2025 to implement a cohesive process. The corrective action is that dismissals related to student conduct follow the same agreed upon process that hiatus and withdrawal follow. The responsible individual no longer works at the University, and their replacement will be fully trained and using the system in place. Name(s) of the contact person(s) responsible for corrective action: Andrew Moyer Planned completion date for corrective action plan: March 31, 2026
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report fir...
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Direct recipients must report key data elements by registering through the FSRS and reporting subaward data through that system. Direct recipients that are awarded a federal grant are required to file a FFATA sub-award report by the end of the month following the month in which the prime awardee awards any sub-grant equal to or greater than $30,000. The City did not submit the required key data elements through the FSRS reporting system as required by the Uniform Guidance and as a result has not completed the appropriate sub-award reporting that is required for direct recipients. Auditor Recommendation: We recommend that the City review its procedures for FFATA reporting through FSRS and ensure that all key data elements are reported timely moving forward. Corrective Action: Upon discovery of the issue in November 2025, City staff corrected the noncompliance by submitting the required report to the appropriate reporting system/entity. To prevent recurrence, management has strengthened internal controls over FFATA reporting and Single Audit preparation by (1) adding review and verification steps, (2) communicating expectations with key personnel, and (3) explicitly assigning submission responsibility to a designated submitter who is independent of the individual(s) responsible for monitoring compliance. These control enhancements are expected to identify and prevent similar deficiencies and, based on implementation to date, appear to be operating effectively. Responsible Person: Jason Denton, Controller Anticipated Completion Date: June 30, 2026
Condition: There were no controls in place for the annual report [FAA Form 5100-126] for the fiscal year ending September 30, 2025 to ensure the report contained accurate infor-mation and was sent timely to the appropriate FAA airports office. Planned Corrective Action: A review of FAA Form 5100-126...
Condition: There were no controls in place for the annual report [FAA Form 5100-126] for the fiscal year ending September 30, 2025 to ensure the report contained accurate infor-mation and was sent timely to the appropriate FAA airports office. Planned Corrective Action: A review of FAA Form 5100-126 will be conducted with ap-propriate personnel, such as the Controller or Vice President, Treasury Management prior to submitting to the FAA. Review and timely submission will be evidenced via time-stamped DocuSign or other electronic means such as an acknowledgment via email. Contact person responsible for corrective action: Sr. Grants Manager Anticipated Completion Date: 03/31/2026
Since the prior audit period, management has taken steps to review and revise OFB’s procurement policy and procedures, in alignment with federal procurement standards. Finance will continue implementing the corrective actions and establishing the internal controls to ensure adherence to the policy, ...
Since the prior audit period, management has taken steps to review and revise OFB’s procurement policy and procedures, in alignment with federal procurement standards. Finance will continue implementing the corrective actions and establishing the internal controls to ensure adherence to the policy, retaining documentation of the procurement process to demonstrate compliance. These recent and planned improvements will enhance transparency, strengthen accountability, and reduce compliance risk, ensuring a more efficient and well-documented procurement process that supports the organization’s long-term financial integrity and operational effectiveness. The anticipated completion date remains June 30, 2026.
U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Title I, Part A – AL #84.010 2025-002 Maintenance of Effort Significant Deficiency Recommendation: The auditor recommends the Organization develop internal controls to ensure expenses are properly reported on the Form 9 report in line ...
U.S. DEPARTMENT OF EDUCATION AND INDIANA DEPARTMENT OF EDUCATION Title I, Part A – AL #84.010 2025-002 Maintenance of Effort Significant Deficiency Recommendation: The auditor recommends the Organization develop internal controls to ensure expenses are properly reported on the Form 9 report in line with guidelines. Planned Corrective Action: The Organization has begun to use an outside vendor skilled in the preparation of Form 9 reporting and up-to-date on standards and compliance. An error in documents provided to this vendor lead to the misrepresentation of information on the report. Moving forward, all employees of the Organization are aware that any changes made that will impact the Form 9 after finalization of the period need to be conveyed to our Form 9 preparer. The Organization has provided modifications to the opening balances to the DOE in order to correct this error. Michelle Krauter, VP, Chief Financial Officer, will work with outside vendor to ensure all records are accurate. This process has already begun as of the date of this report and will be completed within the fiscal year. If the U.S. Department of Education has questions regarding this plan, please call Michelle Krauter, Vice President, Chief Financial Officer at 317.231.0010 Sincerely yours, Michelle Krauter, Vice President, Chief Financial Officer Herron High School, Inc. d/b/a Herron Classical Schools and its Wholly-Owned Subsidiaries
2025-007: Internal Control and Compliance over Special Tests – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to C...
2025-007: Internal Control and Compliance over Special Tests – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
2025-006: Internal Control over Reporting – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible...
2025-006: Internal Control over Reporting – Medicaid Cluster Corrective Action: The District has asked CESA 10 to send the Medicaid claims prior to submission to the District for approval. The District will have a staff member review the salary and fringe information provided to CESA 10. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
2025-005: Internal Control over Reporting – COVID-19: Education Stabilization Fund Corrective Action: Due to its size, it is not cost effective to hire additional staff to complete necessary reporting. Reviews and checks have been put into place prior to claim submissions with existing staff members...
2025-005: Internal Control over Reporting – COVID-19: Education Stabilization Fund Corrective Action: Due to its size, it is not cost effective to hire additional staff to complete necessary reporting. Reviews and checks have been put into place prior to claim submissions with existing staff members. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
2025-003: Internal Control over Eligibility – Child Nutrition Cluster Corrective Action: Acknowledging the lack of controls within the Child Nutrition program's eligibility process, the District has determined that hiring additional staff to resolve this internal control deficiency is not a cost-eff...
2025-003: Internal Control over Eligibility – Child Nutrition Cluster Corrective Action: Acknowledging the lack of controls within the Child Nutrition program's eligibility process, the District has determined that hiring additional staff to resolve this internal control deficiency is not a cost-effective solution. Consequently, the Food Service Director and the Finance Director share the responsibility of reviewing student eligibility forms. Responsible Person: Danielle Mittermeyer Anticipated Completion Date: Ongoing
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with...
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with...
Corrective Action: Trainings, Policy, and Procedures are being developed for all Medicaid caseworkers to follow. Medicaid workers will need to make sure they are working the SSI Termination report to eliminate any future paybacks. Also, a training on SSI Termination / Ex Parte will be conducted with all Medicaid workers, including NC Fast Learning Gateway Training “Supplemental Security Income (SSI) Course”. Proposed Completion Date: June 30, 2026. Certain controls are currently being created and reviewed. Management will continue to monitor the progress of this issues and modify the controls as needed.
Finding 2025-002: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that key control documentation is retained on file. The payroll file will be approved by either the Superintendent or th...
Finding 2025-002: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that key control documentation is retained on file. The payroll file will be approved by either the Superintendent or the CFO prior to payment, and proof of prior approval will be maintained in the School’s files. The new process began in January 2026. Responsible Party: Kemlyn Williams, Superintendent Dynamic Support Solutions, Contract CFO
Finding 2025-001: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that invoices are approved prior to being paid. Expenses are reviewed and approved through the PO process within the Asc...
Finding 2025-001: Allowable cost and activities – Significant deficiency in internal controls over compliance. Management Response: The School has implemented procedures to ensure that invoices are approved prior to being paid. Expenses are reviewed and approved through the PO process within the Ascender System. Each request is evaluated for accurate account coding, appropriateness, and compliance with Federal Grant allowable costs (when necessary). Spending and allowable costs are closely monitored on an ongoing basis. Once orders have been placed, products have been received/services rendered, and invoices received, the accounting clerk will prepare documents for the check run. A “check payments” report is provided which lists all transactions for the check run. The “check payments” document clearly displays the vendor, account code, and amount of each transaction. The “check payments” report is approved by Superintendent. Once “check payment” report is approved by Superintendent, the check run will be initiated. Documentation of prior approval will be kept on file. The new process began in March 2025. Responsible Party: Kemlyn Williams, Superintendent Dynamic Support Solutions, Contract CFO
Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) wi...
Finding 2025-001 Eligibility - Noncompliance and Significant Deficiency in Internal Control Over Compliance Planned Corrective Actions: Historical documentation on patient eligibility for IHS beneficiary status residing in paper financial files (in use at the time of roll and scroll registration) will be scanned in the BMW registration system making them a permanent part of the patients’ electronic health record. Registration staff is requesting beneficiary identification at the time of registration for all patients that do not have it in their EHR. Project is ongoing. Monthly audits of the elements of registration, including documentation of beneficiary status will be conducted to ensure continual compliance. Individual(s) Responsible for Corrective Action Plan Kandy Barlow VP of Health Services 907-442-7385 Anticipated Completion Date: March 31, 2026
Audit Finding 2025-001 Special Tests and Provisions Return of Title IV Funding (R2T4): Significant Deficiency in Internal Control over Compliance Student Financial Services has strengthened the current R2T4 calendar set up and calculation review process. An additional administrator in SFS reviews ea...
Audit Finding 2025-001 Special Tests and Provisions Return of Title IV Funding (R2T4): Significant Deficiency in Internal Control over Compliance Student Financial Services has strengthened the current R2T4 calendar set up and calculation review process. An additional administrator in SFS reviews each calendar created in COD to specifically check and document the total number of days in the payment period including scheduled breaks. In addition, University calendars have now been approved for several years in advance so this will prevent late date changes. At the time this student was identified, all students in this program were reviewed for R2T4s and it was confirmed that this is the only student in the program who withdrew and required an R2T4 calculation. The R2T4 was reprocessed with the corrected number of days. The student was contacted about the error in the calculation and informed of their eligibility for an additional $71 in Direct Loan. The student chose not to increase their loan by the additional $71 so no adjustments were made to the student record or to COD. Contact person responsible for Corrective Action: Alisha Aguilar, Associate Vice President of Student Financial Services and Military & Veteran Services alisha_aguilar@redlands.edu, 909-748-8047 Anticipated Completion Date: January 1, 2026
Contact Person(s): Sandy Fabre, CFO Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement Corrective action planned: Management is responsible for preparing and invoicing for all Federal awards. Completed i...
Contact Person(s): Sandy Fabre, CFO Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement Corrective action planned: Management is responsible for preparing and invoicing for all Federal awards. Completed invoices will be circulated back to key project staff for review prior to final management review, signature, and submission to awarding agency. Training tools on timekeeping will be improved to ensure all staff employed on a Federal award adequately comply with cost principles. Anticipated completion date: 05/01/2026
Contact Person(s): Sandy Fabre, CFO Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement Corrective action planned: Management will complete a two-step review process to ensure expenses are being validated...
Contact Person(s): Sandy Fabre, CFO Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): No disagreement Corrective action planned: Management will complete a two-step review process to ensure expenses are being validated correctly. Additionally, a selective self-audit program will be developed to verify that recordkeeping is complete and effective. Anticipated completion date: 05/01/2026
2025-001 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Incorrect Return of Title IV (R2T4) Calculations (Significant Deficiency). Condition: From a population of 17 students that officially or unofficially withdrew during the term, we tested four students. All four stud...
2025-001 – U.S. Department of Education, SFA Cluster, Special Tests and Provisions - Incorrect Return of Title IV (R2T4) Calculations (Significant Deficiency). Condition: From a population of 17 students that officially or unofficially withdrew during the term, we tested four students. All four students required Return of Title IV (R2T4) refund calculations. During our review, we noted that the University excluded only five days from the total number of days in the semester for the Fall 2024 and Spring 2025 breaks. However, each break period included five weekdays plus the surrounding weekend days, resulting in a total of nine days that should have been excluded. The University did not exclude the four weekend days adjacent to the breaks, leading to incorrect total day counts in the R2T4 calculations. Criteria: Under 34 CFR §668.22(f)(2)(i), the total number of calendar days in a payment period includes all days within the period that a student was scheduled to complete, except scheduled breaks of at least five consecutive days, which must be excluded from both the total number of days and the number of days completed. When classes end on a Friday and resume the following Monday after a week‑long break, both weekends (four days) and the five weekdays of the break are excluded from the R2T4 calculation, for a total exclusion of nine days. Cause: Controls to ensure proper calculation of Title IV refunds did not function as related to the condition above. Effect: R2T4 calculations for the students tested who withdrew during the Fall 2024 and Spring 2025 terms were incorrect. As a result, funds were returned in incorrect amounts to both the students and the U.S. Department of Education. Repeat Finding: No. Recommendation: We recommend the University implement and document enhanced procedures to ensure the accurate preparation and review of all Title IV refund calculations, including verification of the correct number of days excluded for scheduled breaks. View of Responsible Officials: The University acknowledges the condition identified. For the Fall 2024 and Spring 2025 terms, the R2T4 calculations excluded only the five instructional weekdays associated with each break and did not exclude the adjacent weekend days. As a result the total number of days in the payment period was overstated, which affected the R2T4 calculations for the students tested. Corrective Action: The University has reviewed the applicable regulatory requirements under 34 CFR§668.22(f)(2)(i) and confirmed that when a scheduled break consists of at least five consecutive days, all calendar days within the break period-including the surrounding weekends when classes end on a Friday and resume the following Monday-must be excluded from the R2T4 calculation. The University has: 1) Recalculated the affected R2T4 determinations for the students identified to ensure the correct number of days is excluded, 2) Returned or recovered any resulting differences in funds, as required, to or from the U.S. Department of Education and the affected students, 3) Updated internal R2T4 calculation procedures and reference materials to explicitly require exclusion of both weekdays and associated weekend days for qualifying scheduled breaks, and 4) Provided additional training to staff responsible for R2T4 calculations to reinforce regulatory requirements and prevent recurrence. Status: Corrective actions have been applied, and revised controls implemented for all future R2T4 calculations to ensure compliance with federal regulations. If the Federal Audit Clearinghouse has questions regarding this plan, please call Amy Brown, Director of Financial Aid at 704-463-3015.
AUDITEE’S CORRECTIVE ACTION PLAN As required by 2 CFR 200.511, the Rankin County School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Costs for the year ended June 30, 2025: Finding Correction Action...
AUDITEE’S CORRECTIVE ACTION PLAN As required by 2 CFR 200.511, the Rankin County School District has prepared and hereby submits the following corrective action plan for the findings included in the Schedule of Findings and Questioned Costs for the year ended June 30, 2025: Finding Correction Action Plan Details 2025-001 a. Name of Contact Person Responsible for Corrective Action: Lisa Worthy – Chief Financial Officer b. Corrective Action Planned: We will implement policies or procedures to establish an internal control system that will ensure strong financial accountability, including compliance with all federal grant requirements. c. Anticipated Completion Date: Immediately.
The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accuratel...
The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Repeat Finding No Action Taken Management has implemented enhanced internal controls to ensure sliding fee discounts are accurately calculated and fully supported. The Center standardized income verification procedures, reinforced documentation requirements for family size and income, and updated its sliding fee eligibility checklist to ensure consistency. Supervisory review protocols were established to verify proper calculation and supporting documentation prior to approval. Additionally, staff received refresher training on sliding fee policy requirements to promote ongoing compliance. Management will conduct periodic internal audits to monitor adherence and ensure continued effectiveness of these controls. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Sean Murphy, CFO at 860-610-6387.
Finding: 2025-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Frackson Salak, CFO Planned Corrective Action: Christ Community Health Services will perform...
Finding: 2025-001 Condition Found: The Organization has not applied sliding fee discounts to patient charges consistent with its sliding fee discount program. Individual(s) Responsible for Corrective Action: Frackson Salak, CFO Planned Corrective Action: Christ Community Health Services will perform monthly audits on patients who receive a sliding fee discount. The monthly audits will include verifying the correct fee was applied based on documents received during the patients sliding fee enrollment. If any errors are found they will be immediately corrected. Anticipated Completion Date: 06/30/2026
Finding 2025-001 – Education Stabilization – Special Tests and Provisions - Wage Rate Requirements Context: For all six vendors sampled, the School Corporation did not include the necessary clauses for the Davis-Bacon federal wage rate requirements in their contracts. For the two larger vendors repr...
Finding 2025-001 – Education Stabilization – Special Tests and Provisions - Wage Rate Requirements Context: For all six vendors sampled, the School Corporation did not include the necessary clauses for the Davis-Bacon federal wage rate requirements in their contracts. For the two larger vendors representing $3,611,973, weekly payroll reports were properly collected. For the remaining four smaller vendors, the School Corporation did not obtain the weekly payroll report certifications for the work performed totaling $148,522 for the entire audit period. Contact Person Responsible for Corrective Action: Katy Dowling Contact Phone Number: 317-869-4364 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Create an internal control process that ensures roles and responsibilities as it relates to the requirements of the David Bacon Act. Anticipated Completion Date: March 15, 2026
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