Corrective Action Plans

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2025-005: REPORTING Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Othe...
2025-005: REPORTING Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: L. Reporting Condition/Context: During our review of meals claims submitted for reimbursement, we noted variances between the District’s meal counts and what was submitted to the Arizona Department of Education. For four months tested, meals claims were net under-reported by 10,403 lunch and breakfast meals, which calculated to $3,616.29. Additionally, for three of 4 months tested, the District did not maintain any documentation to support that the claims were reviewed by a second person. Action planned in response to finding: The District will ensure a second employee verifies and approves all NSLP Claim forms to ensure the claims submitted are accurate and complete prior to submission. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Jim Serbin, CFO.
The Finance Staff will collaborate with Police Department Staff during the budgeting process to ensure that revenue is not inappropriately budgeted. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Finance Staff will collaborate with Police Department Staff during the budgeting process to ensure that revenue is not inappropriately budgeted. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Accounting Manager assumed responsibility for the quarterly Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) reporting process following the unexpected departure of the former Finance Director. Due to the abrupt transition and issues associated with obtaining access to the portal, the ...
The Accounting Manager assumed responsibility for the quarterly Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) reporting process following the unexpected departure of the former Finance Director. Due to the abrupt transition and issues associated with obtaining access to the portal, the entity experienced a delay in submitting the Q1 2025 Project and Expenditure Report by the required deadline. Management acknowledges the importance of timely compliance with federal reporting requirements. Since access to the Treasury reporting portal was established, all subsequent Project and Expenditure Reports have been submitted timely. Personnel responsible for implementation: Veronica Alvarez, Deputy Finance Director Completion Date: June 30, 2026
June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, S...
June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2025 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2025-001 Corrective Action Plan: DePelchin has implemented an internal review process whereby a grant specialist on the evaluation team conducts a monthly review of all enrollments to verify that eligibility requirements, including priority characteristics and service area criteria, have been met. Program staff, evaluation staff, and data team members have been provided additional training on the applicable eligibility requirements and documentation standards. Additionally, DePelchin has implemented an annual cross-functional review process involving program leadership, evaluation staff, and fiscal representatives to review eligibility requirements and key contract provisions prior to the start of each fiscal year. This review is intended to ensure that any changes in program requirements are identified, communicated, and incorporated into program operations in a timely manner. Based on these corrective actions and enhanced monitoring procedures, DePelchin believes the risk of similar eligibility documentation issues has been substantially mitigated. Contact Person Responsible for Corrective Action: Mr. Brian Pate, Senior VP and CFO Anticipated Completion Date: The corrective action plan is anticipated to be completed by October 31, 2026. Respectfully submitted, Mr. Brian Pate Senior VP and CFO
Finding Number: 2025-002 Application of Rent Reasonableness Standards Planned Corrective Action: 1. Rent reasonableness forms will undergo a secondary review to ensure proper comparability. 2. If the assisted unit is above those of comparable units, documentation will be made and relevant support wi...
Finding Number: 2025-002 Application of Rent Reasonableness Standards Planned Corrective Action: 1. Rent reasonableness forms will undergo a secondary review to ensure proper comparability. 2. If the assisted unit is above those of comparable units, documentation will be made and relevant support will be retained to explain the justifiable reason to ensure no departures occur. Person Responsible for Corrective Action: Heather Ryan-Figueroa, VP of Programs and Colleen Cooper, Director of Finance. Anticipated Date of Completion: July 31, 2026.
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review th...
· Review current cost allocation plan and policy to determine if all information presented and needed is included in the policy document · Work with outside agency to review top down approach to cost allocation philosophy and determine if revisions are warranted · Work to payroll vendor to review the process to re-establish time-and-effort reporting through the timesheet entry process and the consolidation of time-and-effort information into reporting that can be easily summated by department/project and uploaded to MIP · Determine the allocation and cost distribution methods needed and the resulting detail reporting needed to substantiate the allocation methods used for propriety · Reinstitute the timesheet entry process by project/cost code and train staffing at an upcoming All Staff meeting to reset the view of timesheets and their importance of timesheet tracking to minimize errors for cost allocation purposes · Have staff begin using timesheets in Paylocity (by December 1st) · Complete update of Fiscal Policies Manual (inclusive of Cost Allocation methodology and philosophy) and timely reviews (i.e. at a minimum semiannually or with major program changes/contracts) to ensure no substantive changes needed to policy or actions needed to ensure appropriate accounting updates
In its 2025 Compliance Report, auditors made the following finding: Finding 2025‐001: Reporting – Significant deficiency in internal controls over compliance and compliance finding. Criteria: Under this grant program, the Foundation is required to complete semi‐annual performance reports in the Disa...
In its 2025 Compliance Report, auditors made the following finding: Finding 2025‐001: Reporting – Significant deficiency in internal controls over compliance and compliance finding. Criteria: Under this grant program, the Foundation is required to complete semi‐annual performance reports in the Disaster Recovery Grant Reporting (DRGR) system. Condition: During reporting testing, it was noted that the Foundation had not completed or submitted the required performance reports during the year. Cause: The Foundation didn’t implement an effective control for ensuring the required reporting under the grant was completed and submitted timely. Effect: Internal control was not properly designed to identify the required reporting and prevent noncompliance, and the Foundation was not in compliance with the reporting requirement. Recommendation: The Foundation should implement internal controls over the reporting process that ensures the required reporting is submitted in a timely manner. In addition, the Foundation should ensure grant agreements are reviewed in detail so no required reporting is overlooked. In response, Southern Gateway Public Green Foundation commits to the following Corrective Action Plan:  Remedy: In order to remedy this violation, staff will take immediate action to file missing semiannual reports in cooperation with general contractor.  Responsibility for Implementing Remedy: Reports will be filed by Anne Hagan, VP of Strategic Initiatives.  Verification of Remedy: Reports will be reviewed by April Allen, President and CEO, and filing of reports will also be confirmed by April Allen, President and CEO  Deadline for Remedy: As soon as possible but no later than 7/31/26.  Consequences in the event remedy is not undertaken: Failure to file reports could result in request for reimbursement of grant revenue.  Training to Prevent future violations: Reporting requirements and grant agreements will be reviewed by Anne Hagan.  Statement on Consequences of Repeated Violations: If future reports are late or missed, already reimbursed grant payments may have to be repaid and SGPGF may not be eligible for future grant payments.
Finding 2025-005 - Untimely Release of Title IV Credit Balances (Significant Deficiency): Condition - During testing of student account activity, we identified that fourteen (14) out of sixty (60) sampled students had Title IV created credit balances that remained on their accounts for more than 14 ...
Finding 2025-005 - Untimely Release of Title IV Credit Balances (Significant Deficiency): Condition - During testing of student account activity, we identified that fourteen (14) 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. All refunds were eventually released to the students. Corrertive Action Plan The College experienced significant staff turnover within the business office. In addition, the College is undergoing conversion to a new Enterprise Resource Planning (ERP) system which affected its ability to complete some functions within a timely manner. A new bursar was hired in May 2026. Timely processing of student refunds was emphasized during her training. Going forward, student refunds will be released within 14 days after credit balances are reflected on student accounts." Completion Date - September 30, 2026 Responsible Party - Chief Financial Officer
Management agrees with the finding above. Management will review the existing accounting policies and procedures and implement additional controls to validate timely submission of reports.
Management agrees with the finding above. Management will review the existing accounting policies and procedures and implement additional controls to validate timely submission of reports.
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code with...
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code within the Union College system specifically related to graduation and withdrawal dates. A report that includes status code changes will be reconciled with student status changes transmitted by the National Student Clearinghouse (NSC) to the National Student Loan Database System (NSLDS), and any necessary corrections will be made in the appropriate time frame. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented at the end of the Spring 2026 term.
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal con...
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal controls over the application of indirect cost rates to federally funded awards. Although corrective actions were initiated following the prior year's finding, the College has identified opportunities to enhance the review and monitoring of indirect cost rate calculations to ensure consistent compliance with Uniform Guidance. Going forward, the accounting group, in collaboration with the Office of Sponsored Programs, will maintain the current federally negotiated indirect cost rates, apply approved rates to applicable awards, and perform periodic reviews to verify that the correct rates are consistently applied. Timeline for Implementation of Corrective Action Plan: The College will finalize written procedures governing the application and review of indirect cost rates, implement a documented review process for indirect cost calculations prior to posting, and provide guidance to employees responsible for grant accounting. These actions will be completed by September 30, 2026. Management will periodically monitor compliance to ensure indirect cost rates are applied accurately and in accordance with federal requirements.
Management has implemented procedures effective 7/1/2025 to ensure that reports are submitted timely and that any new filing deadlines will be documented and met without exception.
Management has implemented procedures effective 7/1/2025 to ensure that reports are submitted timely and that any new filing deadlines will be documented and met without exception.
2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before i...
2025-003 ACTIVITES ALLOWED/ALLOWABLE COST PRINCIPLES Planned Corrective Action: This CMHSP will strengthen its grant financial management procedures. Finance staff will verify that all indirect cost calculations comply with the approved grant budget and the requirements of the federal award before indirect costs are charged to the grant. A grant expenditure tracking process will be established to monitor direct and indirect costs against the approved budget throughout the grant period. The Chief Financial Officer will review indirect cost calculations and budget-to-actual expenditures monthly to ensure expenditures remain within approved budget limitations and comply with applicable federal regulations and grant requirements. This CMHSP will create grant management policies and procedures, outside of the County of Lapeer’s grant management policy, to include documented reviews of indirect cost calculations, monthly budget monitoring, and supervisory approval of grant expenditures to ensure compliance with federal awards. Responsible Party: Emma McQuillan, Chief Financial Officer Anticipated Completion Date: 09/30/2026
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Correct...
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City concurs with this finding. City has hired additional resources to perform review of subrecipient transactions. On a monthly basis, the new position will review system generated reports to timely capture reportable subrecipient transactions. Additionally, the City has an ongoing quarterly meeting with all grant managers. Training will be provided to grant managers to ensure proper identification of subrecipient contracts and proper entry into the SAM.gov system. Anticipated Completion Date: December 31, 2026
Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges...
Finding Number: 2025-003 Finding Title: Reporting – PR29 CDBG Cash on Hand Quarterly Report Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City acknowledges this finding. City has communicated directly with Housing and Urban Development for clarification on reporting requirements and intends on following the updated guidance they provided. Anticipated Completion Date: July 31, 2026
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the...
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the Town will take the following steps: Before sending any future reports to the federal government, the Finance Department will match the report numbers directly to the Town's official accounting records (the general ledger). A second person in the finance department will review and sign off on the report before it is submitted. We will save copies of the accounting records and the signed approval forms to show future auditors. Planned Implementation Date of Corrective Action: September 1, 2026 Person Responsible for Corrective Action: Town Accountant/ Finance Director
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.
See pdf of corrective action plan
See pdf of corrective action plan
Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended Decem...
Finding No. 2025-001 Federal Award Finding Significant Deficiency in Internal Control over Compliance Noncompliance over Special Tests and Provisions (Sliding Fee Discount Schedule) Cowlitz Family Health Center (CFHC) respectfully submits the following corrective action plan for the year ended December 31, 2025. Summary of finding: Testing of 40 patient encounters identified 2 instances in which the sliding fee discount schedule (SFDS) was not applied in accordance with established requirements. These instances included the incorrect application of the sliding fee scale and the failure to apply the discount when required. As a result, certain patients were undercharged or overcharged for services received. Planned corrective action: CFHC management concurs with the finding. CFHC has policies and procedures in place to ensure compliance. CFHC will provide additional training to the Patient Services Representatives and Billing Clerks to ensure the existing policies and procedures are followed. The CFHC Billing Manager will develop additional reviews to discover, correct, and educate when non-compliance is suspected. CFHC will provide targeted trainings as necessary for site level personnel. Monitoring and review will be an ongoing effort as the positions responsible for real-time compliance tend to be highly transitory. Additional review steps have already been implemented and will become part of the typical workflows to monitor compliance. Anticipated Completion Date: June 1, 2026 Contact Person: Jim Merrill, Chief Financial Officer Email: jmerrill@cfamhc.org Phone: 360-703-6701 Name and Address of Independent Public Accounting Firm: Aprio, LLP 3 Centerpointe Dr, Ste 300 Lake Oswego, OR 97035
Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically tes...
Special Tests and Provisions Health Center Program Cluster – Assistance Listing No. 93.224 Recommendation: We recommend the following controls be put into place: •Implement a secondary review or approval control to validate that assigned discount levels align with documented income •Periodically test a sample of sliding fee determinations to ensure consistent application of the fee schedule •Provide training to registration and billing staff to reinforce SFDP requirements and documentation standards. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: We will implement an additional review of all sliding fee applications received and provide additional training for intake staff. Name(s) of the contact person(s) responsible for corrective action: Jennifer Smith Planned completion date for corrective action plan: 6/29/2026
2025-002 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The disbursement date being reported to COD by the College did not match the disbursement date shown on student account detail reports. Recommendation: Management should review and update internal control proces...
2025-002 Student Financial Assistance Cluster – Assistance Listing No. 84.SFA Condition: The disbursement date being reported to COD by the College did not match the disbursement date shown on student account detail reports. Recommendation: Management should review and update internal control processes over COD reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This system error has been corrected and additional training offered to bursar’s office. Name(s) of the contact person(s) responsible for corrective action: Wendy Davis Planned completion date for corrective action plan: 06/26/2026
Finding 2025-006 Reporting Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reporting, there was no documentation ...
Finding 2025-006 Reporting Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reporting, there was no documentation available for the review and approval procedures performed for one of the reports tested. Responsible Individuals: Janet Warren, Director of Financial Operations Corrective Action Plan: Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over reporting. In the future, management will ensure that documentation of the approval process for reporting is kept. Anticipated Completion Date: June 5, 2026.
Finding 2025-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reimbursement requests, there wa...
Finding 2025-005 Cash Management Federal Agency Name: U.S. Department of Health and Human Services Program Name: Certified Community Behavioral Health Clinic Expansion Grants Federal Financial Assistance Listing Number: 93.696 Finding Summary: During audit testing of reimbursement requests, there was no documentation available for the review and approval procedures performed. Responsible Individuals: Janet Warren, Director of Financial Operations Corrective Action Plan: Management agrees with the finding. There was turnover in staff and the prior CFO did not keep a record of his review over cash management. In the future, management will ensure that documentation of the approval process for reimbursement is kept. Anticipated Completion Date: June 5, 2026.
Management agrees with the finding and acknowledges that documentation of timesheet and payroll reviews was not consistently retained during the audit period. Management notes that this finding relates primarily to the documentation and consistency of review controls rather than an indication that r...
Management agrees with the finding and acknowledges that documentation of timesheet and payroll reviews was not consistently retained during the audit period. Management notes that this finding relates primarily to the documentation and consistency of review controls rather than an indication that reviews were not performed. To address this finding, management has implemented a formal, documented review process for timesheets and payroll prior to disbursement. Timesheets will be reviewed and approved through a centralized system or documented workflow to ensure that evidence of supervisory review is retained. Payroll changes require CEO approval prior to or concurrent with processing and documentation retained. Each payroll is subject to independent review and confirmation. Cumulative payroll and allocation are further subject to independent quarterly review by the CEO with supporting documentation. These procedures will be incorporated into standard operating practices and monitored periodically to ensure consistent application and retention of audit evidence. Anticipated Implementation Date: Implemented and ongoing; formal policy incorporation expected by September 1, 2026. Contact Person Responsible for Corrective Action: Shahara Wright, Chief Operating Officer & General Counsel and Brook Abitz, Director of People and Operations
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