Corrective Action Plans

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All quarterly reports were reviewed and combined into a single report. All obligations and expenses as of 6/30/2024 and 6/30/2025 were examined and a determination of correct obligation and expenses was made. These new numbers were used for the report dated 10/15/2025. By the time the FY24 report wa...
All quarterly reports were reviewed and combined into a single report. All obligations and expenses as of 6/30/2024 and 6/30/2025 were examined and a determination of correct obligation and expenses was made. These new numbers were used for the report dated 10/15/2025. By the time the FY24 report was completed and issue was found, FY25 was over. This issue is corrected for FY26.
Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: A new allocation process was implemented in...
Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: A new allocation process was implemented in September 2025. Starting that month, each employee now completes their timecard in ADP, dividing hours worked by Revenue Source Code (grant or non-grant). Timecards are reviewed each pay period by the employee’s Supervisor for accuracy of time allocation and coding. A report is then generated from ADP to identify the grant allocations and prepare the journal entry. ADP does not allocate time spent on leave (vacation, sick, holiday, jury duty, other leave). Anything not automatically allocated on the ADP report is allocated manually based on the percentage of time the employee spent on that grant during the payroll period. For salaried employees, the Payroll Specialist manually prepares the allocation of wages and benefits to each grant based on the percentage of time the employee coded to that grant in their timecard (ADP does not automatically allocate salaried employees). Once allocations are complete, the Payroll Specialist prepares the journal entry and imports into the accounting system. The journal entry reviewer (the Controller or another team member) completes a detailed review of the manual portion of allocation of wages and benefits to grants. For the portion of wages and benefits that are automatically allocated to based on the approved timecards, ADP internal controls are relied upon. Anticipated completion date: The new process was implemented September 2025.
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, ...
Contact Person(s): Brianna Mariani - BriannaMariani@housinghope.org Kathryn Opina - KathrynOpina@housinghope.org Explanation and specific reasons for disagreement with the audit finding or that corrective action is not required (if applicable): N/A Corrective action planned: Beginning July 1, 2025, the Payroll Specialist began saving physically signed timesheets that document allocations to grants. Beginning August 1, 2025, allocations to grants are captured within the payroll system, ADP, along with the supervisor approval. The Payroll Specialist verifies each line on the timesheet is approved, which the system requires for the employee to receive payment. Anticipated completion date: Corrective action of signed allocation timesheets was implemented July 1, 2025. Corrective action of allocations to grants within ADP was implemented August 1, 2025.
Cognizant or Oversight Agency for Audit: Colegio Catolico Notre Dame Corp. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Gonzalez. Torres & Co., PSC, San Jose Tower 1250 Ponce de Leon Ave. Suite 801...
Cognizant or Oversight Agency for Audit: Colegio Catolico Notre Dame Corp. respectfully submits the following corrective action plan for the year ended June 30, 2025. Name and address of independent public accounting firm: Gonzalez. Torres & Co., PSC, San Jose Tower 1250 Ponce de Leon Ave. Suite 801, San Juan, PR 00907-3912 Audit Period: June 30, 2025 The findings from the June 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS – FINANCIAL STATEMENT AUDIT Finding 2025-001: Accounting Records and Reporting System Reportable Condition: See Statement of Condition 2025-001 Recommendation: The Organization should design and implement an integrated accounting system that would allow for the preparation of monthly closings, as well as the preparation of year-end financial statements in accordance with accounting principles generally accepted in the United States of America. Corrective Action – Finding 2025-01 The Organization will implement an integrated accounting closing process, and establish procedures for monthly and year-end closing processes. Management will assign responsible personnel to perform and review the necessary reconciliations, adjustments, and supporting schedules to ensure that the financial records are complete and maintained in accordance with accounting principles generally accepted in the United States of America (U.S. GAAP). Management will also establish a timeline for the monthly and year-end closing process and monitor compliance with the established procedures. FINDINGS – FEDERAL AWARDS Finding 2025-002: Reporting Reportable Condition: See Statement of Condition 2025-002 Recommendation: Management should continue to fulfill their auditee responsibilities as stated in 2 CRF 200.508 which among other things, require management to prepare appropriate financial statements and provide the auditor with access to personnel, accounts, books, records, supporting documentation, and other information as needed for the auditor to perform the audit and to ensure that subsequent financial reporting packages are submitted timely. Corrective Action-Finding 2025-02 Management will ensure that financial statements and required supporting documentation are prepared timely and that the auditor is provided with timely access to personnel, records, accounts, and other information necessary to complete the audit. Management will also monitor the submission of required financial reporting packages to ensure they are submitted within the applicable deadlines. If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please contact us at 787-743-3693.
Agency will develop a written process for submitting FSRS as required to include tracking schedule by subcontract to ensure timely submissions within one month following the signing of a new award. In Addition, the agency has appointed a cost specialist to carry out this responsibility with the Head...
Agency will develop a written process for submitting FSRS as required to include tracking schedule by subcontract to ensure timely submissions within one month following the signing of a new award. In Addition, the agency has appointed a cost specialist to carry out this responsibility with the Head Start Director serving as back up. The report is submitted to the CFO and filed in the agency’s fiscal electronic filing system in preparation for the annual audit. The FSRS for FY2026 is complete and timely submitted in alignment with subcontract renewals.
Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033. Finding Reference Number 2025-017 1. Finding Summary The auditor identified one (1) of sixty (60) students selected for student eligibility testing who was not awarded the full amount of Federal Pell Grant funds for wh...
Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033. Finding Reference Number 2025-017 1. Finding Summary The auditor identified one (1) of sixty (60) students selected for student eligibility testing who was not awarded the full amount of Federal Pell Grant funds for which the student was eligible. As a result, the institution could not demonstrate compliance with Title IV eligibility requirements, creating a risk that Federal Pell Grants funds could be awarded in an incorrect amount. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that the university should strengthen its procedures for reviewing student hours to ensure Federal Pell Grant funds are awarded in correct amount. 3. Root Cause Analysis The root cause of this finding resulted from an isolated oversight in the enrollment intensity review process and management will work to provide additional training to staff for review procedures. 4. Corrective Action(s) Management will provide additional training to staff. Description of Corrective Actions Management will provide additional training for staff in the Office of Financial Aid. Additionally, management will review the exception and award any Title IV aid determined to be underawarded. The University is also investing in a new cloud-based Enterprise Resource Planning (ERP) software designed for higher education institutions, Ellucian Colleague, which should automate the enrollment intensity and awarding process. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions mitigate the risk of aid being awarded incorrected based on enrollment intensity by strengthening and automating review procedures and ensuring staff are adequately trained to complete and document the review. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Director of Financial Aid • Name (optional): ____________ _ 7. Implementation Timeline • Corrective action implemented: D Yes IZI No • If not fully implemented, expected completion date: June 30, 2027 8. Status of Corrective Action (For Prior-Year or Repeat Findings) D Fully implemented D Partially implemented D Not yet implemented Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Continued staff training and immediate correction of any isolated exceptions including awarding/returning Title IV aid, if applicable.
Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-015 1. Finding Summary The auditor identified one (1) of sixty (60) students selected for student eligibility testing whose ISIR maintained did not reflect the appropriate dependency model....
Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-015 1. Finding Summary The auditor identified one (1) of sixty (60) students selected for student eligibility testing whose ISIR maintained did not reflect the appropriate dependency model. As a result, the institution could not demonstrate compliance with Title IV eligibility requirements, creating a risk that aid could be awarded based on incomplete or unsupported eligibility information. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that the university should strengthen its procedures for reviewing ISIR transactions prior to awarding and disbursing Title IV aid. 3. Root Cause Analysis The root cause of this finding resulted from an isolated oversight in the ISIR review process and management will work to provide additional training to staff for ISIR review procedures. 4. Corrective Action(s) Management will provide additional training to staff. Description of Corrective Actions Management will provide additional training for staff in the Office of Financial Aid. Additionally, management will review the exception and return any Title IV aid determined to be improperly disbursed. 5. Risk Mitigation (Required - Even if Disagreeing) These corrective actions mitigate the risk of aid being awarded based on incomplete or unsupported eligibility information by strengthening ISIR review procedures and ensuring staff are adequately trained to complete ISIR reviews. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Director of Financial Aid • Name (optional): ------------- 7. Implementation Timeline • Corrective action implemented: D Yes IZI No • If not fully implemented, expected completion date: September 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) D Fully implemented D Partially implemented D Not yet implemented Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Continued staff training and immediate correction of any isolated exceptions including the return of Title IV aid, if applicable.
Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-011 1. Finding Summary The auditor determined that the institution did not consistently obtain and document required verification information prior to disbursing Title IV federal student aid...
Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-011 1. Finding Summary The auditor determined that the institution did not consistently obtain and document required verification information prior to disbursing Title IV federal student aid for students selected for verification. As a result, the institution could not demonstrate compliance with federal verification requirements, increasing the risk that Title IV funds were disbursed before verification was completed. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that required verification documentation was not consistently obtained and documented prior to the disbursement of Title IV federal student aid for students selected for verification. 3. Root Cause Analysis The root cause of this finding resulted from weaknesses in verification monitoring procedures and inadequate review controls, which allowed Title IV aid to be packaged and disbursed prior to the completion and documentation of required verification. 4. Corrective Action(s) Management has implemented standardized checklists and workflows, added secondary review, provided additional training to staff, and implemented periodic internal monitoring. Description of Corrective Actions Management has implemented enhanced verification workflows and system controls to prevent packaging or disbursement of Title IV aid until verification is fully completed. A mandatory supervisory review has been established, and targeted staff training has been conducted to reinforce verification requirements. Periodic internal monitoring and quality assurance reviews will be performed to ensure ongoing compliance. 5. Risk Mitigation (Required - Even if Disagreeing) The corrective actions mitigate the risk of disbursing Title IV funds prior to verification completion by strengthening verification workflows, system controls, and supervisory review. Targeted staff training and ongoing internal monitoring further reduce the likelihood of premature disbursements and support sustained compliance with federal verification requirements. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Director of Financial Aid • Name (optional): ____________ _ 7. Implementation Timeline • Corrective action implemented: ~ Yes D No • If not fully implemented, expected completion date: 8. Status of Corrective Action (For Prior-Year or Repeat Findings) ~ Fully implemented D Partially implemented D Not yet implemented Evidence of Implementation Evidence of verifications completed in May through July 2026. 9. Monitoring and Sustainability Management will conduct regular supervisory and periodic internal reviews of verification files to confirm that required documentation is completed prior to Title IV packaging and disbursement. Continued staff training, maintained system controls, and standardized verification procedures will be sustained to ensure long-term compliance and timely identification of any deficiencies.
Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-010 1. Finding Summary The auditor identified that one (1) out of sixty (60) sampled students lacked required docwnentation of high school completion or an allowable alternative in their fil...
Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2025-010 1. Finding Summary The auditor identified that one (1) out of sixty (60) sampled students lacked required docwnentation of high school completion or an allowable alternative in their files, yet were awarded Title IV federal student aid. As a result, the institution could not demonstrate compliance with Title IV student eligibility requirements, creating a risk of disbursement to ineligible students. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that required documentation of high school completion or an allowable alternative was not consistently maintained in student files prior to the disbursement of Title IV federal student aid. 3. Root Cause Analysis The root cause of this finding was insufficient supervisory review of student eligibility documentation and decentralized documentation practices that resulted in inconsistent collection and retention of required records. 4. Corrective Action( s) Management has implemented standardized checklists and workflows, added secondary review, enhanced system controls, and implemented periodic internal monitoring. Description of Corrective Actions The institution has taken corrective action to strengthen compliance with Title IV student eligibility requirements related to documentation of high school completion. Management has implemented standardized eligibility checklists and documented workflows to ensure required documentation is collected and verified prior to awarding or disbursing federal student aid. A mandatory supervisory or secondary review has been added to confirm eligibility and documentation completeness before processing or disbursement occurs. In addition, system controls within the Student Information System (SIS), financial aid software, and document management systems have been enhanced to require receipt and retention of acceptable high school completion documentation before Title IV funds can be awarded. Targeted staff training has been conducted to reinforce federal eligibility requirements, institutional procedures, and documentation standards. To ensure ongoing compliance, the institution has established periodic internal monitoring and quality assurance reviews of student files to verify documentation accuracy and consistency. These measures are designed to prevent recurrence of the finding and support sustained compliance with federal regulations. 5. Risk Mitigation (Required - Even if Disagreeing) The implemented corrective actions mitigate the risk of awarding or disbursing Title IV funds to ineligible students by ensuring that high school completion documentation is collected, verified, and retained prior to aid processing. Standardized workflows, enhanced system controls, supervisory review, targeted staff training, and ongoing internal monitoring collectively strengthen compliance oversight, reduce documentation errors, and promote consistent adherence to federal student eligibility requirements. 6. Responsible Party • Office/Department: Office of Admissions • Title of Responsible Official: Director of Admissions • Name (optional): ____________ _ 7. Implementation Timeline • Corrective action implemented: 181Y es D No • If not fully implemented, expected completion date: 8. Status of Corrective Action (For Prior-Year or Repeat Findings) 181F ully implemented D Partially implemented D Not yet implemented Evidence of Implementation Evidence of high school completion for students. 9. Monitoring and Sustainability Management will conduct periodic internal reviews and quality assurance checks of student eligibility files to confirm that required high school completion documentation is consistently obtained and maintained prior to Title IV disbursement. Supervisory reviews, ongoing staff training, and continued use of standardized workflows and system controls will be sustained to reinforce compliance, identify issues timely, and ensure long-term adherence to federal Title IV eligibility requirements.
Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033. Finding Reference Number 2025-009 1. Finding Summary The auditor identified that five (5) out of sixty (60) sampled students had Title IV-created credit balances that remained on their accounts for more than 14 days wi...
Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033. Finding Reference Number 2025-009 1. Finding Summary The auditor identified that five (5) out of sixty (60) sampled students had Title IV-created credit balances that remained on their accounts for more than 14 days without being released to the student or parent. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that the identified condition resulted from the system not pulling credit balances per semester. 3. Root Cause Analysis The root cause was the absence of the system not pulling credit balances per semester. Therefore, it is a manual process to verify if the current semester aid creates a refund for current semester charges when a balance from a prior semester is rolling forward. 4. Corrective Action(s) Management has enhanced system controls and implemented periodic internal monitoring. Description of Corrective Actions To address this finding and prevent recurrence, the University is performing weekly reviews of all student accounts that had aid processed during that week. This review is important because all statements are reviewed even if a credit balance is not showing to identify if the aid for the period creates a credit for the semester despite a beginning balance. Further, the University is transitioning to a new accounting system which will identify credit by term. The new system, Colleague, which will automate the process, will be implemented in approximately 18 months. 5. Risk Mitigation (Required - Even if Disagreeing) The institution recognizes the importance of mitigating compliance risk in this area. Accordingly, the corrective actions described above are designed to timely identify student accounts with a refundable credit balance and future audit findings. 6. Responsible Party • Office/Department: Business Office • Title of Responsible Official: Senior Accountant • Name (optional): ____________ _ 7. Implementation Timeline Manual corrective actions have been implemented and are ongoing as part of standard operating procedures. The automated process is anticipated to be fully in place within 18 months once the University transitions to the Colleague system. • Corrective action implemented: IZI Yes D No • If not fully implemented, expected completion date: Action is fully implemented, but will transition to a new automated process at a later date. 8. Status of Corrective Action (For Prior-Year or Repeat Findings) IZI Fully implemented D Partially implemented D Not yet implemented Evidence of Implementation An example can be provided for a student with a balance who received a refund for the current semester despite not showing a credit balance. 9. Monitoring and Sustainability The University will continue its manual review process until it can be automated.
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University recognizes the importance of full compliance with the Gramm-Leach-Bliley Act (GLBA) and the updated Safeguards Rule. The University will continue working to complete and document the remaining requi...
Gramm-Leach-Bliley Act (GLBA) Compliance Planned Corrective Action: Southwestern Christian University recognizes the importance of full compliance with the Gramm-Leach-Bliley Act (GLBA) and the updated Safeguards Rule. The University will continue working to complete and document the remaining requirements of its written information security program, including risk assessment and mitigation, multifactor authentication, security monitoring, employee training, service provider assessments, incident response procedures, and ongoing oversight. The University will work closely with Nomerel, our IT specialist, along with the Qualified Individual and appropriate University personnel, to review current safeguards, identify remaining gaps, and implement the necessary policies, procedures, and controls to achieve and maintain compliance. The University will also ensure that the required annual assessment and reporting of the information security program are completed and documented. The University will monitor compliance on an ongoing basis and update its information security program as necessary to address changes in technology, threats, and regulatory requirements. Person Responsible for Corrective Action Plan: Dustin Sells (VP of Academic Affairs) - Qualified Individual, in coordination with Mark Arthur (Chief Financial Officer), Nomerel IT personnel, and University Administration. Anticipated Date of Completion: June 30, 2027
Management Response: Management agrees that the single audit was submitted past the March 31, 2026 deadline. While the County of Del Norte accepts ultimate responsibility, the delay resulted from a combination of factors, including communication breakdowns and personnel issues with our external audi...
Management Response: Management agrees that the single audit was submitted past the March 31, 2026 deadline. While the County of Del Norte accepts ultimate responsibility, the delay resulted from a combination of factors, including communication breakdowns and personnel issues with our external audit firm. During the audit, the County Auditor-Controller was notified that key points of contact were nonresponsive. Despite requesting to be looped into all correspondence, the Auditor-Controller was bypassed. This lack of direct communication prevented timely intervention to resolve issues and ensure an on-time filing. Notably, this is the County of Del Norte’s first late audit filing in over 14 years under the current management team. Estimated Completion Date: We fully expect to have our June 30, 2026 audit to be filed by the March 31, 2027 deadline. Responsible Party: Staff from the Office of the Auditor-Controller in conjunction with departmental level staff.
The City will establish and implement a formal tracking system and related internal controls for all contracts and projects subject to prevailing wage requirements, including CDBG-funded projects. The system should identify all applicable prime contractors and subcontractors and ensure that weekly c...
The City will establish and implement a formal tracking system and related internal controls for all contracts and projects subject to prevailing wage requirements, including CDBG-funded projects. The system should identify all applicable prime contractors and subcontractors and ensure that weekly certified payroll reports are submitted and reviewed timely in accordance with prevailing wage requirements.
Management Response: The Organization agrees with the auditor’s finding and will take actions to ensure that future documentation and reporting meets the standards required.
Management Response: The Organization agrees with the auditor’s finding and will take actions to ensure that future documentation and reporting meets the standards required.
Finding 2025-12 Special Tests and Provisions: Title IV Credit Balance Disbursements – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will enhance monitoring of Title IV credit balances to ensure balances are identified, reviewed, and...
Finding 2025-12 Special Tests and Provisions: Title IV Credit Balance Disbursements – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will enhance monitoring of Title IV credit balances to ensure balances are identified, reviewed, and disbursed within the required 14-day period. Student account and financial aid personnel will establish a recurring review of outstanding credit balances, document follow-up and resolution, and escalate unresolved balances before the federal deadline.; Anticipated Completion Date: July 1, 2027
Finding 2025-11 Special Tests and Provisions: NSLDS Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen procedures for identifying and reporting enrollment status changes, including degree conferrals occurring ...
Finding 2025-11 Special Tests and Provisions: NSLDS Reporting – Noncompliance and Significant Deficiency in Internal Control Over Compliance; Planned Corrective Action Plan: APU will strengthen procedures for identifying and reporting enrollment status changes, including degree conferrals occurring outside the normal graduation cycle. Appropriate personnel will periodically review enrollment and graduation activity to identify changes requiring submission to the National Student Clearinghouse and NSLDS, and documentation of the review and reporting will be retained.; Anticipated Completion Date: July 1, 2027
Finding 2025-10 Special Tests and Provisions: Key Personnel Changes –Significant Deficiency in Internal Control Over Compliance, Planned Corrective Action Plan: APU will establish a centralized process for identifying key personnel requirements contained in federal awards. Grant records will identif...
Finding 2025-10 Special Tests and Provisions: Key Personnel Changes –Significant Deficiency in Internal Control Over Compliance, Planned Corrective Action Plan: APU will establish a centralized process for identifying key personnel requirements contained in federal awards. Grant records will identify positions or individuals subject to agency notification or prior approval requirements. Key personnel assignments will be reviewed periodically and when personnel changes occur and required agency or pass-through entity communications and approvals will be retained with the grant record.; Anticipated Completion Date: July 1, 2027
Finding Number 2025-224: The Department overstated federal grant expenditures on the Schedule of Expenditures of Federal Awards (SEFA) closing package. Federal Program: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The department agrees with t...
Finding Number 2025-224: The Department overstated federal grant expenditures on the Schedule of Expenditures of Federal Awards (SEFA) closing package. Federal Program: 21.027 – Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The department agrees with the finding and asserts that it was a one-of-a-kind error in the timing of recording of one expenditure transaction. The error went undetected for a few months during the very confusing and difficult Luma transition year. When staff detected the error they believed the expenditure was still required to be reported on a SEFA and the only option available was to report it in FY 2025. Corrective Action: Staff have already completely familiarized themselves with the guidance on “New Requirement for Wire Payment Requests” issued by SCO on October 6, 2025. We are confident that our understanding of these new procedures will prevent any future occurrence. Anticipated Corrective Action Date: September 28, 2026 Responsible for Corrective Action: Steve Martin, Financial Officer Steve.Martin@idpr.idaho.gov (208) 869-4120
Finding Number 2025-220: Payroll adjustments lacked sufficient internal controls. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Grants to States for Medicaid 93.958 - Block Grants for Community Mental Health Services ...
Finding Number 2025-220: Payroll adjustments lacked sufficient internal controls. Federal Programs: 93.777 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.778 - Grants to States for Medicaid 93.958 - Block Grants for Community Mental Health Services Related to Prior Finding: 2024-234 Agency’s view: The agency agrees with the finding. Corrective Action: Updated ISD interface training and procedure documents. The ISD interface protocol has been revised to specifically address the required approval process for corrections. Updated training educates Financial Specialists on the proper procedures and reinforces the requirement to obtain documented approval via email before any corrections are interfaced. The Training documents also stress the importance of attaching the documents to the system to maintain proper records of such approval. Refresher training was also provided for all analysts. Expected outcome: These actions establish consistent, documented approval control for ISD corrections, and ensure that email approval evidence is retained with each transaction. Anticipated Corrective Action Date: June 30, 2026 Responsible for Corrective Action: Brooke Jenkins, Financial Specialist, Principal Brooke.Jenkins1@dhw.idaho.gov (208) 334-5500
Finding Number 2025-216: The Department understated federal expenditures on the Children's Health Insurance Program (CHIP) CMS-21 Base Reports by $1,088,209. Federal Program: 93.767 - Children's Health Insurance Program Related to Prior Finding: N/A Agency’s view: The agency agrees with the finding....
Finding Number 2025-216: The Department understated federal expenditures on the Children's Health Insurance Program (CHIP) CMS-21 Base Reports by $1,088,209. Federal Program: 93.767 - Children's Health Insurance Program Related to Prior Finding: N/A Agency’s view: The agency agrees with the finding. Corrective Action: During the FFY 2026, Quarter 1 CMS-21 reporting cycle, the Medicaid Budget Team identified underreported indirect expenditures for State Fiscal Years 2024 and 2025. The discrepancies were traced to initial reporting issues following the LUMA system go-live in July 2023, which resulted in indirect expenditures not being incorporated into the CMS-21 reporting process. To address the underreporting, the Medicaid Budget Team entered prior-period adjustments on CMS 21P forms to claim the eligible expenditures for the affected eight quarters, consistent with applicable CMS reporting requirements. To strengthen internal controls and prevent recurrence, the Medicaid Budget Team developed a new report that automatically incorporates indirect expenditures into the CMS-21 workpapers. This automated process reduces the risk of indirect expenditures being omitted and provides additional control to improve the completeness and accuracy of future CMS-21 reporting. Included is the CMS 21 Summary Sheet which shows the consolidation of the prior period adjustments make to claim all identified expenditures that had been omitted (line 2). Anticipated Corrective Action Date: October 1, 2025 Responsible for Corrective Action: Erica Williams, Financial Specialist Principal Erica.Williams@dhw.idaho.gov (208) 334-5500
Finding Number 2025-210: The Department did not provide documented support to verify the accuracy of a Low Income Energy Assistance Program (LIHEAP) performance report. Federal Program: 93.568 - Low-Income Home Energy Assistance Related to Prior Finding: 2024-230 Agency’s view: The agency agrees wit...
Finding Number 2025-210: The Department did not provide documented support to verify the accuracy of a Low Income Energy Assistance Program (LIHEAP) performance report. Federal Program: 93.568 - Low-Income Home Energy Assistance Related to Prior Finding: 2024-230 Agency’s view: The agency agrees with the finding. Corrective Action: The Department has updated a process document that will strengthen our internal controls regarding the LIHEAP performance report. The Department will compile and retain sufficient documentation to support the information included in the LIHEAP Performance report. Anticipated Corrective Action Date: The process document was updated on September 9, 2026, and will be utilized when completing the upcoming LIHEAP performance report. Responsible for Corrective Action: Lisa Johnson, Program Manager Lisa.Johnson@dhw.idaho.gov (208) 334-5739
Finding Number 2025-209: The Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) project and expenditure reports (P&E) contained misstatements. Federal Program: 21.027 - Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Division agrees with the ...
Finding Number 2025-209: The Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) project and expenditure reports (P&E) contained misstatements. Federal Program: 21.027 - Coronavirus State and Local Fiscal Recovery Fund Related to Prior Finding: N/A Agency’s view: The Division agrees with the finding and recognizes that additional controls are needed to ensure CSLFRF Project and Expenditure reports are accurate, fully supported, and more thoroughly reconciled to the State’s accounting system before submission. The Division notes that the identified errors were below the program’s materiality threshold and did not result in a finding of material noncompliance or a material weakness. The Division also corrects reporting errors when they are identified. However, Treasury’s published FAQ and written correspondence (attached) confirm that submitted reports cannot be reopened after the reporting deadline. Because P&E reports are cumulative, any necessary corrections must be reflected in a subsequent reporting period. This required correction process contributed to some of the differences identified during the audit because adjustments related to prior periods were necessarily recorded in later reports. Accordingly, the timing of these adjustments was consistent with Treasury’s prescribed reporting process. Corrective Action: The Division will implement the following corrective actions for all remaining CSLFRF P&E reports: 1. Required agency support. Each administering agency will submit a completed reporting template for every active project. If no activity occurred, the agency must provide documented confirmation of no change. Missing templates will be tracked and escalated before the report is finalized. 2. Reconciliation to Luma. Current and cumulative expenditures and obligations will be reconciled by administering agency to Lumat. All differences will be documented and resolved before submission. 3. Independent detailed review. The review will cover source templates, Luma reconciliations, current and cumulative amounts, prior-period balances, adjustments, and evidence supporting projects reported with no change. 4. Procedures, training, and retention. The Division will document the reporting process, provide training and cross-training to staff involved in CSLFRF reporting, and retain the templates, reconciliations, agency confirmations, review checklist, and final submission support in a centralized reporting file. 5. Correction of prior reporting errors. The Division will correct the identified errors through Treasury's prescribed process. In written email correspondence to Justin Collins, the U.S. Department of the Treasury confirmed: 'Prior submitted reports are not eligible to be reopened for revisions since the reporting deadline has passed. The SLFRF Project and Expenditure Reports are cumulative reports, and any adjustments needed will need to be made in the next reporting period.' Accordingly, the Division will document and include the necessary adjustments in the next available cumulative P&E report and retain Treasury's email as support for the correction method. Anticipated Corrective Action Date: January 31, 2027. The revised controls will be applied before submission of the next required quarterly CSLFRF P&E report. Responsible for Corrective Action: Justin Collins, Deputy Administrator | State Financial Officer Justin.collins@dfm.idaho.gov (208) 854-3063
UNAUTHORIZED CHANGE IN REQUIRED MONTHLY DEPOSIT IN REPLACEMENT RESERVE Supportive Housing for the Elderly – Assistance Listing Number 14.155 Recommendation: CLA recommends that processes and procedures be evaluated to strengthen internal control over compliance relating to HUD-restricted accounts. E...
UNAUTHORIZED CHANGE IN REQUIRED MONTHLY DEPOSIT IN REPLACEMENT RESERVE Supportive Housing for the Elderly – Assistance Listing Number 14.155 Recommendation: CLA recommends that processes and procedures be evaluated to strengthen internal control over compliance relating to HUD-restricted accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions Taken: Management will review compliance requirements for HUD programs related to replacement reserve withdrawals to ensure they are followed in the future. Name of the contact person(s) responsible for corrective action: Lindsey Beyer, Administrator Planned completion date for corrective action plan: September 2026
2025-002 UNAUTHORIZED WITHDRAWAL FROM REPLACEMENT RESERVE Supportive Housing for the Elderly – Assistance Listing Number 14.155 Recommendation: CLA recommends that processes and procedures be evaluated to strengthen internal control over compliance relating to HUD-restricted accounts. Explanation of...
2025-002 UNAUTHORIZED WITHDRAWAL FROM REPLACEMENT RESERVE Supportive Housing for the Elderly – Assistance Listing Number 14.155 Recommendation: CLA recommends that processes and procedures be evaluated to strengthen internal control over compliance relating to HUD-restricted accounts. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Actions Taken: Management will review compliance requirements for HUD programs related to replacement reserve withdrawals to ensure they are followed in the future. Name of the contact person(s) responsible for corrective action: Lindsey Beyer, Administrator Planned completion date for corrective action plan: September 2026
Findings Relating to Financials Statement: Finding 2025-002 – Late Filing SUGGESTED CORRECTIVE ACTION PLAN ON LATE FILING Planned Corrective Actions Management will implement a formal Single Audit filing calendar that identifies all statutory deadlines for Federal Single Audit (FAC) and Florida Sing...
Findings Relating to Financials Statement: Finding 2025-002 – Late Filing SUGGESTED CORRECTIVE ACTION PLAN ON LATE FILING Planned Corrective Actions Management will implement a formal Single Audit filing calendar that identifies all statutory deadlines for Federal Single Audit (FAC) and Florida Single Audit submissions, including interim milestones for close, audit fieldwork, report issuance, and filing. The Controller will be assigned to oversee audit coordination, monitor progress against deadlines, and ensure timely submission of all required reporting packages and certifications. Management will implement a submission checklist to verify completeness of the reporting packages prior to submission and will retain documentation evidencing timely filing with both the Federal Audit Clearinghouse and the Florida Auditor General. Management will accelerate year‑end close and audit preparation to allow sufficient time for review and filing prior to statutory deadlines. In addition to the audit filing status being periodically communicated to Executive Leadership Team, the Chair of the Audit Committee and the Chair of the Finance Committee, the calendar will also be shared going forward to enhance governance to support oversight and accountability. Anticipated Completion Date: 09/15/2026 Responsible Person/Title: April Dobes, CFO Management Statement: Management believes these actions will prevent recurrence and ensure timely filing of future Federal and Florida Single Audits.
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