Corrective Action Plans

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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/categori...
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 all documentation supporting the sliding discount provided is retained. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization continues to make improvements to processes and procedures to ensure the accurate documentation and application of the sliding fee discounts. An improvement over the prior year's finding was realized, however more active internal audit checks and balances will need to be made to fully resolve these issues.
FINDINGS— FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2025-001 Suspension and Debarment Recommendation: We recommend the District review and update procurement policies for the entire District to ensure it meets the minimum requirements of 2 CFR 200 for all federal grants and establish a pr...
FINDINGS— FEDERAL AWARD PROGRAMS AUDITS SIGNIFICANT DEFICIENCY 2025-001 Suspension and Debarment Recommendation: We recommend the District review and update procurement policies for the entire District to ensure it meets the minimum requirements of 2 CFR 200 for all federal grants and establish a procurement process in order to ensure this policy is followed which includes adding language over suspension and debarment. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The District is working on reviewing policies and procedures and updating as necessary. Further, training will be available to all those involved in grants. Name(s) of the contact person(s) responsible for corrective action: Courtney Mueller Planned completion date for corrective action plan: 5/31/2026
Management established corrective measures immediately upon identifying the deficiency related to the untimely submission of the required reports. The Municipality implemented formal procedures to monitor reporting deadlines and ensure the timely submission of reports required by ACUDEN. Management ...
Management established corrective measures immediately upon identifying the deficiency related to the untimely submission of the required reports. The Municipality implemented formal procedures to monitor reporting deadlines and ensure the timely submission of reports required by ACUDEN. Management will continue monitoring compliance with these corrective measures to ensure the timely submission of reports in future periods.
VILLAGE OF BELLEVUE 201 N. Main St. Bellevue, MI 49021 269-763-9571 • Fax 269-763-9998 manager@bellevuemi.net • www.bellevuemi.net treasurer@bellevuemi.net 69 CORRECTIVE ACTION PLAN Certain matters were brought to our attention as a result of the audit process. These are described more fully in the ...
VILLAGE OF BELLEVUE 201 N. Main St. Bellevue, MI 49021 269-763-9571 • Fax 269-763-9998 manager@bellevuemi.net • www.bellevuemi.net treasurer@bellevuemi.net 69 CORRECTIVE ACTION PLAN Certain matters were brought to our attention as a result of the audit process. These are described more fully in the Schedule of Findings and Questioned Costs. We evaluated the matters as noted below and have described our planned actions as a result. 2025-001 MATERIAL JOURNAL ENTRIES PROPOSED BY AUDITORS Views of Responsible Officials: Management agrees with the finding and will take appropriate steps to remedy noted finding. Corrective action plan response: The Village will take steps to ensure that material journal entries are not necessary at the time future audit analysis is performed. Responsible Party: Nicole Roberts (Village Manager) and Michelle Pennington (Assistant Village Manager). Date of Planned Corrective Action: December 31, 2026 2025-002 SEGREGATION OF DUTIES OVER KEY FINANCIAL PROCESSES Views of Responsible Officials: Management agrees with the finding and has taken appropriate action to remedy the bank reconciliation portion of the finding during fiscal year 2025. Corrective action plan response: The Village will take steps to actively seek ways to strengthen its internal control structure. This may include requiring as much independent review, reconciliation, and approval of journal entries and bank reconciliations by qualified members of management and documenting such review as part of the Village’s control procedures. Responsible Party: Nicole Roberts (Village Manager) and Michelle Pennington (Assistant Village Manager). Date of Planned Corrective Action: December 31, 2026 2025-003 BANK RECONCILIATIONS Views of Responsible Officials: Management agrees with the finding and will take appropriate steps to remedy noted finding. Corrective action plan response: The Village will take steps to ensure that bank reconciliations are documented as reviewed and reconciliating items are properly documented. Responsible Party: Nicole Roberts (Village Manager) and Michelle Pennington (Assistant Village Manager). Date of Planned Corrective Action: December 31, 2026
Corrective actions were delayed due to the anticipated implementation of a new system that ws expected to address access and segregation of duties concerns. Since the new system will not be imiplemented immediately, management is proceeding with corrective action under the current system. Management...
Corrective actions were delayed due to the anticipated implementation of a new system that ws expected to address access and segregation of duties concerns. Since the new system will not be imiplemented immediately, management is proceeding with corrective action under the current system. Management is working to define and separate HR and Payroll rolls and access responsibilities so that employee information, pay rates, and payroll related functions are restricted to authorized personnel based on job duties. In the interim, periodic reviews of employee information, user access, and payroll related transactions will be performed. Any unauthorized changes will be documented and retained.
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater ...
Corrective Action Plan: The organization has implemented targeted training, revised patient intake forms to include standardized income calculations, and established monthly audits for 2026 to ensure compliance with Sliding Fee Discount Program requirements. Clinics identified with a 10% or greater error rate are receiving focused retraining and ongoing monitoring, with audit results shared with leadership to promote accountability. Two mandatory training sessions for CARs, AR staff, and administrators are being conducted to reinforce consistent and compliant program implementation. Persons Responsible: Steven Hansen, President & CEO; Pearl Lujan, Central Billing Office Director Estimated Completion Date: December 31, 2026
Federal program: ALN 84.041 Impact Aid Federal agency: U.S. Department of Education Pass-through entity: NA Criteria: As a grantee under Impact Aid (ALN 84.041), the District is required to submit an annual application to the U.S. Department of Education that is accurate and supported by underlying ...
Federal program: ALN 84.041 Impact Aid Federal agency: U.S. Department of Education Pass-through entity: NA Criteria: As a grantee under Impact Aid (ALN 84.041), the District is required to submit an annual application to the U.S. Department of Education that is accurate and supported by underlying enrollment and financial records, in accordance with program regulations and 2 CFR 200. Condition: The District submitted the required annual Impact Aid application; however, key data elements, including total membership enrolled in state‑approved education programs for children with disabilities, did not agree to the underlying student membership and accounting records. Management Response and Planned Corrective Actions Criteria: Management agrees with this finding and is working on implementing an annual application reconciliation process as staffing allows. Responsibility for Corrective Action: Chris Smith, Superintendent and Brittany Clark, Business Manager Anticipated Completion Date: Summer 2026
FEDERAL FINDING 2025-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Fede...
FEDERAL FINDING 2025-001 – SIGNIFICANT DEFICIENCY- PROCUREMENT AND SUSPENSION AND DEBARMENT- INTERNAL CONTROL OVER VERIFICATION AGAINST THE SYSTEM FOR AWARD MANAGEMENT (“SAM”) Description of Finding: 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Uniform Guidance) requires compliance with provisions of procurement, suspension, and debarment. Non-federal entities are required to ensure that they do not award contracts or make subawards to any parties that are suspended or debarred from receiving federal funds. This verification may be accomplished by checking the System for Award Management (SAM). The Town does not have a process in place to check that vendors are not suspended or debarred by checking the System for Award Management (SAM). Statement of Concurrence or Nonconcurrence: The Town agrees with the audit finding. Corrective Action: The Town will establish policies and procedures to ensure vendors are not suspended or debarred by checking the System for Award Management (SAM) and maintain documentation showing that verification. Name of Contact Person: Shelley Cates, Finance Director, (860) 779-3411 x133. Projected Completion Date: June 30, 2026.
The Center will perform a thorough review of its subaward management process in response to this finding to ensure that this remains an isolated instance caused by the extenuating circumstances of the federal funding shutdown.
The Center will perform a thorough review of its subaward management process in response to this finding to ensure that this remains an isolated instance caused by the extenuating circumstances of the federal funding shutdown.
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversig...
Finding Number: 2025-001 Significant Deficiency -Internal Control over Compliance Planned Corrective Action Plan: Health Projects Center will address the finding by talcing the steps outlined below: 1. As of November 2025, Health Projects Center has hired a new Finance Director to strengthen oversight of financial reporting and internal controls. This role will be responsible for ensuring timely and accurate financial close processes and supporting audit readiness. 2. Health Projects Center will implement a more structured and timely year-end close process, with the goal of completing the fiscal year close within the first quarter following year-end. With the improved close timeline, Health Projects Center aims to complete the annual audit by the end of the second quarter. Person Responsible for Corrective Action Plan: John Beleutz, Executive Director Anticipated Date of Completion: June 30, 2026 fiscal year-end
Management notes that the questioned costs identified in FY2025 represent a continuation of items previously reported in FY2024 and addressed through an established corrective action plan. As part of the prior year response, management implemented a comprehensive action plan and engaged an independe...
Management notes that the questioned costs identified in FY2025 represent a continuation of items previously reported in FY2024 and addressed through an established corrective action plan. As part of the prior year response, management implemented a comprehensive action plan and engaged an independent forensic audit to assess the identified irregularities. Building on these efforts, management is further strengthening internal controls to ensure sustained compliance. These actions include:  Continued implementation and monitoring of corrective measures identified in the prior year audit and forensic review.  Enhanced oversight of credit card issuance, approval, and reconciliation processes.  Reinforced segregation of duties to reduce the risk of unauthorized transactions.  Strengthened monitoring of cash receipts and deposit procedures to ensure all program funds are accurately recorded and deposited promptly.  Ongoing compliance reviews to confirm that prior audit findings are fully resolved and do not recur.
To prevent recurrence, we will implement the following actions:  Monthly reconciliation of drawdowns and PMS records to ensure expenditures and receipts are properly aligned and discrepancies are identified promptly.  Pre-submission reconciliation checklist to verify drawdowns, expenditures, and P...
To prevent recurrence, we will implement the following actions:  Monthly reconciliation of drawdowns and PMS records to ensure expenditures and receipts are properly aligned and discrepancies are identified promptly.  Pre-submission reconciliation checklist to verify drawdowns, expenditures, and PMS balances prior to report submission.  Enhanced coordination with finance staff to ensure all drawdowns are accurately charged to the correct program at the time of posting.  Formal escalation process for unresolved PMS or federal reporting system issues to ensure timely resolution with the federal agency.  Earlier internal reporting deadlines to allow sufficient time for review and resolution of any discrepancies prior to federal due dates.  Documentation retention procedures to ensure all communications, PMS discrepancies, and resolution steps are maintained to support audit review.  Ongoing training/refresher guidance for finance and program staff on drawdown procedures and federal reporting requirements.
Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) respon...
Action taken in response to finding: The Club will implement procedures to periodically review and update internal policies to ensure compliance with current regulatory requirements including requesting auditor review on procurement policies prior to approval. Name(s) of the contact person(s) responsible for corrective action: Julie Adelmund Planned completion date for corrective action plan: 05/28/2026
Ruth Casper has redesigned Barton’s Return to Title IV worksheet designed to eliminate errors. Additionally, Ruth has been assigned specific responsibility of verification and approval controls before initiating a return to Title IV action can occur without infringing upon required reporting timelin...
Ruth Casper has redesigned Barton’s Return to Title IV worksheet designed to eliminate errors. Additionally, Ruth has been assigned specific responsibility of verification and approval controls before initiating a return to Title IV action can occur without infringing upon required reporting timelines. This situation stemmed primarily from the same person who is no longer at Barton College. Management is assured that this situation will not occur under Ruth Casper’s leadership teamed with the revised internal verification and reporting controls.
Finding 2025-002 - Enrollment Reporting - Significant Deficiency (Repeat of prior year finding 2024-001) Criterion: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of an enrollment report from the Secretary of the Department of Education (Secretary), institutions must update all i...
Finding 2025-002 - Enrollment Reporting - Significant Deficiency (Repeat of prior year finding 2024-001) Criterion: Title IV regulations (34 CFR 685.309(b)) require that upon receipt of an enrollment report from the Secretary of the Department of Education (Secretary), institutions must update all information included in the report and return the report to the Secretary: (i) in the manner and format prescribed by the Secretary; and (ii) within the timeframe prescribed by the Secretary. Unless the institution expects to submit its next updated enrollment report to the Secretary within the next 60 days, an institution must notify the Secretary within 30 days after the date the institution discovers that: (i) a loan under Title IV of the Act was made to or on behalf of a student who was enrolled or accepted for enrollment at the institution, and the student has ceased to be enrolled on at least a half-time basis or failed to enroll on at least a half-time basis for the period for which the loan was intended or (ii) a student who is enrolled at the institution and who received a loan under Title IV of the Act has changed his or her permanent address. Condition and Context: Exceptions were noted for 2 out of the 25 students tested. The exceptions are noted as follows:  For 1 student, the withdrawal date reported to the National Student Loan Data System (NSLDS) did not agree to University support.  For 1 student, an incorrect status was reported to NSLDS. Corrective Action Plan: The following procedures are in process of being implemented to ensure accurate reporting in the future. Occasionally there are students who are delayed in having their degree conferred. This has resulted in miscommunication between University departments causing a delay in reporting. Going forward, the associate registrar will notify the University registrar upon completion of all late conferrals. The associate registrar will provide the University registrar with the name and identification for each of these students. During the monthly enrollment submission (approximately the 15th of every month) the University Registrar will ensure that each identified student is properly reflected in the National Student Clearinghouse (NSC) and National Student Loan Data System (NSLDS) Anticipated Completion Date: June 30, 2026 Name of Responsible Person: Scott Spencer, University Registrar Office (412) 392-3876 sspencer@pointpark.edu
Point Park University respectively submits the following corrective action plans for the year ended August 31, 2025. Finding 2025-001 - Return of Title IV Funds Criterion: Title IV regulations (34 CFR 668.22) requires that when a recipient of Title IV grant or loan assistance withdraws from an insti...
Point Park University respectively submits the following corrective action plans for the year ended August 31, 2025. Finding 2025-001 - Return of Title IV Funds Criterion: Title IV regulations (34 CFR 668.22) requires that when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV grant or loan assistance that the student earned as of the student's withdrawal date in accordance with Federal regulations and return the unearned portion of the grant or loan funds to the Title IV programs as soon as possible but no later than 45 days after the withdrawal date. Condition and Context: The return of Title IV funding for one student, out of seven selected for testing, was not returned within 45 days of withdrawal. Corrective Action Plan: The University is implementing additional procedures to include secondary reviews, by the financial aid office and registrar’s office, of the current period withdrawals to ensure timely return of Title IV funds. Anticipated Completion Date: June 30, 2026 Name of Responsible Person: Scott Spencer, University Registrar Office (412) 392-3876 sspencer@pointpark.edu
Finding 2025-005 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications to return Title IV funds within the required timeframe as outlined in the Federal Direct Student Loans Program. Anticipated Complet...
Finding 2025-005 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications to return Title IV funds within the required timeframe as outlined in the Federal Direct Student Loans Program. Anticipated Completion Date The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar
Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direc...
Finding 2025-004 Corrective Action Plan The Finance team will collaborate with the Director of Financial Aid and the Registrar to strengthen the format of notifications so that credit balances are paid to the students or parent borrowers within the required timeframe as outlined in the Federal Direct Student Loans Program. The corrective action plan is anticipated to be completed on or before August 31, 2026. Names of Contact People Responsible for Corrective Action Jeanne Cavalieri-Grover –Director of Fiancial Aid Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Karen West – Coordinator of Student Billing Jade Jackman – Registrar
Audit Finding Reference: 2025-002 Document Policies and Procedures Over Federal Awards Planned Corrective Action: - Perform a comprehensive review of existing federal award policies and procedures - Develop and formally document policies covering federal award administration, allowable costs, procur...
Audit Finding Reference: 2025-002 Document Policies and Procedures Over Federal Awards Planned Corrective Action: - Perform a comprehensive review of existing federal award policies and procedures - Develop and formally document policies covering federal award administration, allowable costs, procurement, cash management, subrecipient monitoring, reporting, and record retention Planned Implementation Date of Corrective Action: 1/1/2026 Person Resposible for Corrective Action: Finance Director/Senior Accountant Grant Administrator
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort and eligibility requirements. Name, address, and telephone of District contact person: Karen Walters 235 Sunset Ave Wenatchee, WA 98801 (509) 663-8161 Corrective...
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls and did not comply with time-and-effort and eligibility requirements. Name, address, and telephone of District contact person: Karen Walters 235 Sunset Ave Wenatchee, WA 98801 (509) 663-8161 Corrective action the auditee plans to take in response to the finding: Time-and-Effort The district will update time-and-effort forms to reflect actual work time. During this audit, the district implemented a regular time-and-effort review schedule to ensure the district is complying with requirements. Eligibility The district will allocate school funding based on the grant application’s school eligibility ranking. Additionally, the district will allocate carryover funding based on the ranking allocation. During the school year, the district will periodically review budget aligns with the eligibility ranking. Anticipated date to complete the corrective action: Summer 2026
Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that management strengthen and formalize internal control procedures over federal awards, including documented reviews, approvals, and reconciliations. We also recommend management provide training to staff ...
Student Financial Aid Cluster – Assistance Listing No.: Various Recommendation: We recommend that management strengthen and formalize internal control procedures over federal awards, including documented reviews, approvals, and reconciliations. We also recommend management provide training to staff responsible for federal program administration to ensure understanding of Uniform Guidance requirements. Lastly, management should establish periodic internal reviews to verify that control activities are consistently performed and documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to the finding: Due to staff turnover, the loan reconciliation process was performed by the Director of Financial Aid. While the design of the internal controls over the Title IV loan reconciliation process remain accurate, timely, and compliant with federal requirements, Management will formalize procedures to ensure appropriate independent review when the Director completes the reconciliation in the event of staff absences or turnover. Specifically, internal control procedures will require that all reconciliations be reviewed and approved by a qualified supervisor, with documentation retained to evidence both the performance and review of the control. Additionally, the policy will designate appropriate backup personnel to perform the review function in situations where the primary supervisor is unavailable due to absence or staffing changes. Name of the contact person responsible for corrective action: Jackie Kelley, Director of Financial Aid & Scholarship Planned completion date for corrective action plan: June 2026
Corrective Action Plan To the extent possible, monitoring of monthly financial results and compliance information will continue in the County Courthouse offices and the County Health Department. Anticipated Completion Date The County is not in a financial position to hire additional employees. The i...
Corrective Action Plan To the extent possible, monitoring of monthly financial results and compliance information will continue in the County Courthouse offices and the County Health Department. Anticipated Completion Date The County is not in a financial position to hire additional employees. The increased monitoring will begin December 1, 2025. Responsible Parties John Spangler, Fulton County Board Chairman 257 West Lincoln Street Lewistown, Illinois 61542 (309)547-0901 Staci Mayall, County Treasurer 100 North Main Street Lewistown, Illinois 61542 (309)547-3041 Patrick O’Brian, County Clerk 100 North Main Street Lewistown, Illinois 61542 (309)547-3041
Subrecipient Monitoring 2025-001 Plan: The University implemented corrective actions in response to the prior-year finding, including enhanced monitoring, oversight, and tracking procedures related to subrecipient Single Audit reviews and management decision issuance. While delays identified during ...
Subrecipient Monitoring 2025-001 Plan: The University implemented corrective actions in response to the prior-year finding, including enhanced monitoring, oversight, and tracking procedures related to subrecipient Single Audit reviews and management decision issuance. While delays identified during the current audit period occurred during the implementation of those corrective actions, the University believes the controls now in place are designed to support timely completion and documentation of required monitoring activities in accordance with Uniform Guidance requirements. Implementation Date: 09/01/2025 Contact: LaShawnda V. Hall Assistant Vice President for Research Financial Operations Accounting Services for Research Sponsored Projects (ASRSP) Northwestern University 1800 Sherman Ave, Suite 6-6000 Evanston, IL 60201 lashawnda.hall@northwestern.edu Phone: 847.491.4716
Finding ref number: 2025-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility requirements. Name, address, and telephone of District contact person: DeeDee Buckingham, HR Director Director of Human Resources Yelm Community Schools...
Finding ref number: 2025-002 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility requirements. Name, address, and telephone of District contact person: DeeDee Buckingham, HR Director Director of Human Resources Yelm Community Schools (360) 458-6105 Corrective action the auditee plans to take in response to the finding: Mandatory Staff Training & Professional Development: • Food Services staff responsible for processing and managing student meal applications using Qmlativ will undergo training provided by ESD113 in August and online OSPI CNEEB Application and Direct Certification Training. • Training will explicitly cover federal regulations under 7 CFR Part 245.6 (Application, Eligibility, and Certification) and 2 CFR Part 200.303 (Internal Controls over federal programs). Implementation of Dual-Review Internal Controls: • The District will establish written protocols for processing online and paper applications. • In collaboration with ESD 113, a report will be developed which will be run monthly reviewing any application that have not been validated for income eligibility or direct certification provided by the state. Anticipated date to complete the corrective action: . System Controls: Fully implemented by August 1, 2026 (prior to the rollout of the 2026-27 school year application window). . Staff Training Completion: No later than September 1, 2026.
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility requirements. Name, address, and telephone of District contact person: Marci Bannan, Director of Business Services 121 Whitesell St NE Orting, WA 98360 ...
Finding ref number: 2025-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with federal eligibility requirements. Name, address, and telephone of District contact person: Marci Bannan, Director of Business Services 121 Whitesell St NE Orting, WA 98360 Corrective action the auditee plans to take in response to the finding: Eligibility: The District will document the internal controls that are in place for the monthly direct certification downloads and will print the certification download along with saving it electronically so that the files are easy to provide for future audits. Anticipated date to complete the corrective action: July 31, 2025
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