Corrective Action Plans

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FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2025-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring a...
FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding, 2025-001: Major Program: Supportive Housing for the Elderly (Section 202 Capital Advance - Accumulated Balance), Federal Assistance Listing Number 14.157 RECOMMENDATION The auditor recommends ensuring all bank account balances at each bank remain below the FDIC limit. ACTION TAKEN The Project will be monitoring bank accounts more frequently throughout the year and has been restructuring the bank accounts ensure bank balances do not exceed the FDIC limit.
Finding Number: 2025-004 Condition: All disbursements need either an approved invoice or credit card receipt for the amount charged to the grant. Planned Corrective Action: Imagine! will send out a communication to all employees reviewing the current internal control process that requires receipts a...
Finding Number: 2025-004 Condition: All disbursements need either an approved invoice or credit card receipt for the amount charged to the grant. Planned Corrective Action: Imagine! will send out a communication to all employees reviewing the current internal control process that requires receipts and / or invoices from vendors to be attached to credit card disbursements. Employees who do not abide by the process are subject to losing credit card privileges. Contact person responsible for corrective action: Melody Kim Anticipated Completion Date: 7/31/2026
The Organization filed the required reports in 2026.
The Organization filed the required reports in 2026.
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. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have found that our electronic medical record (eCW) is automatically classifying the federal poverty level (FPL) for all patients no matter if we have their insurance or household income inputted into the system. This has led to some inaccuracies in the rating of their FPL in eCW. We are actively manually overriding this setting, so we will have full control when to run the FPL after patient information is collected.
See the response at Finding 2025-004 for the history of homes purchased under the Department of Labor’s National Farmworkers Jobs Program and administration of the program. The Organization received the results of the July 2025 program monitoring report by the Department of Labor on March 30, 2026. ...
See the response at Finding 2025-004 for the history of homes purchased under the Department of Labor’s National Farmworkers Jobs Program and administration of the program. The Organization received the results of the July 2025 program monitoring report by the Department of Labor on March 30, 2026. The Organization is currently working to resolve the compliance findings and to provide additional documentation, as requested. Additionally, the Organization is reviewing the monitoring report to determine whether changes to the current grant controls are deemed necessary. In the event that the Department of Labor deems that pre-approval is necessary, adequate pre-obligation workflow procedures will be developed and implemented immediately.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will take measures to ensure future compliance with all requirements of federal grants.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to inform them of all grants and federal monies that Pottawatomie County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.
The Board of County Commissioners will work to assess and identify risks to design a written county-wide controls policy over federal grant programs to ensure compliance with grant requirements.
The City has taken steps to strengthen internal controls over the CDBG program. The City will additionally implement formalized procedures requiring, centralized project files containing procurement documentation, cost support, and project eligibility records, document procurement procedures consist...
The City has taken steps to strengthen internal controls over the CDBG program. The City will additionally implement formalized procedures requiring, centralized project files containing procurement documentation, cost support, and project eligibility records, document procurement procedures consistent with Uniform Guidance requirements, including cost/price analysis and justification for contractor selection, collection and review of Davis-Bacon documentation, including wage determinations and certified payrolls, when applicable, verification that required permits are obtained prior to construction and retention of inspection and completion documentation, and secondary review by City staff to ensure all required documentation is complete prior to project closeout. Additionally, the City will provide training to staff involved in CDBG program administration. Responsible Persons: Community Development Director Date of Implementation: Initiate FY 2025-26 with ongoing monitoring into FY 2026-27
The City will update its written procurement procedures to incorporate suspension and debarment review requirements consistent with 2 CFR Part 180 and 2 CFR §200.214. Training will be provided for staff responsible for purchasing and grant administration to ensure compliance with federal requirement...
The City will update its written procurement procedures to incorporate suspension and debarment review requirements consistent with 2 CFR Part 180 and 2 CFR §200.214. Training will be provided for staff responsible for purchasing and grant administration to ensure compliance with federal requirements. Responsible Persons: Police Chief/Finance Director Date of Implementation: Initiate FY 2025-26 with ongoing monitoring into FY 2026-27
2025-003: Allocating Funds to Eligible School Attendance Areas and Schools Condition: The district’s approved Title I application established school-level building allocations under Title I Targeting Step 5 using a per-pupil allocation methodology based on low-income counts. The district should docu...
2025-003: Allocating Funds to Eligible School Attendance Areas and Schools Condition: The district’s approved Title I application established school-level building allocations under Title I Targeting Step 5 using a per-pupil allocation methodology based on low-income counts. The district should document school-level expenditures to verify that the per-pupil allocation is followed. The district does not have effective controls to monitor school-level expenditures for compliance with approved Title I building allocations. Six of the 20 schools overspent their allocation by approximately $554,000. The other schools were under their allocations as a result. Corrective Action Planned: The district is working with ISBE to ensure that our site-based resource allocations align with the district’s budget. Name of the Contact Person Responsible for Corrective Action: Mr. Daniel Ulrich, Executive Direct of Finance/ District Accountants/Auditor, Judy Freeman, District Accounts Grant Auditor, Chanbopha Loera Anticipated Completion Date: July 1st 2026.
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.
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