Corrective Action Plans

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2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were per...
2025-004 – Lack of Documentation for SAM.gov Exclusion Checks. Auditor Description of Condition and Effect. Although the Village has processes in place to cover these areas, and completes SAM.gov exclusion checks, the Village did not retain documentation to support that the exclusion checks were performed for vendors. As a result, there is no evidence that the Village verified whether these parties were suspended or debarred prior to entering covered transactions. Auditor Recommendation. We recommend that the Village retain evidence that SAM.gov exclusion checks are being completed for vendors to document that vendors are not suspended or debarred prior to entering covered transactions. Corrective Action. The Village will begin retaining documentation for its SAM.gov exclusion checks that it completes for vendors to verify whether these parties were suspended or debarred prior to entering covered transactions. Responsible Person. Ross Wilson, Village Clerk/Treasurer. Anticipated Completion Date: February 2026.
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 and that the support for the sliding fee discounts is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization has recognized the deficiency of internal controls regarding this determination, recording, and monitoring of the sliding fee process from application through making the adjustment. The Organization has implemented a comprehensive input and verification process that applies to both the initial application and the subsequent adjustment phases. This includes enhanced checks to ensure accuracy in data entry and calculation, as well as verification of application information. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Tricia Lippert, Comptroller at 970-327-0537.
Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its procedures to ensure controls are in place to ensure to catch any inconsistencies that occur during the year. Explanation of disagreement with audit finding: No disagreement with the au...
Student Financial Assistance Cluster – CFDA No. 84.063, 84.268 Recommendation: We recommend the College review its procedures to ensure controls are in place to ensure to catch any inconsistencies that occur during the year. Explanation of disagreement with audit finding: No disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office will maintain documentation of monthly communication between the External Programs Manager, the Financial Aid Director and the Director of Accounting, related to the monthly reconciliation of Federal Direct Loans, Federal Pell Grant. Federal SEOG and Federal Work Study programs. Name of the contact person responsible for corrective action: Jenae Schmidt, Director of Financial Aid Planned completion date for corrective action plan: September 30, 2025
BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by th...
BOYS & GIRLS CLUBS OF WEBER-DAVIS CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person and title: Angie Pitt Completion date: October 2, 2025 Agency's response: Concur Management's Response: The Boys & Girls Clubs of Weber-Davis has not been required by the grant facilitator to provide member income data. However, to ensure compliance with federal reporting requirements, we will begin requesting income information from our members. In addition, we will reach out to our partner schools to determine whether they can confirm which of our members participate in the free or reduced lunch program.
To safeguard from future errors and ensure data accuracy, Human Resources partnered with Enterprise Application Services department to develop an automated process that populates earnings codes and project account codes based on employee, job record and earnings code. This enhancement streamlines da...
To safeguard from future errors and ensure data accuracy, Human Resources partnered with Enterprise Application Services department to develop an automated process that populates earnings codes and project account codes based on employee, job record and earnings code. This enhancement streamlines data entry by consolidating it into a single interface, reducing the risk of manual entry errors. Additionally, the HR Technology Manager has implemented a new monitoring report to track employees with multiple salary distribution accounts as a part of payroll process. The biweekly report will be automatically generated and sent via email to HR’s HRIS Consultants for review. The HRIS Consultants will analyze the report, resolve any discrepancies and escalate any issues to the HR Technology Manager or Lead Application Consultant as necessary. These processes will be routinely reviewed, with adjustments made as needed.
View Audit 370942 Questioned Costs: $1
Oversight Agency for Audit, Senior Citizens Housing Development Fund Corporation of Steuben County Two, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N Universit...
Oversight Agency for Audit, Senior Citizens Housing Development Fund Corporation of Steuben County Two, Inc. respectfully submits the following corrective action plan for the year ended March 31, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201 Coral Springs, Florida 33067 Audit period: April 1, 2024 through March 31, 2025 The findings from the March 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. SECTION III - FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING NO. 2025-001: Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should make sufficient deposits to the escrow account in a timely manner and correctly allocate policy premiums. The excess workers’ compensation policy premium should be returned to the Project. Also, the Project should replenish the funds that were transferred from the escrow account to the operating account and improve monitoring of the escrow account balance to ensure it is properly funded. Action Taken: The project will fund the shortfall and replenish funds that were incorrectly transferred from the escrow account. Escrow balances will be reviewed on a regular basis to ensure adequate funding.
Student Financial Assistance Cluster Assistance Listing Number 84.268 Federal Direct Student Loans, and 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2024-2025 Criteria or Specific Requirement – Disbursements to or on behalf of students, 34 CFR Section 668.164(h)(2) Con...
Student Financial Assistance Cluster Assistance Listing Number 84.268 Federal Direct Student Loans, and 84.063 Federal Pell Grant Program U.S. Department of Education Program Year 2024-2025 Criteria or Specific Requirement – Disbursements to or on behalf of students, 34 CFR Section 668.164(h)(2) Condition – Students did not receive refunds within the required timeframe Questioned Costs – N/A Context – 7 out of 25 students tested received their credit balance refund more than 14 days after the credit balance was generated. All but 1 of these students received their refund within 16 days of the generation of the credit balance. Our sample was not, and was not intended to be, statistically valid. Effect – Noncompliance with federal regulations requiring timely disbursement of credit balance refunds Cause – Due to the high volume of credit balance refunds being processed, the University encountered operational constraints that prevented all refunds from being generated within the designated 14-day timeframe. Indication as a Repeat Finding – N/A Recommendation – To ensure timely refund of student credit balances, implement a control that flags any refund not processed before the end of the 14-day timeframe for immediate review and escalation. Additionally, establish a monitoring report to track refund timeliness weekly and reinforce accountability for processing within the required timeframe. Views of Responsible Officials and Planned Corrective Actions – Amy Schlup, Director of Student Financial Services, and Carrie Hamilton, Assistant Director of Financial Aid, will oversee the corrective action plan. As part of this process, they will review the daily Student Refund Report to identify and assist the personal financial counselor in expediting student refunds. The Student Financial Services team will also review and retrain on the proper procedures for processing refunds within the required timeframe. The corrective action plan is already in progress and will be fully implemented by October 1, 2025. Office of Financial Services PO Box 11000 Oklahoma City, OK 73136 405.425.5190 financialservices@oc.edu
Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration...
Summary of finding: Five out of 40 charts reviewed by the auditors’ showed exceptions to the Sliding Fee Discount Schedule (SFDS) that are not supported by policy or documentation. Findings were identified in three primary categories: inconsistent collection and scanning of documents at registration, Electronic Health Records (EHR) not operating as expected for one line of the SFDS and error not caught and corrected, and a significant process change from percentage to fixed fee SFDS causing inconsistent application during transition and training period. Planned corrective action: System Configuration:  Leaders for all service lines and Billing Department will work with EHR Support Team and vendor to review and test all possible SFDS options to verify rules are functioning as expected and as outlined in the SFDS policy.  Annual review and testing of EHR rules governing SFDS to validate ongoing compliance. Contact person: Jennifer Velez, Revenue Cycle Director Completion date for action: 10/31/2025 Staff Training and Documentation:  All staff responsible for registration and income verification in all service lines, programs, and sites will receive a review of income eligibility assessment, documentation, and application.  Registration Program Manager and EHR Trainers will work with Learning and Development Department to develop competency standard for income eligibility assessment, documentation, and application for all staff responsible for registration and income verification in all service lines, programs, and sites. All identified staff will be required to demonstrate competence annually using the Learning Management System (LMS).  The Center will audit 5 patient records for FPL (Federal Poverty Level) documentation per site or program two times annually during C-Qual (the Center’s internal audit process). This will result in 180 charts each year.  Site Managers or Department Administrators will review front office dashboard in monthly management meetings and develop site specific action plans if exceptions are identified. This was added to the standing agenda for the Primary Care Clinic Managers (PCCM) meeting in September 2025. Contact person: Angela Hurley, Director of Operations Completion date for action: 12/31/2025 Implementation Controls:  Update SFDS policy to include review and verification of EHR alignment with fee schedule following any update or change approved by the Board of Directors.  Develop checklist for roll-out of changes in SFDS that prompts change management and training team to review readiness and validation procedures before going live with changes. Contact person: Angela Hurley, Director of Operations Completion date for action: 9/30/2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action Pending Anticipated Completion Date July 15, 2025
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee t...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED FEBRUARY 28, 2025 Title 2, U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Subpart F, Section 511 – Audit Findings Follow-up requires the auditee to prepare a corrective action plan to address each audit finding included in the current year auditor’s reports. The Corrective Action Plan for Current Year Findings present our corrective action plan for the Financial Statement and/or Federal Award Findings described in the accompanying Schedule of Findings and Questioned Costs for the period ended February 28, 2025. Responsible Party Name: Tamara Wallace Position: Executive Director – Management Agent Telephone Number: 816-233-4250 Federal Agency U.S. Department of Housing and Urban Development Federal Program Mortgage Insurance for Rental and Cooperative Housing (Section 221(d)(4)) Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Auditee’s Comment on Finding We agree with the auditors’ finding. Corrective Action We will ensure that the accounts reconcile to source documents as part of our month-end closing process. Anticipated Completion Date August 31, 2025
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. ...
Finding 2025-007 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Auditee’s Comment on Finding We agree with the auditor’s finding. Corrective Action Management will ask HUD for retroactive permission for these expenditures. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completio...
Finding 2025-005 Compliance Requirements A/B Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures immediately. Anticipated Completion Date July 1, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025
Finding 2025-003 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will contact HUD to discuss resolution of this matter within 30 days. Anticipated Completion Date September 30, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025
Finding 2025-002 Compliance Requirements N – Special Tests and Provisions Finding Type Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action We will deposit $732 into the residual receipts account within 30-days. Anticipated Completion Date July 31, 2025
View Audit 370220 Questioned Costs: $1
Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and com...
Finding 2025-001 Compliance Requirements N – Special Tests and Provisions Finding Type Financial Statement and Federal Awards Comment on Finding We agree with the auditor’s finding. Corrective Action Management will follow its policies and procedures to ensure accounting records are accurate and complete. Anticipated Completion Date September 30, 2025
Federal and State Financial Assistance Programs Year Ended May 31, 2025 CORRECTIVE ACTION PLAN Audit Finding Reference: 2025-001 Planned Corrective Action: The University conducted a full review of the population of cancellations for the fiscal year ending May 31, 2025, comprising of 53 students. Th...
Federal and State Financial Assistance Programs Year Ended May 31, 2025 CORRECTIVE ACTION PLAN Audit Finding Reference: 2025-001 Planned Corrective Action: The University conducted a full review of the population of cancellations for the fiscal year ending May 31, 2025, comprising of 53 students. The review identified seven instances of late reporting, all of which were previously corrected through the University’s monthly disbursement reconciliation processes, but beyond the 15 calendar day reporting requirement. Each of the identified instances resulted from a system defect which caused canceled BBAY Direct Loans reduced to zero (“0”) to receive an automatic null attendance cost. Due to the automatic null value, the record was excluded from the financial aid management system to COD record extraction process. The University has created a report to identify instances where the attendance cost value is null. When identified, action will be taken to populate the attendance cost to zero and allow extraction. The records will be subsequently verified to confirm extraction for submission to COD and reports will be reviewed weekly by the supervisor. The University will continue to review and implement additional controls to ensure disbursement records are submitted to COD within 15 calendar days. To ensure enhanced oversight and monitoring controls are effective to maintain compliance and timely reporting to COD, management will incorporate this review into their routine Assurance validation processes for students from the identified population. These remediation efforts and risk management strategies will continue to be reviewed and implemented throughout fiscal year 2026. The University continues to update controls as needed to ensure compliance with an estimated completion date of May 31, 2026. Contact Person: Suzanne Weems Controller Baylor University Phone: (254) 710-3731
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made wi...
Condition: We noted no indication that certified payrolls were obtained and reviewed by Township officials prior to payment being made to a contractor for construction work performed in one instance. Planned Corrective Action: While controls are in place to ensure payments to vendors are not made without completed review of certified payrolls, staff acknowledges records kept did not provide adequate backup to verify these controls. Going forward, staff will not only be sure to keep copies of certified payrolls with related invoices, they will also maintain records that confirm invoices without certified payrolls did not include labor that is subject to Davis-Bacon wage requirements. These records will likely come in the form of detailed invoice cost breakdowns (showing absence of labor costs) or correspondence affirming no labor costs were included in the invoice. Contact person responsible for corrective action: Matthew Wallace Anticipated Completion Date: Immediately
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project complet...
Condition: We noted no formal evidence that the stated control to ensure performance of required inspections prior to contract approval had been implemented effectively in one instance. We also noted no formal evidence that the stated control to verify inspections were performed upon project completion to ensure that work was carried out in accordance with contract specifications had been implemented effectively in one instance. Planned Corrective Action: Staff will review folders at various stages of the project to ensure all records of inspections at both the beginning and end of the project are in the file. Staff has already set up either bi-weekly or monthly meetings (depending on project activity levels) to report on the status of ongoing projects. These meetings were intended to help staff keep current projects in line with the overall project budget (i.e. not obligating funds beyond what’s available). Using these same meetings to check project files for all necessary records will be an adjustment of negligible effort. In instances where there is a sizable gap between portions of a project (e.g. part of the project can’t be completed until spring) staff will consider closing out the completed portion of the project and completing a final inspection on the balance of the job at a later date. Contact person responsible for corrective action: Edwin Manninen, Matthew Wallace Anticipated Completion Date: Immediately
Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, perio...
Finding 2025-001 Federal assistance listing number and name: 10.415 Rural Rent Housing Loans Awards numbers and years: 2025 Federal agency: United States Department of Agriculture Compliance Requirement: Activities allowed or unallowed, allowable costs/ cash management, eligibility, equipment, period of performance, procurement, program income, reporting, special tests Questioned Costs: None Name of contact person and title: Pat Bishop, President Condition and Context: The auditee did not submit the required audit reports to the Federal Audit Clearinghouse (FAC) and Rural Development (RD) in a timely manner. Specifically:  The 2023 Audit Report was not submitted to the FAC as required under 2 CFR Part 200, Subpart F.  The 2024 Audit Report was submitted past the regulatory deadline to both the FAC and RD. Management Response: Management plans to develop and implement an internal audit compliance calendar with clearly defined submission deadlines for all audit-related deliverables, including due dates for the FAC and RD and Create an internal checklist and sign-off process to confirm that each audit deliverable has been submitted to all required agencies and portals. Status: In progress Anticipated Completion Date: Estimated 2025
Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the securi...
Statement of condition #2025-001: A tenant moved out on February 26, 2025, and was owed a security deposit of $407. The disbursement was not made until August 25, 2025, 180 days after move out. Comments on the Finding and Each Recommendation: The management agent should disburse $407 from the security deposit cash account to the former tenant. Action(s) taken or planned on the finding: The management agent refunded $407 to the former tenant on August 25, 2025.
View Audit 368134 Questioned Costs: $1
Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. 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 will ...
Statement of condition #2025-001: Management fees of $3,118 were prepaid at May 31, 2025. 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 will reimburse $3,118 to the Corporation.
View Audit 368133 Questioned Costs: $1
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contac...
Finding Number: 2025-006 Condition: The Township did not have the appropriate processes and controls in place to ensure FFATA reports were appropriately submitted. Planned Corrective Action: The Township will put processes and controls in place to ensure FFATA reports are submitted as needed. Contact person responsible for corrective action: Finance Director Anticipated Completion Date: 3/31/2026
Management drafted an updated procurement policy to comply with the requirements of the Uniform Guidance, which was approved by the Village Council at a special meeting on June 23, 2025.
Management drafted an updated procurement policy to comply with the requirements of the Uniform Guidance, which was approved by the Village Council at a special meeting on June 23, 2025.
Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.
Management of Miami-Cass REMC and Subsidiary will properly adhere to its written policy that governs the process for the procurement of materials and services in the future and add additional monitoring to prevent future error. Management agrees with the findings.
FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported wit...
FINDING 2025‐002 – Special Tests and Provisions – Return of Title IV (R2T4) Funds Significant Deficiency in Return of Title IV Funds Processing Recommendation: The University should enhance its monitoring and review procedures to ensure that all unofficial withdrawals are identified and reported within the federally required timeframe. Strengthening this process will support the timeliness of federal compliance. Response: There is no disagreement with this audit finding. Action taken in response to finding: Some of the corrective actions noted in our response to finding 2025-001 also apply here. For example, quality assurance reports to identify students who withdraw from all classes in a part of term and the upcoming joint training and process mapping session with Student Financial Services and the Registrar’s Office will strengthen understanding of how enrollment status updates drive downstream compliance, including R2T4 processing. These steps will also ensure exceptions are addressed consistently and that communication channels between offices are clear. To address immediate gaps specific to R2T4 compliance, the Registrar’s Office has enhanced training regarding R2T4 compliance requirements related to recording withdrawals and enrollment changes in a timely, accurate and consistent manner. Additional quality checks are being implemented to confirm that withdrawal dates and status changes are entered accurately into the student information system so that R2T4 calculations are completed within federal timeframes. Together, these interventions are designed to ensure the timeliness and accuracy of R2T4 processing and compliance with federal requirements. We expect to have these corrective actions completed by September 12, 2025. Contact Person(s): Sarah Everitt, Dean of Student Financial Services; Maxwell Kwenda, University Registrar & Director of Institutional Research
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