Corrective Action Plans

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The Cutter Morning Star is deeply disappointed by the findings identified through the audit and review involving the former superintendent. The State Board determined that violations occurred involving district, state, and/or federal policies and laws, including failure to honestly report enrollment...
The Cutter Morning Star is deeply disappointed by the findings identified through the audit and review involving the former superintendent. The State Board determined that violations occurred involving district, state, and/or federal policies and laws, including failure to honestly report enrollment, misuse of public funds, and misuse of school property. These actions do not reflect the values, expectations, or standards of the district. The findings exposed the district to unnecessary risk and damaged the trust that the community places in its school leadership. The district remains committed to operating with integrity, transparency, accountability, and full compliance with all applicable laws and policies moving forward.
The Band has developed and initiated a procedure to subject all employees with access to vulnerable populations to be subjected to background investigations. The Band has instituted these procedures; however, they were initiated post the September 30, 2025 financial statements. OMB will continue to ...
The Band has developed and initiated a procedure to subject all employees with access to vulnerable populations to be subjected to background investigations. The Band has instituted these procedures; however, they were initiated post the September 30, 2025 financial statements. OMB will continue to monitor this process in a quarterly review with Human Resources.
The Band has added additional staff within its OMB to increase their ability to perform more thorough seperation of duties and more accurately process these submissions. A complete internal review of the Band's OMB policies and procedures is scheduled and expected completion is December 31, 2026.
The Band has added additional staff within its OMB to increase their ability to perform more thorough seperation of duties and more accurately process these submissions. A complete internal review of the Band's OMB policies and procedures is scheduled and expected completion is December 31, 2026.
Finding – 2025-003 Allowable Costs and Cost Principles and Activities Allowed and Unallowed – Significant Deficiency in Internal Controls Over Compliance Federal Program: Provider Relief Funds Assistance Listing Number: 93.498 Year(s): 2025 Federal Agency: US Department of Health and Human Services ...
Finding – 2025-003 Allowable Costs and Cost Principles and Activities Allowed and Unallowed – Significant Deficiency in Internal Controls Over Compliance Federal Program: Provider Relief Funds Assistance Listing Number: 93.498 Year(s): 2025 Federal Agency: US Department of Health and Human Services Corrective Action: The Division will enhance controls to ensure that documentation of cost review is retained and stored for audit purposes. The Division will continue to train field staff on the importance of document retention. 1. Internal process to be continued throughout FY 2026. 2. The program managers and/or contract billing specialist will save all work pertaining to an invoice/bill (i.e. monthly, quarterly, addendums, etc.) and electronically via email submit to program directors for review and approval before submission can proceed to granting agency to ensure accuracy and for contract fulfillment and requirements. 3. The program managers and/or contract billing specialist will save all documentation of the reviewed and submitted process to the regional internal digital file storage system, as well as send a copy of the finance department for review/approval/storage for audit purposes and the finance department will lastly make sure it is filled out and fulfills the requirement of the contract, as a last line of grant requirement fulfillment. 4. Continued training of field staff and program directors to occur. Anticipated Completion Date: 10/01/2026 Responsible Contact Person: Kendall Phillips, Grants & Contracts Accountant
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we wil...
Corrective Action Plan Year Ended September 30, 2025 Finding 2024-002 AL Numbers: 93.837 Program: National Heart, Lung and Blood Institute Correction Action: Brown Health management concurs with this finding. We have already initiated re-training at the department level. For fiscal year 2026, we will perform a detailed review of all salaries charged to federal grants to ensure there is no salary over the cap. Additionally, we will review automated control enhancements within our ERP system where possible to assist in recognizing compliance rules and/or enhance monitoring controls where possible. Contacts: Stephen Almonte, Vice President and Corporate Controller Salmonte3@brownhealth.org Bharat Ramratnam, MD, Senior Vice President of Research BRamratnam@brownhealth.org Planned Completion Date: October 31, 2026
Effective immediately, the Executive Director will conduct a mid-year review each June to confirm that the first required subrecipient monitoring has been completed, and ensuring the second monitoring is scheduled and completed prior to fiscal year-end.
Effective immediately, the Executive Director will conduct a mid-year review each June to confirm that the first required subrecipient monitoring has been completed, and ensuring the second monitoring is scheduled and completed prior to fiscal year-end.
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: ...
FINDING 2025-003 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: We intend to include a section in all future agreements with the town to confirm that contractors/vendors acknowledge their suspension and debarment status. These agreements and contracts will be signed and approved by multiple Town officials. Anticipated Completion Date: This adjustment to agreements and contracts will go into effect April 24, 2026.
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with ...
FINDING 2025-002 Finding Subject: COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Ryan Schwab Contact Phone Number and Email Address: 260-338-2700; ryan.schwab@huntertown.in.gov Views of Responsible Officials: We concur with this finding Description of Corrective Action Plan: Prior to the submission of the P&E report, a copy will be printed and reviewed by another individual from our office (Town Manager or Utility Office Manager), or a member of our Town Council and that individual will initial or sign off on the document after their review. Anticipated Completion Date: This procedure will go into effect on June 1, 2026.
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective ac...
CFDA 10.558 — Child and Adult Care Food Program Finding Type: Noncompliance / Significant Deficiency Corrective Action Plan The YMCA acknowledges the finding related to missing participant eligibility documentation maintained by operating sites. Management has implemented the following corrective actions: 1. Establish standardized procedures requiring all operating sites to submit enrollment forms and Income Eligibility Forms prior to reimbursement claims being submitted. 2. Develop a monitoring checklist to verify that all required participant documentation is collected, complete, and retained. 3. Require monthly compliance reviews of participant files for each operating site. 4. Provide additional training to site administrators regarding CACFP eligibility documentation and retention requirements. Responsible Party Jeff Reynolds and Sonja Williams Expected Completion Date September 30, 2026
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, t...
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, the procedure has been updated to report bi-weekly rather than monthly to ensure reporting under 30 days. The GMO Director will also provide continuous training to staff outside of the GMO to ensure staffing will not become a barrier, as experienced in early 2026. As of June 1, 2026, all FFATA entries as of the May 25th purchase order (R071) report have been reported. Additionally, as we plan for the forthcoming electronic grants management system (eGMS) we’re in discussion to add a report feature that will provide needed info for FFATA entry i.e., UEI, FAIN, award amount and purchase order # to automate the process. SEFA Reporting Compliance: Prior to the submission of the SEFA, the grant expenditures will be reviewed with the Accounting Officer, The AFO, and the Grants Program Manager for a detailed review of the SEFA to confirm expenditures are correctly categorized by fund and grants, reconciles to the DIFS R019 report and reflects the amount expended for sub-recipients. Effective FY26, subrecipient totals are uniquely identified with an account number that will reflect in the R019 report as a subset of total expenditures. This report will be used to complete the SEFA going forward.
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split betwee...
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split between grant and local projects can record their time to each funding source. This new process will be rolled out starting June 12, 2026.
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, t...
The Department of Behavioral Health (DBH) Office of the Chief Financial Officer (OCFO) concurs with this finding. FFATA Reporting Compliance: In February 2026, the DBH Grants Management Office created an FFATA procedure to ensure compliance with timely FFATA reporting. As a result of this finding, the procedure has been updated to report bi-weekly rather than monthly to ensure reporting under 30 days. The GMO Director will also provide continuous training to staff outside of the GMO to ensure staffing will not become a barrier, as experienced in early 2026. As of June 1, 2026, all FFATA entries as of the May 25th purchase order (R071) report have been reported. Additionally, as we plan for the forthcoming electronic grants management system (eGMS) we’re in discussion to add a report feature that will provide needed info for FFATA entry i.e., UEI, FAIN, award amount and purchase order # to automate the process. SEFA Reporting Compliance: Prior to the submission of the SEFA, the grant expenditures will be reviewed with the Accounting Officer, The AFO, and the Grants Program Manager for a detailed review of the SEFA to confirm expenditures are correctly categorized by fund and grants, reconciles to the DIFS R019 report and reflects the amount expended for sub-recipients. Effective FY26, subrecipient totals are uniquely identified with an account number that will reflect in the R019 report as a subset of total expenditures. This report will be used to complete the SEFA going forward.
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income su...
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This would be automating the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. DCWET will work with DICM to request that a JIRA ticket be created to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The ESA DPO needs to conduct staff training (re-training) of all SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to providing adequate training to SSRs involved in updating customers’ employment information in DCAS. The DCWET Deputy Administrator will take the lead with the DPO counterpart to implement the necessary training starting before September 30, 2027.
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. The Office of Financial Aid experienced staff turnover, which impacted the timeliness of reporting submissions to the Common Origination and Disbursement (COD) system. This challenge was ...
The University of the District of Columbia (UDC) agrees with the conditions and recommendations of this finding. The Office of Financial Aid experienced staff turnover, which impacted the timeliness of reporting submissions to the Common Origination and Disbursement (COD) system. This challenge was further compounded by the need to train and cross-train staff to ensure continuity in reporting responsibilities. To address this issue, the office has identified and trained two staff members who are capable of originating and submitting enrollment reporting to COD. Additionally, we have implemented enhanced internal controls, including weekly reporting processes, to ensure compliance with all required deadlines. These measures are designed to ensure that records are submitted within the mandated 15-day timeframe.
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) concurs with the auditor’s findings and recommendations. Create clear communications and instructions for DMPED grant administrators to include as a required reporting responsibility. Add internal controls and policies that...
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) concurs with the auditor’s findings and recommendations. Create clear communications and instructions for DMPED grant administrators to include as a required reporting responsibility. Add internal controls and policies that include a supervisory review of the report information before it is submitted to the System for Award Management (sam.gov) website.
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury)...
The Office of the Deputy Mayor for Planning and Economic Development (DMPED) does not concur with the auditor’s finding regarding the allowability of subtenant improvement allowance per the CPF guidance. DMPED has sought express approval from the Federal awarding agency (U.S. Department of Treasury) regarding the use of funds. DMPED has evaluated its procedures to ensure only allowable expenses are charged to the program as required under 2 CFR Section 200.403. DMPED determined in FY25 that it needed to seek approval from the awarding Federal agency on allowable costs, which it completed in 2026.
The Office of the State Superintendent of Education (OSSE) concurs with the auditor’s finding and recommendations related to this finding. This oversight occurred during the transition to the new corrective action plan instituted during the prior fiscal year. OSSE is confident in its new review proc...
The Office of the State Superintendent of Education (OSSE) concurs with the auditor’s finding and recommendations related to this finding. This oversight occurred during the transition to the new corrective action plan instituted during the prior fiscal year. OSSE is confident in its new review process of FFATA that will prevent the underlying reporting issue from recurring. OCFO concurs with the auditor’s finding. The original classification reflected OCFO’s judgment during report compilation rather than lack of control. Based on the initial analysis, the OCFO had not bifurcated the amount of the subrecipients’, School Food Authorities (SFAs) and Food Service Program Sponsors (SFSPs), expenditures in the SEFA under the Passed Through to Subrecipients column. CNC program operated as a reimbursement mechanism where School Food Authorities (SFAs) and Summer Food Services Program (SFSP) Sponsors received payments as Subrecipients. Subsequently reviewed, OCFO bifurcated the related expenditure in the SEFA, which resulted in updating the SEFA accordingly. OCFO remains committed to complying with its policies and procedures and will implement an additional layer of review to ensure the accuracy of the SEFA.
The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Quarterly UPO internal audits and Quarterly Regis audits will continue to assist in identifying areas of noncompliance and improvement. In addition, t...
The Office of the Chief Financial Officer/Office of Finance and Treasury (OCFO/OFT) for Department of Human Services (DHS) concurs with this finding. Quarterly UPO internal audits and Quarterly Regis audits will continue to assist in identifying areas of noncompliance and improvement. In addition, the EBT Manager and Supervisors will implement enhanced review and validation procedures of daily card production documentation, including targeted quality checks and supervisory oversight, to ensure alignment with established requirements. Employees will be held accountable for performing in accordance with documented procedures, and corrective actions will be applied as needed to address gaps. These efforts are intended to improve consistency, reduce risk, and ensure sustained compliance with program requirements.
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implement...
Management’s Action Plan: Management concurs with the findings. The deficiency was due to a lapse in management oversight related to the review and approval of independent contractor timesheets. To strengthen internal controls and ensure compliance with federal requirements, management has implemented corrective actions through the full implementation of a new enterprise resource planning system, Fusion. Under this process, all timecards are now entered, reviewed, and approved directly within Fusion and cannot be processed for payment unless they have been formally approved by appropriate management personnel. This ensures proper documentation, accountability, and adherence to internal control policies. Name of Person Responsible for the Plan: Katherine Hill, Manager of Accounting Jason Lynn, Vice President of Finance and Controller Anticipated Completion Date of the Plan: Completed – fully implemented with the rollout of the Fusion system (May 2025).
Corrective Action Plan: Dallas County HCVP leadership addressed EIV compliance during the April 2026 and May 2026 monthly staff meetings and will continue to emphasize the requirement. Review of meetings agendas dated April 22, 2026, and May 20, 2026, confirm that EIV compliance was discussed. Addit...
Corrective Action Plan: Dallas County HCVP leadership addressed EIV compliance during the April 2026 and May 2026 monthly staff meetings and will continue to emphasize the requirement. Review of meetings agendas dated April 22, 2026, and May 20, 2026, confirm that EIV compliance was discussed. Additionally, the HCVP Housing Supervisor issued an email to all staff reiterating the requirement to retain EIV reports for all transactions, including but limited to recertifications, interims, and relocations. Implementation Date: June 11, 2026 Responsible Party: Kesete Yohannes, Assistant Director of Housing
Corrective action plan: The Ryan White Grants Management Division will ensure the addition of enhanced controls to the existing subaward agreement template. Implementation dates: August 30, 2026 Responsible persons: Sonya Hughes, Assistant Director, Ryan White Grants Compliance
Corrective action plan: The Ryan White Grants Management Division will ensure the addition of enhanced controls to the existing subaward agreement template. Implementation dates: August 30, 2026 Responsible persons: Sonya Hughes, Assistant Director, Ryan White Grants Compliance
We concur with the finding and are implementing procedures to address all issues. Civil Air Patrol (CAP) experienced turnover in key positions within the General Counsel and Contracting offices, which resulted in a lapse in the consistent execution of procurement file review controls. As a result, c...
We concur with the finding and are implementing procedures to address all issues. Civil Air Patrol (CAP) experienced turnover in key positions within the General Counsel and Contracting offices, which resulted in a lapse in the consistent execution of procurement file review controls. As a result, certain required procurement reviews were not completed in accordance with CAP policy. CAP has since filled the vacant positions and initiated a comprehensive review of procurement files. This review includes the completion of the CAPF GCC-06 Procurement File Review Checklist, as required, and the retroactive reconciliation of procurement documentation to the extent practicable. In addition, CAP is strengthening internal controls by enhancing monitoring procedures to ensure procurement file completeness prior to closeout and providing targeted training to procurement and program staff on applicable federal and internal documentation requirements. CAP expects to complete the retrospective file review and fully implement these enhanced controls by 30 September 2026.
American Rescue Plan Elementary and Secondary School Emergency Relief (ARP ESSER) Fund – Assistance Listing No. 84.425 Recommendation: We recommend the District establish and document formal procedures to ensure compliance with equitable services requirements for ESSER funds. These procedures should...
American Rescue Plan Elementary and Secondary School Emergency Relief (ARP ESSER) Fund – Assistance Listing No. 84.425 Recommendation: We recommend the District establish and document formal procedures to ensure compliance with equitable services requirements for ESSER funds. These procedures should include timely and meaningful consultation with private school officials, proper documentation of consultation and decision‑making, and ongoing monitoring to ensure services are provided in accordance with federal requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We will ensure compliance with equitable services to private schools. Name(s) of the contact person(s) responsible for corrective action: Stacy Rodriguez Director of Finance Planned completion date for corrective action plan: September 2025
Audit Finding Reference Number: 2025 – 003 Finding: NERACOOS submitted FFATA reports for the initial subaward agreements; however, the reports were not updated timely for subsequent subaward amendments. Specifically, amended subaward amounts and amendment dates were not reported timely and accuratel...
Audit Finding Reference Number: 2025 – 003 Finding: NERACOOS submitted FFATA reports for the initial subaward agreements; however, the reports were not updated timely for subsequent subaward amendments. Specifically, amended subaward amounts and amendment dates were not reported timely and accurately in SAM.gov. Corrective Action Plan: Develop a subaward amendment tracking log to record all subaward modifications, including amendment dates, revised subaward amounts, and FFATA reporting due dates. The log will be updated each time a subaward amendment is executed. Establish a written procedure requiring that any subaward amendment triggering a change in amount or key data be reported in SAM.gov within the required timeframe (no later than the end of the month following the month in which the obligation or award was made). Designate a staff member responsible for FFATA reporting compliance and assign a backup to ensure coverage during absences. Implement a quarterly reconciliation between executed subaward agreements/amendments and SAM.gov reporting records to identify and remediate any unreported or inaccurate entries. Provide training to relevant Finance and Grants Management staff on FFATA reporting requirements under 2 CFR Section 200.332 and SAM.gov reporting procedures. Retroactively update SAM.gov for any subaward amendments identified during the audit as not having been reported or reported inaccurately. Responsible Official: Jake Kritzer, Executive Director Anticipated Completion Date: August 31, 2026 (retroactive corrections); ongoing quarterly reconciliation beginning July 2026
FINDING 2025-004 The City does not have documented procurement policies and procedures in place as required by the Uniform Guidance. Furthermore, the City did not monitor contractor compliance with BABA provisions. Management’s Response The City will adopt documented procurement policies and procedu...
FINDING 2025-004 The City does not have documented procurement policies and procedures in place as required by the Uniform Guidance. Furthermore, the City did not monitor contractor compliance with BABA provisions. Management’s Response The City will adopt documented procurement policies and procedures and monitor contractor compliance with BABA provisions in FY 2026.
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