Corrective Action Plans

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Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 th...
Item: 2026-001 Assistance Listing Number: 93.332 Program: Cooperative Agreement to Support Navigators in Federally-Facilitated Exchanges Federal Agency: U.S. Department of Health and Human Services Pass-Through Agencies: N/A Pass-Through Grantor Identifying Number: N/A Award Year: August 27, 2024 through August 26, 2029 Compliance Requirement: Subrecipient Monitoring Criteria: In accordance with 2 CFR 200.332 (e), (g) and (h) - pass-through entities must monitor subrecipient activity through reviewing financial and performance reports, verifying that subrecipients are audited if they meet the single audit criteria, and ensure that subrecipients take corrective action on single audit findings. Condition: AACHC implemented revised subrecipient monitoring procedures in October 2025 as part of its corrective action plan to address the prior-year finding. The revised procedures were applied to all active and new subrecipient agreements beginning October 2025. However, because certain subrecipient agreements had already concluded before the new procedures were implemented, AACHC did not retrospectively apply the monitoring process to those closed agreements. As a result, AACHC did not obtain and review financial statement audit or Single Audit reports for three subrecipients whose agreements ended prior to implementation of the revised procedures. Name of Contact Person: Brenda Hanserd, CFO Phone Number: 602-288-7559 Anticipated Completion Date: March 31, 2027 Views of Responsible Officials and Corrective Action Plan: In October 2025, AACHC implemented revised subrecipient monitoring procedures in response to the prior-year audit finding. The exception identified in the current audit relates solely to three subrecipient agreements that had already concluded before the revised procedures were implemented and therefore could not be incorporated into the new monitoring process. Effective October 1, 2025, AACHC implemented enhanced procedures requiring evaluation of Single Audit applicability, collection and review of applicable audit reports, and follow-up on any findings. In addition, AACHC now requires subrecipients to submit audit documentation covering the entire period of performance under the agreement, ensuring that monitoring activities are completed even when a subrecipient agreement ends prior to the completion of the audit cycle. This corrective action addresses the circumstances that gave rise to the finding and provides assurance that all subrecipient agreements are subject to appropriate audit review and follow-up moving forward.
Comments on the Finding and Each Recommendation: During the year ended May 31, 2026, $11,836 was withdrawn from the reserve for replacements without HUD approval. Management should transfer $11,836 from the operating account to the reserve for replacements account. Action(s) taken or planned on the ...
Comments on the Finding and Each Recommendation: During the year ended May 31, 2026, $11,836 was withdrawn from the reserve for replacements without HUD approval. Management should transfer $11,836 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding Agree. Management concurs with the finding and recommendation. On August 11, 2026, management transferred $11,836 from the operating account to the reserve for replacements account.
Finding 2026-001: Statement of condition #2026-001: Management fees of $3,192 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the findin...
Finding 2026-001: Statement of condition #2026-001: Management fees of $3,192 were prepaid at May 31, 2026. Comments on the Finding and Each Recommendation: The Agent should reduce management fees charged in the following periods or repay the balance prepaid. Action(s) taken or planned on the finding: The Agent reimbursed $3,192 to the Corporation on August 11, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will ...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add subrecipient monitoring policies and procedures to the organization’s grants compliance manual. These policies and procedures will be in compliance with Uniform Guidance to ensure proper annual monitoring. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCA America will add suspension and debarment policies and procedures to the organization’s grants compliance manual. It will ensure vendor verification for suspension and debarment prior to entering into a transaction/contract. With annual review of suspension and debarment throughout the program lifecycle. Name(s) of the contact person(s) responsible for corrective action: Dr. Bart Klika, Chie_x001F_ Research O􀆯icer Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026.
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCAA will implement a formal year-end close communication process for vendors and subrecipients. Fiscal year-end reminders will be distributed by email,...
Views of responsible o􀆯icials and planned corrective actions: There is no disagreement with the audit finding. Action taken in response to finding: PCAA will implement a formal year-end close communication process for vendors and subrecipients. Fiscal year-end reminders will be distributed by email, with a request that final invoices be submitted before the books are closed. PCAA will also maintain the books open for six weeks after fiscal year-end to help ensure expenditures are recorded in the proper fiscal year. Name(s) of the contact person(s) responsible for corrective action: Alina Birenyte, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by August 31, 2026
Significant Deficiency - Suspended or Debarred Covered Transactions Corrective Action Plan: The Village administration team will collaborate with the engineering team and funding source to establish required written and documented procedures to ensure that contractors and sub-contractors working on ...
Significant Deficiency - Suspended or Debarred Covered Transactions Corrective Action Plan: The Village administration team will collaborate with the engineering team and funding source to establish required written and documented procedures to ensure that contractors and sub-contractors working on projects within the Village are not suspended or debarred. Responsible Party: Thomas J. Ostrander, Village Manager Proposed Completion Date: February 28, 2027
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-e...
Finding 2026-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2027 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2026, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
Finding Number: 2026-002 Condition: The Organization did not appropriately monitor subrecipient audit findings to determine whether prompt and appropriate corrective action has been taken. Planned Corrective Action: The Organization has implemented system and process improvements to ensure review of...
Finding Number: 2026-002 Condition: The Organization did not appropriately monitor subrecipient audit findings to determine whether prompt and appropriate corrective action has been taken. Planned Corrective Action: The Organization has implemented system and process improvements to ensure review of subrecipient audit reports. To the extent that findings are identified, allowable mitigation measures will be considered by the Organization and documented as allowed under 2 CFR. The Organization has and will continue to maintain appropriate staffing level and sufficient training to ensure appropriate review is taking place. Contact Person Responsible for Corrective Action: Hannah Bonacci, Director, Public Partnerships Anticipated Completion Date: July 31, 2026
Finding Number: 2026-001 Condition: The Organization failed to correctly record grant revenue for certain federal programs during their 2026 fiscal year. Planned Corrective Action: Management will continue to evaluate current processes and practices to determine that contributions are being recogniz...
Finding Number: 2026-001 Condition: The Organization failed to correctly record grant revenue for certain federal programs during their 2026 fiscal year. Planned Corrective Action: Management will continue to evaluate current processes and practices to determine that contributions are being recognized in a timely manner based on when expenses are incurred, regardless of when they get reported to the Organization by the subrecipient. This will include building out currently utilized flowcharts/checklists as well as adding indicators into their assessment which will result in additional clarity regarding the status of the transaction and the timing of revenues and expenses to be recorded. Contact Person Responsible for Corrective Action: Emily West, Controller Anticipated Completion Date: July 31, 2026
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training cont...
Corrective action planned: Management concurs with the finding and recognizes the importance of consistently applying the correct sliding fee discount schedule in effect at the time services are rendered. To address this finding, the organization has implemented enhanced monitoring and training controls over the application of the sliding fee discount schedules. The Director of Patient Services (or designee) will perform monthly audits of 25 randomly selected patients accounts that received a sliding fee discount to verify that the correct discount schedule was applied and that the patient responsibility was calculated accurately. In addition, for any future changes to the sliding fee discount schedule, management will implement a transition review process that includes: • Verification that the updated fee schedule is accurately loaded into the billing system prior to the effective date and old fee schedules are inactivated. • Additional training for billing staff before implementation of any revised sliding fee schedule. • Continued monthly audits of sliding fee discounted patient accounts. • Quarterly reporting of audit results to Chief Financial Officer, to identify recurring issues and ensure corrective actions taken are effective. Anticipated completion date: July 31, 2026
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a p...
Recommendation – We recommend the Center provide proper training to employees to ensure that the sliding fee discounts are being properly applied and documented. In addition to implementing policies and procedures to ensure the sliding fee discounts are being properly monitored and supervised on a periodic basis to ensure compliance. Action Taken – We concur with the audit finding. While the Center has a policy that meets the compliance requirements, management is responsible for the implementation and monitoring of those processes and procedures. Additional staff training on slide fee discounts is in place and monthly review and testing of compliance with Center sliding fee discount policy will be done.
Finding 2026-001 – Internal Control over Financial Reporting – Allowable Costs U.S. Department of Treasury Passed Through the County of Erie COVID-19: Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 Allowable Costs Contact Person Responsible for Corrective Action: Name: Tammi Michali T...
Finding 2026-001 – Internal Control over Financial Reporting – Allowable Costs U.S. Department of Treasury Passed Through the County of Erie COVID-19: Coronavirus State and Local Fiscal Recovery Funds, ALN 21.027 Allowable Costs Contact Person Responsible for Corrective Action: Name: Tammi Michali Title: Office Manager Phone/Email: 814-897-2690 / tmichali@ecgra.org Auditor’s Recommendation: The auditors recommend that management implement procedures to ensure all disbursements charged to federal programs are formally reviewed and approved by the Board, or by a properly designated approver, and that such approval is evidenced in writing and maintained with the supporting disbursement documentation. Management should also implement a monitoring procedure to identify any disbursements processed without timely approval and ensure corrective action is taken. Corrective Action Plan: A resolution was passed by the Erie County Gaming Revenue Authority’s Board of Directors affirming their consent to disburse funds for Round 2 of the Educator Retention Awards. The Board was informed by the executive director that this was a clerical oversight as the action to fund Round 2 had been discussed and was given verbal approval at previous Strategic Planning meetings. Anticipated Completion Date: Corrective Action Plan was completed on May 21, 2026
The issue was administrative rather than financial, and the Project is making extra payments to fully fund the replacement reserve balance.
The issue was administrative rather than financial, and the Project is making extra payments to fully fund the replacement reserve balance.
Name of auditee: Anchor Community, Inc. HUD auditee identification number: 101-HD029 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended March 31, 2026 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Telephone number: 901-435-7764 Curren...
Name of auditee: Anchor Community, Inc. HUD auditee identification number: 101-HD029 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended March 31, 2026 CAP prepared by Name: Tashawndra Welch Position: Chief Financial Officer Telephone number: 901-435-7764 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2026-001: At March 31, 2026, the Corporation's reserve for replacements fund was not invested in an interest-bearing account. Comments on the Finding and Each Recommendation: The Agent should transfer the reserve for replacements fund into an interest-bearing account. Action(s) taken or planned on the finding: Agreed. The Agent concurs with the finding and auditor's recommendation.
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization is aware of this issue and meets regularly to discuss the workflows identified to minimize this issue until the vendor has implemented an interface to resolve this issue. The Organization has procedures in place to address the internal controls related to determining, recording, and monitoring the sliding fee process. The goal is to ensure that the appropriate sliding fee rates/categories are utilized for each encounter for each patient. The Organization has been working with the electronic health record vendor to interface the medical and dental components of the system to ensure the information is flowing across both components of the application. The sliding fee scale information is housed in the medical component of the system and does not consistently flow to the dental component of the system. The tentative go live date for this interface is scheduled for September 2026. Until then the team will continue to assess all dental sliding fee scale patients accounts manually to ensure accurate sliding fee rates/categories are utilized for each sliding fee encounter/patient.
Finding 2026-001 Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align...
Finding 2026-001 Plan: Please see below the new process ensuring replacement reserve requests are being made in a timely manner: 1) Quarterly Assessment: Quarterly review are now in place to assess reserve balances and ensure funds are used for necessary repairs. Monthly cash flow reports will align reserve balances with property needs. 2) Formal Utilization Procedure: A written procedure has been established for requesting and using replacement reserve funds. This includes clear guidelines, approval workflows, and thresholds for reserve levels based on property needs. 3) Monitoring & Reporting: Periodic audits will ensure funds are spent according to HUD guidelines. 4) Staff Training & Oversight: Staff will receive training on proper reserve management, and management will increase oversight to ensure funds are used appropriately. Completion Date: 11/1/2026 Contact: Jackie Oliveira-Director of Affordable Housing
Remaining balance was deposited on April 16, 2026. In the future management will ensure deposits are made timely or obtain HUD appproval permitting delay if there were cash flows issues.
Remaining balance was deposited on April 16, 2026. In the future management will ensure deposits are made timely or obtain HUD appproval permitting delay if there were cash flows issues.
Statement of Condition 2026-001 (Assistance Listing 14.155): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended January 31, 2026. Recommendation: Management should notify the lender of the new reserve for replacement deposit amount and make an ad...
Statement of Condition 2026-001 (Assistance Listing 14.155): The Corporation did not make all of the HUD required reserve for replacement deposits for the year ended January 31, 2026. Recommendation: Management should notify the lender of the new reserve for replacement deposit amount and make an additional $565 deposit to the reserve for replacements fund on the next billing. Management Response: Agree. Management has notified the lender of the new required deposit and will make an additional $565 deposit to the reserve for replacements fund on the next billing.
The BoatU.S. ADVs contract will be amended for fiscal year 2026 contracts to include the ALN, and the need for a Single Audit for subrecipients that expend over $1,000,000 in federal funding in their given fiscal year. BoatU.S. will implement stricter deadlines for subrecipients to submit their bian...
The BoatU.S. ADVs contract will be amended for fiscal year 2026 contracts to include the ALN, and the need for a Single Audit for subrecipients that expend over $1,000,000 in federal funding in their given fiscal year. BoatU.S. will implement stricter deadlines for subrecipients to submit their biannual reports in 2026. Progress monitoring will be done throughout the year and documented by BoatU.S. personnel. This should also include project cost documentation of the subrecipient is used for authorized purposes. These reports may need to include photos of the tasks completed, if necessary. BoatU.S. plans to only reimburse for progress costs as incurred by the subrecipient.
Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction concurs with this finding. This issue was addressed in the prior audit. The grant ended shortly after completion of that audit, and there was no opportunity to change awarded amounts once the issue wa...
Noncompliant Eligibility Determinations - Literacy - OPI - The Montana Office of Public Instruction concurs with this finding. This issue was addressed in the prior audit. The grant ended shortly after completion of that audit, and there was no opportunity to change awarded amounts once the issue was identified. The previous superintendent agreed not to pull funds back. The matter has been corrected in the new grant that began in October 2024, and the issue does not appear to affect the new grant. Mechanisms have been implemented to ensure that only schools meeting eligibility requirements receive funds. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Support for Federal Reimbursement - Literacy - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented mo...
Inadequate Support for Federal Reimbursement - Literacy - OPI - The Montana Office of Public Instruction partially concurs with this finding. The prior audit was not completed in time for the Office to implement changes before the fiscal years reviewed in the current audit. The Office implemented more stringent criteria for cash requests from schools in late 2024, and these requirements have been in place since that time. Although there has been considerable pushback from local education agencies due to the added burden, the Office has remained firm on the information required. Cash requests are audited quarterly by the Internal Control Auditor against submitted budget documents, and any issues identified are addressed. The more stringent criteria are fully implemented, and no further corrective actions are needed beyond continuing the current process. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the ne...
Inadequate Support for Benefit Accuracy Measurement Reviews - UI - DLI - The Montana Department of Labor and Industry began retaining copies of the on-demand report generated from the Sun System upon learning of the concern. This process continued until October 2024, when staff confirmed that the newly developed view in the Montana Unemployment System Enhancement (MUSE) system was functioning as intended. The MUSE system now includes a real-time interface that compares its data with the Sun System, providing staff with immediate information to monitor the volume of items selected for workload sampling. Responsible Party - Robin Graham, Central Services Division Administrator, Montana Department of Labor and Industry Target Implementation Date - 12/31/2026
Inadequate Support for Federal Reimbursement - Title I - OPI - The Montana Office of Public Instruction partially concurs with this finding. Training and new process documentation were implemented in April 2025 to correct the issue. The previous audit was not completed until October 2024, with the f...
Inadequate Support for Federal Reimbursement - Title I - OPI - The Montana Office of Public Instruction partially concurs with this finding. Training and new process documentation were implemented in April 2025 to correct the issue. The previous audit was not completed until October 2024, with the final audit committee meeting held in December 2024, and the new process was put in place and communicated as quickly as possible. The process is now functioning correctly. The Office has implemented a tracking mechanism to ensure appropriate time reporting. For fiscal year 2027, the Office has added an additional monthly review of each federal budget to confirm that time reported aligns with expected and allocated time for each project. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Subrecipient Audit Monitoring - TANF - DPHHS - The Montana Department of Public Health and Human Services obtained copies of the Single Audit reports for the two subrecipients identified in the finding and verified the audit outcomes. The department did not document its review of those re...
Inadequate Subrecipient Audit Monitoring - TANF - DPHHS - The Montana Department of Public Health and Human Services obtained copies of the Single Audit reports for the two subrecipients identified in the finding and verified the audit outcomes. The department did not document its review of those reports. The subrecipient relationships in question have since ended. The department will obtain, review, and document its review of subrecipient Single Audit reports, including issuing management decisions on any applicable findings, as required by 2 CFR 200.332(e), and will retain that documentation regardless of whether the subrecipient relationship continues. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 8/31/2026
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