Corrective Action Plans

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Management concurs with Audit Finding 2025-002 and will reinforce controls over USDA food distribution documentation to ensure all distributions are properly acknowledged and supported in accordance with Food Distribution Cluster recordkeeping requirements. Management will implement the following co...
Management concurs with Audit Finding 2025-002 and will reinforce controls over USDA food distribution documentation to ensure all distributions are properly acknowledged and supported in accordance with Food Distribution Cluster recordkeeping requirements. Management will implement the following corrective actions: 1. Required Agency Acknowledgment at Delivery Management will reinforce procedures requiring recipient agency signatures or equivalent acknowledgment on all USDA food distribution invoices at the time of delivery. Distribution staff and drivers will be reminded that unsigned delivery documentation is considered incomplete. 2. Post-Delivery Follow-Up Control Management will implement a follow-up control, such as a delivery log or checklist, to track all USDA distributions recorded at the time of delivery. The log will include verification that a signed receipt has been obtained and returned for each transaction. 3. Reconciliation of Distributions to Signed Documentation On a periodic basis, management will reconcile USDA distribution activity to signed agency invoices to identify any missing acknowledgments. Missing signatures will be promptly investigated and resolved, with documentation of follow-up retained. 4. Supervisory Review and Oversight Supervisory personnel will perform periodic documented reviews of distribution documentation to verify that signed agency receipts are obtained, complete, and retained. Evidence of review will be maintained. 5. Training and Awareness Management will provide refresher training to distribution staff and drivers on USDA documentation requirements and the importance of obtaining signed acknowledgment to support program accountability and reporting accuracy. Expected Completion Date: Within 60-90 days Responsible Parties: Andrelle Bowen, Transportation Manager, (901-373-0402)
Single Audit – Federal Funds Finding Organization: Pathways In Education – Illinois (PIE-IL) Audit Period: FY25 (or applicable fiscal year) Prepared By: [Brittany Barsevick/Manager of Instructional Compliance] Date: [1/21/2026] Federal Program: ALN 84.010 Title I, Part A, Basic grants Low-Income and...
Single Audit – Federal Funds Finding Organization: Pathways In Education – Illinois (PIE-IL) Audit Period: FY25 (or applicable fiscal year) Prepared By: [Brittany Barsevick/Manager of Instructional Compliance] Date: [1/21/2026] Federal Program: ALN 84.010 Title I, Part A, Basic grants Low-Income and Neglected Audit Finding Reference: 2025-001 ________________________________________ 1. Finding Summary The Single Audit identified a deficiency in the documentation and communication of federally funded position percentages and the alignment of Time & Effort attestations with the actual period of work performed. Specifically, the current CPS Federal Funds platform (Oracle) generates Time & Effort Attestation reports based on the month reimbursement claims are submitted, rather than the period during which the work was performed, creating a compliance gap. ________________________________________ 2. Root Cause ● Staff were not consistently informed of the exact percentage of their position funded by federal sources at the start of each semester. ● Time & Effort attestations were generated from the CPS Oracle system based on claim submission timing, not the actual work period. ● There was no formal internal SOP layer to supplement Oracle-generated reports with staff attestation aligned to Semester 1 and Semester 2 work periods. ________________________________________ 3. Corrective Actions Action 1: Internal Funding Percentage Notification System Description: PIE-IL will implement an internal tracking and notification system to ensure all staff funded in whole or in part with federal funds are formally notified of the exact percentage of their position supported by federal funding. Implementation Steps: ● Develop a standardized Federal Funding Allocation Notice template. ● Distribute notices to all applicable staff at the start of Semester 1 and Semester 2. ● Require staff acknowledgment (electronic or signed) confirming receipt and understanding. ● Maintain records centrally in the federal compliance folder. Responsible Party: Manager of Instructional Compliance Timeline: Implemented by the first day of each semester Monitoring: Semester-based review of acknowledgment logs ________________________________________ Action 2: Semester-Based Time & Effort Attestation Description: All federally funded staff will complete and sign a Time & Effort Attestation for both Semester 1 and Semester 2, certifying that time worked aligns with the funding source and percentage assigned. Implementation Steps: ● Issue Time & Effort forms at the end of each semester. ● Require staff to certify actual work performed during the semester. ● Collect supervisor verification signatures. ● Store completed attestations in the federal compliance repository. Responsible Party: Site Administrators / Federal Compliance Officer Timeline: Within 10 business days of semester end Monitoring: Quarterly internal compliance audits ________________________________________ Action 3: Internal SOP as Supplemental Documentation Layer Description: PIE-IL will implement a formal Standard Operating Procedure (SOP) for Time & Effort as a self-managed, internal documentation layer that supplements CPS Oracle-generated attestation reports. This SOP will ensure that Time & Effort documentation reflects the actual period of work performed, rather than the month in which reimbursement claims are submitted. Implementation Steps: ● Draft and approve a written SOP outlining: ○ Semester-based attestation requirements ○ Alignment between funding percentages and staff assignments ○ Reconciliation process between internal records and Oracle reports ● Train administrators and federally funded staff on SOP procedures. ● Maintain SOP as a controlled document with annual review and updates. Responsible Party: Federal Programs Director / Compliance Manager Timeline: SOP finalized within 30 days of audit response submission Monitoring: Annual SOP review and internal compliance testing ________________________________________ 4. Reconciliation Process with CPS Oracle System PIE-IL will perform a monthly reconciliation between: ● Oracle-generated Time & Effort Attestation reports (claim-based), and ● Internal Semester-Based Time & Effort attestations (work-period-based). Any discrepancies will be documented, corrected, and reviewed by the Federal Compliance Officer prior to reimbursement submission. ________________________________________ 5. Evidence of Implementation The following documentation will be maintained for audit and monitoring purposes: ● Federal Funding Allocation Notices with staff acknowledgments ● Signed Semester 1 and Semester 2 Time & Effort Attestation forms ● Approved Time & Effort SOP document ● Training sign-in sheets and materials ● Monthly reconciliation logs between Oracle and internal records ________________________________________ 6. Completion Dates Corrective Action Target Completion Date Funding Percentage Notification System [9/30/2026] Semester-Based Time & Effort Attestation Process [02/06/2026] SOP Finalization and Staff Training [02/28/2026] Monthly Reconciliation Process Ongoing ________________________________________
Finding 2025-004 Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for timely and accurate reporting of a student’s enrollment status and changes in those enrollment statuses, whether they report directly or via a third-party servicer. When an Instituti...
Finding 2025-004 Finding Summary: 34 CFR 690.83(b)(2) and 34 CFR 685.309 states that Institutions are responsible for timely and accurate reporting of a student’s enrollment status and changes in those enrollment statuses, whether they report directly or via a third-party servicer. When an Institution is made aware of a change in a student’s enrollment status, the Institution has 60 days to update the change in enrollment status via NSLDS. During testing of compliance for Enrollment Reporting, there were 3 instances out of 60 where the College did not report a student’s change in enrollment status accurately or within the required time limit of 60 days from the effective date of the student’s change in enrollment status. Corrective Action Plan: Enrollment reporting has been centralized under a single point of contact, thereby mitigating risk, ensuring consistency, accountability, and regulatory compliance. This structure was formally implemented last summer with the hiring of an Academic Records Compliance Specialist, significantly strengthening oversight and operational controls. Responsible Individual(s): Monze Stark – Dean of Enrollment Services, Noah Briscoe – Assistant Registrar Anticipated Completion Date: 12/31/2025
The City concurs with the finding. Audit testing identified no reporting errors, no noncompliance, and no questions costs; however, the City acknowledges that documentation of independent supervisory review was not formally required or retained prior to submission of federal reports and reimbursemen...
The City concurs with the finding. Audit testing identified no reporting errors, no noncompliance, and no questions costs; however, the City acknowledges that documentation of independent supervisory review was not formally required or retained prior to submission of federal reports and reimbursement requests. To strengthen documentation of internal control over compliance, the City will implement a formalized and documented secondary review process for all federal financial reports, performance reports, and reimbursement requests, to be retained in grant files in accordance with CFR §200.334 record retention requirements.
Corrective Action Plan Description: Effective October 2025, FH will strengthen its documentation controls to ensure that only the final, approved version of each timesheet is maintained as support for payroll charges to federal awards. Any timesheet revised during the review and approval process wil...
Corrective Action Plan Description: Effective October 2025, FH will strengthen its documentation controls to ensure that only the final, approved version of each timesheet is maintained as support for payroll charges to federal awards. Any timesheet revised during the review and approval process will be clearly marked as “void,” and removed from the official support file. Payroll and grant personnel will be instructed on this updated procedure to ensure compliance with 2 CFR 200 documentation standards. FH will perform periodic reviews to confirm consistent application of the revised process. Responsible: GSC Grants Finance Officer Due Date: 02/28/2026
Matching – Assistance Listing No. 93.671 Recommendation: We recommend the Organization enhance its internal controls over the review of the payroll allocation to ensure matching contributions are accurately calculated and supported. Explanation of disagreement with audit finding: There is no disagre...
Matching – Assistance Listing No. 93.671 Recommendation: We recommend the Organization enhance its internal controls over the review of the payroll allocation to ensure matching contributions are accurately calculated and supported. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Senior Accountant or Director of Grants and Compliance will conduct the initial review to ensure that match costs are allowable, properly supported, and accurately calculated. The Chief Financial Officer will perform a secondary review and approval to validate completion of the initial review and confirm that reported match amounts reconcile to supporting documentation. Evidence of review will be documented through dated signatures or electronic approval within the grant billing file. Name of the contact person responsible for corrective action: Ashley Freivogel Planned completion date for corrective action plan: September 30, 2026
Title: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review all R2T4 calculations to confirm accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken...
Title: Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review all R2T4 calculations to confirm accuracy. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We added an additional validation step in our process to confirm that the original charge amounts are accurate. Name(s) of the contact person(s) responsible for corrective action: Danielle Hayden Planned completion date for corrective action plan: October 1, 2025
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disag...
Title: Student Financial Assistance Cluster – Assistance Listing Nos. 84.007, 84.033, 84.063, 84.268 Recommendation: We recommend the College review its reporting procedures to ensure that students’ statuses are accurately and timely reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We identified that the issue is related to transferring data between NSC (where we report enrollment for all students) and NSLDS (where federal aid recipients are monitored). To bridge this gap, we have provided a member of the Registrar’s Office with access to NSLDS to audit the data submitted to NSC and the transfer of information. Additionally, we are conducting research to determine if there are alternative reporting options that may provide greater accuracy. Name(s) of the contact person(s) responsible for corrective action: Theresa Rodriguez Planned completion date for corrective action plan: March 2026
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.559 2025-002 Internal Control Over Compliance with Allowable Activities Requirements Finding Su...
SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE – U.S. DEPARTMENT OF AGRICULTURE, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION – CHILD NUTRITION CLUSTER – FEDERAL ALN 10.553, 10.555, AND 10.559 2025-002 Internal Control Over Compliance with Allowable Activities Requirements Finding Summary 7 CFR § 210.8 requires the District to establish and maintain effective internal control over compliance with requirements applicable to federal program allowable activities, including meal count requirements applicable to child nutrition cluster federal programs. During our audit, we noted the District did not have sufficient controls over meals counts submitted for afterschool snack reimbursement claims. For two months tested, the District’s internal tracking records for afterschool snacks served did not agree to the meal counts submitted to the Minnesota Department of Education (MDE) for reimbursement. In both cases, the internal records had been altered after the meal counts submissions to the MDE had been completed to add eligible afterschool snacks that had been missed. This resulted in underclaimed meals for eligible snacks served. Corrective Action Plan Actions Planned – The District will review and update its policies and procedures relating to eligible afterschool snack meal tracking and reimbursement submission for its child nutrition cluster federal program to ensure compliance with the Uniform Guidance in the future. Official Responsible – The District’s Director of Food Service, Dorie Pavel. Planned Completion Date – June 30, 2026. Disagreement With or Explanation of Finding – The District agrees with this finding. Plan to Monitor – The District’s Director of Food Service, Dorie Pavel, will assure appropriate internal controls and procedures are updated and in place for afterschool snack meal tracking and reimbursement submission to ensure the accuracy of District claims for eligible meal reimbursements in the future.
Management engaged an external HR consultant to assist with revising the Accounting Policy Manual to formally document written policies and procedures related to compensation and fringe benefits. Draft policies have been developed and are currently under management review for accuracy and alignment ...
Management engaged an external HR consultant to assist with revising the Accounting Policy Manual to formally document written policies and procedures related to compensation and fringe benefits. Draft policies have been developed and are currently under management review for accuracy and alignment with existing practices. The finalized policies will be presented for Board approval and implemented by March 18, 2026, and responsibility for ongoing monitoring and periodic review has been assigned to the Chief Financial Officer and Director of Administration to ensure continued compliance. Training will be provided to applicable staff, and compliance with the updated policies will be incorporated into management’s periodic internal reviews.
In order to maintain procedures to verify the disbursement dates in the COD System agree to the date funds are credited to the student’s account in the colleges Accounts Receivable subledger to the general ledger, the institute has updated its procedures. The Financial Aid Office will adjust the sch...
In order to maintain procedures to verify the disbursement dates in the COD System agree to the date funds are credited to the student’s account in the colleges Accounts Receivable subledger to the general ledger, the institute has updated its procedures. The Financial Aid Office will adjust the scheduled disbursement date according to updated procedures when disbursement occurs earlier than the scheduled date to ensure accuracy of reporting data to COD. These are updates to the current Disbursement Policy and Procedures.
The Cooperative will make deposits to the general operating reserve to meet the HUD regulatory agreement. The management agent will implement a process to ensure deposits are made as required by the regulatory agreement.
The Cooperative will make deposits to the general operating reserve to meet the HUD regulatory agreement. The management agent will implement a process to ensure deposits are made as required by the regulatory agreement.
The Cooperative will make deposits to the general operating reserve to meet the HUD regulatory agreement. The management agent will implement a process to ensure withdrawals are made as required by the regulatory agreement.
The Cooperative will make deposits to the general operating reserve to meet the HUD regulatory agreement. The management agent will implement a process to ensure withdrawals are made as required by the regulatory agreement.
Recommendation: We recommend the College review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:...
Recommendation: We recommend the College review its reporting procedures to ensure the students' statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office updated procedures when citizenship documentation is received for a student previously classified as a noncitizen. The Financial Aid Office will notify the Office of Records and Registration of the student’s status change. Prior to disbursing Title IV aid, the Financial Aid Office will verify with the Office of Records and Registration that the student has been added to required NSLDS reporting. Name(s) of the contact person(s) responsible for corrective action: Tasha Marwitz Planned completion date for corrective action plan: Effective immediately.
Finding 2025-002: MAINTENANCE OF EFFORT – SIGNIFICANT DEFICIENCY Federal Program: Title I, Part A (84.010) Auditee Contact Person: James Ragsdale, CFO Expected Completion Date: July 31, 2026 Condition: The School’s Form 9 report, used by the IDOE to calculate Maintenance of Effort, was found to be u...
Finding 2025-002: MAINTENANCE OF EFFORT – SIGNIFICANT DEFICIENCY Federal Program: Title I, Part A (84.010) Auditee Contact Person: James Ragsdale, CFO Expected Completion Date: July 31, 2026 Condition: The School’s Form 9 report, used by the IDOE to calculate Maintenance of Effort, was found to be unreliable. Reported expenditures on the Form 9 did not reconcile with the Network’s cash-basis financial records for the period of July 1, 2024, to June 30, 2025. Corrective Action Plan: To ensure accurate reporting and compliance with Federal MOE standards, Purdue Polytechnic High School of Indianapolis, Inc. will implement the following: Form 9 Reconciliation Protocol: The School will implement a mandatory reconciliation between the general ledger cash-basis reports and the Form 9 Biannual Financial Report prior to each submission (January and July). Standardized Chart of Accounts: The CFO will review all account mappings to ensure they strictly follow the SBOA Uniform Compliance Guidelines for Indiana Charter Schools. This will ensure expenses are categorized correctly by fund, object, and function as required for IDOE reporting. Quarterly Internal Audits: The Finance Team will perform a Form 9 reconciliation quarterly to identify and correct any discrepancies in cash-basis recording before the official reporting window opens. Staff Training: The CFO will attend IDOE Office of School Finance training sessions specifically focused on Form 9 submission and Maintenance of Effort compliance. Audit Trail Documentation: For every Form 9 submission, the CFO will maintain a "reconciliation folder" containing the original trial balance and the crosswalk used to generate the Form 9.
The district has updated procedures to include review of the Quarterly Financial Summary reports by someone other than the preparer of the reports prior to submission. Review will be documented. This finding was corrected in time for the 2nd Quarterly Financial Summary reporting (Oct-Dec 2024). Due ...
The district has updated procedures to include review of the Quarterly Financial Summary reports by someone other than the preparer of the reports prior to submission. Review will be documented. This finding was corrected in time for the 2nd Quarterly Financial Summary reporting (Oct-Dec 2024). Due to the timing of the 2024-25 Single Audit, the 1st Quarterly Financial Summary had already been submitted under the old process, which resulted in this finding to be a repeat of a prior year finding.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of the review and approval of grant reports prior to being submitted, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure notification to federally funded employees of their funding source twice a year and will make sure supervisors get reports and sign certifications for work duties in compliance with the federal grants twice a year. Date of implementation - effective immediatel...
The Chief Financial Officer will ensure notification to federally funded employees of their funding source twice a year and will make sure supervisors get reports and sign certifications for work duties in compliance with the federal grants twice a year. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
The Chief Financial Officer will ensure staff retain documentation of review and approval of the indirect costs charged to the federal programs, effective immediately. Date of implementation - effective immediately, January 30, 2026.
2025-001 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that required HQS are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in re...
2025-001 Housing Voucher Cluster – Assistance Listing No. 14.871/14.879 Recommendation: We recommend the Authority implements controls to ensure that required HQS are completed timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: See narrative below. SC Housing’s inspection team strives to represent both the organization and HUD at the highest level. The HCV inspections team takes pride in being timely, professional, and thorough, as evidenced by the single finding noted in our most recent audit. SC Housing has taken several corrective steps to mitigate and prevent late inspections. First, we implemented modifications to our organizational structure. Late inspections resulted from the previous structure and business practices, which assigned staff to specific families and required them to oversee all HCV-related tasks for those families, including inspections. While this approach promoted continuity, it created challenges when staff were absent for extended periods, as there was no backup capacity to absorb the workload. As a result, SC Housing reorganized the HCV program to significantly reduce the likelihood of late HQS inspections. Inspections are now centralized as a primary function, and the inspection team has been restructured to be smaller, more flexible, and more responsive. Second, SC Housing has enhanced its monitoring processes. In addition to regularly pulling system-generated reports to identify inspections due, staff are now fully utilizing PIC reports to proactively identify families approaching the maximum 24-month inspection timeframe, thereby reducing the risk of late inspections. Lastly, staff leaves and absences are being managed more effectively to ensure adequate coverage at all times. This approach ensures that sufficient staffing is available to complete all inspection types timely and without delay. Name(s) of the contact person(s) responsible for corrective action: Lisa Wilkerson, Director of Rental Assistance and Compliance Lenzy Morris, HCV Inspections Manager Planned completion date for corrective action plan: Immediately and Ongoing If the U.S. Department of Housing and Urban Development has questions regarding this plan, please call Lisa Wilkerson at (803) 896-7030.
Corrective Action Plan 2025-001: The College concurs with the finding and has adjusted its processes and controls beginning with the Fall 2025 semester to ensure that all Title IV funding sources including FSEOG are drawn down in accordance with the Heightened Cash Monitoring requirements. Completio...
Corrective Action Plan 2025-001: The College concurs with the finding and has adjusted its processes and controls beginning with the Fall 2025 semester to ensure that all Title IV funding sources including FSEOG are drawn down in accordance with the Heightened Cash Monitoring requirements. Completion Date: August 2025 Contact Person: Laura Crawley
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jessica Johnston, Chief Financial Officer Anticipated Completion Date: August 20, 2025, immediately following the determination that the number o...
Finding Number: 2025‐001 Program Name/Assistance Listing Title: Child Nutrition Cluster Assistance Listing Numbers: 10.553, 10.555, 10.559 Contact Person: Jessica Johnston, Chief Financial Officer Anticipated Completion Date: August 20, 2025, immediately following the determination that the number of meals reported for reimbursement for the January and March claims did not agree to supporting documentation. Planned Corrective Action: The District has modified its internal controls related to child nutrition claims. The revised procedures include a secondary verification of reimbursable meals, which is completed and submitted by personnel independent of the data entry process.
Name of Contact Person: Daniel Nolan, Finance Officer Corrective Action Plan: Management will implement controls and procedures to ensure that consultation with private school officials takes place in a timely manner each year and that documentation is maintained on file to evidence these consultati...
Name of Contact Person: Daniel Nolan, Finance Officer Corrective Action Plan: Management will implement controls and procedures to ensure that consultation with private school officials takes place in a timely manner each year and that documentation is maintained on file to evidence these consultations. Proposed Completion Date: Immediately
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