Corrective Action Plans

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Finding 1177825 (2025-001)
Material Weakness 2025
Condition: Management did not have controls in place to ensure documentation was maintained evidencing the organization's verification that contractors are not suspended or debarred from participating in a federally funded activity. Planned Corrective Action: Management concurs with the finding. We ...
Condition: Management did not have controls in place to ensure documentation was maintained evidencing the organization's verification that contractors are not suspended or debarred from participating in a federally funded activity. Planned Corrective Action: Management concurs with the finding. We acknowledge that, for the awards issued under the Inflation Reduction Act Urban and Community Forestry Program (Assistance Listing Number 10.727), the required suspension and debarment verification was performed; however, the supporting documentation evidencing this verification was not retained by the responsible department. This represents a documentation lapse rather than a deficiency in internal controls as Openlands routinely performs suspension and debarment verifications for all applicable vendors, contractors, and subrecipients receiving federal funds in accordance with 2 CFR 200.214. This requirement applies to entities and individuals awarded federally funded contracts or subawards exceeding the micro-purchase threshold and excludes routine commercial vendors for indirect administrative costs or purchases under $15,000. Management believes this was an isolated documentation lapse prior to the current audit period when the contractor was selected, and is currently in the processes of executing an update to internal control policies to ensure these checks are maintained prior to entering into a contract by the responsible department as well as updating a clause to all standard vendor contracts requiring a self-certification that they are not excluded, debarred, or suspended from entering into covered transactions with the federal government. Contact person responsible for corrective action: Paul Spector (Director of Finance) Anticipated Completion Date: January 31, 2026
Finding 2025-002 – Education Stabilization – Special Tests and Provisions - Wage Rate Requirements Context: The School Corporation did not obtain the weekly payroll reports certifications from a company that performed renovations to replace fan coil units and HVAC equipment in the building. Therefor...
Finding 2025-002 – Education Stabilization – Special Tests and Provisions - Wage Rate Requirements Context: The School Corporation did not obtain the weekly payroll reports certifications from a company that performed renovations to replace fan coil units and HVAC equipment in the building. Therefore, no review was performed to ensure that pay rates complied with the federal wage rate requirements. The amount disbursed and reported on the SEFA during the audit period is $119,190 and the labor portion was not determinable by the School Corporation. Contact Person Responsible for Corrective Action: Kimberly Nieves Contact Phone Number: 219-766-2214 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: As an internal control, the Director of Business Affairs and Human Resources has reviewed the Davis-Bacon Act. We will collect weekly payroll documentation for any constructions projects where Federal Grant money is used. Anticipated Completion Date: February 2024
The City acknowledges the audit findings and recommendations. The City will strengthen its procedures for preparing and reviewing the SEFA by enhancing review checklists, performing reconciliations to accounting records and grant tracking schedules, and verifying award information with granting agen...
The City acknowledges the audit findings and recommendations. The City will strengthen its procedures for preparing and reviewing the SEFA by enhancing review checklists, performing reconciliations to accounting records and grant tracking schedules, and verifying award information with granting agencies or pass-through entities as needed. Additionally, grant expenditures will be monitored to ensure the expenditure does not exceed approved budget, particularly for grants spanning multiple federal fiscal years. Personnel responsible for implementation: Hnin Phyu (Accounting Manager), Priscilla Carreras (Accountant II), Janelle Morris (Accountant II), Jane Manalo (Accountant I) Position of responsible personnel: See above Expected date of implementation: CAP has been implemented as of July 1st, 2025.
2025-003: Noncompliance with Record Retention and Documentation Requirements for Receipt of Food Commodities Corrective Action Plan: Quarterly file audits to ensure appropriate documentation is on file. Managements Plan: We have created a new process for internal Fiscal Year file audits which includ...
2025-003: Noncompliance with Record Retention and Documentation Requirements for Receipt of Food Commodities Corrective Action Plan: Quarterly file audits to ensure appropriate documentation is on file. Managements Plan: We have created a new process for internal Fiscal Year file audits which includes checking quarterly (Q1 September, Q2 December. Q3 March, Q4 June) to ensure we have the appropriate documents for the correct years. That change helped us find out if there is something missing for a site before the end of the fiscal year so it can be addressed in a timely ,matter, and we have all documents accounted for accordingly. Name of Responsible Person: Meredith Knopp, Chief Executive Officer Anticipated Completion Date: Implemented effective October 31, 2025
2025-002: Lack of Operating Effectiveness on Internal Control Over Compliance for Distributions of Food Commodities Corrective Action Plan: Established three checks and balances that are currently in practice: I. Invoices are reviewed by Senior Transportation Manager to ensure signed. 2. Once review...
2025-002: Lack of Operating Effectiveness on Internal Control Over Compliance for Distributions of Food Commodities Corrective Action Plan: Established three checks and balances that are currently in practice: I. Invoices are reviewed by Senior Transportation Manager to ensure signed. 2. Once reviewed by Senior Transportation Manager, invoice is handed off to Partner Services Representative for verification of signatures and electronically scanned into centralized database. 3. Director of Operations reviews all invoices for completion. of signature in database on a weekly basis. Director of Operations uses a control sheet to check against CERES ERP system. Managements Plan: We will continue to monitor and identify any gaps in the CAP outlined above to ensure compliance with appropriate signatures is met. Name of Responsib le Person: Meredith Knopp, Chief Executive Officer Anticipated Completion Date: Implemented effective October 31, 2025
Finding 2025-001: Lack of Operating Effectiveness on Internal Control Over Compliance for Receipt of Food Commodities Corrective Action Plan: Receipt of food commodities process has been modified to include Microsoft Power Bl tools that provide DOR and AOR that are outstanding. This provides guidanc...
Finding 2025-001: Lack of Operating Effectiveness on Internal Control Over Compliance for Receipt of Food Commodities Corrective Action Plan: Receipt of food commodities process has been modified to include Microsoft Power Bl tools that provide DOR and AOR that are outstanding. This provides guidance to stqff on items that need attention in order to be processed in a timely manner, Created SOP 's and RA Cl model for digital document retention. Managements Plan: Weekly audits performed by Director of Operations to ensure adherence to processes and procedures which include follow up conversations with key stakeholders to correct any errors. Name of Responsible Person: Meredith Kno pp, Chief Executive Officer Anticipated Completion Date: Implemented effective October 31, 2025
Section III – Federal Award Finding and Questioned Costs Finding 2025-002 – Eligibility Federal Program: Child and Adult Care Food Program (ALN 10.558) Views of Responsible Officials: NDS management met with CACFP staff to review procedures intended to enhance oversight of student eligibility determ...
Section III – Federal Award Finding and Questioned Costs Finding 2025-002 – Eligibility Federal Program: Child and Adult Care Food Program (ALN 10.558) Views of Responsible Officials: NDS management met with CACFP staff to review procedures intended to enhance oversight of student eligibility determinations on February 10, 2026. The Assistant Administrator for the Child and Adult Care Food Program, Ms. Dawn McCoy, (dmccoy@ndsarch.org) will be responsible for ensuring adherence to these updated procedures.
2025-004 (2024-004) Special Tests and Provisions: Provider Eligibility (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: Re-implementation of the recertification and revalidation processes is currently completed in the provider enrollment system. We are movin...
2025-004 (2024-004) Special Tests and Provisions: Provider Eligibility (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: Re-implementation of the recertification and revalidation processes is currently completed in the provider enrollment system. We are moving forward with the revalidation/recertification implementation. Initial provider notifications (90-day notice) will be issued in March 2026. Who Will Act: Bureau Chief, Provider Enrollment Services Bureau, Medical Assistance Division When Will Action(s) be Completed: Corrective actions are expected to be implemented by June 30, 2026.
Management concurs with the finding and notes that the Town is actively working to complete the integration of the payroll module within the new accounting platform. Management has arranged system training to ensure staff understand the payroll and reconciliation functions and can effectively utiliz...
Management concurs with the finding and notes that the Town is actively working to complete the integration of the payroll module within the new accounting platform. Management has arranged system training to ensure staff understand the payroll and reconciliation functions and can effectively utilize the module once configuration is complete. In the interim, the Town will continue to prepare timely reconciliations and record necessary adjusting entries to ensure accurate financial reporting.
FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Procurement Suspension and Debarment Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: 812-254-5536 calford@wcs.k12.in.us Views of Responsible Officials: “We concur with the finding.” De...
FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Procurement Suspension and Debarment Contact Person Responsible for Corrective Action: Carrie Alford Contact Phone Number and Email Address: 812-254-5536 calford@wcs.k12.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: To address this repeat finding, the Business Manager will now review all federal purchase requests before any funds are committed. We will ensure the correct procurement method is used by requiring and filing at least three competitive quotes for any small purchase between $10,000 and $150,000. For any transaction $25,000 or greater, the Business Manager will verify the vendor’s eligibility on SAM.gov and keep a date-stamped screenshot in the file as proof of the search. This centralized oversight and mandatory documentation process will ensure we maintain a proper history of procurement and prevent further noncompliance. Anticipated Completion Date: 02/01/2026
FINDING 2025-003 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Summary of Finding: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). During fiscal years 2022-2023 and 2023-2024, the Cooperative oper...
FINDING 2025-003 Finding Subject: Special Education Cluster (IDEA) – Procurement and Suspension and Debarment Summary of Finding: The School Corporation is a member of the Northeast Indiana Special Education Cooperative (Cooperative). During fiscal years 2022-2023 and 2023-2024, the Cooperative operated the special education program and spent the federal money on behalf of all its members. As the grant agreement was between the Indiana Department of Education (IDOE) and each member school, the School Corporation was responsible for ensuring and providing oversight of the Cooperative. The School Corporation did not have internal controls in place to ensure that the Cooperative complied with the procurement and the suspension and debarment requirements. The Cooperative did not have adequate procedures in place to ensure that the requirements for the simplified acquisition threshold and for small purchases were met for each applicable procured good or service or to ensure that vendors were not suspended or debarred prior to entering a covered transaction. Contact Person Responsible for Corrective Action: Susan Loftain Contact Phone Number and Email Address: (260) 693-2007 loftains@sgcs.k12.in.us Views of Responsible Officials: Option 1: “We concur with the finding.” Description of Corrective Action Plan: Procurement: All vendors procured through NEISEC we will need to take action to secure bids and quotes and keep copies and make we are within compliance Suspension and Debarment: We will be sure to complete our own verifications and not rely on NEISEC to check on suspension and debarment Anticipated Completion Date: Immediately
The City acknowledges the internal control deficiencies related to the tracking, recording, and monitoring of grant receivables, related revenue and deferred revenue, and the timely preparation of reimbursement requests for federal and state grants. Management recognizes that the current process, wh...
The City acknowledges the internal control deficiencies related to the tracking, recording, and monitoring of grant receivables, related revenue and deferred revenue, and the timely preparation of reimbursement requests for federal and state grants. Management recognizes that the current process, which relies heavily on individual departments to initiate reimbursement activity, has resulted in delays and incomplete financial reporting. To address the issue, the City will implement the following corrective actions: 1. Centralized Grant Monitoring Process: The Accounting Department will assume responsibility for proactively identifying and recording grant receivables and associated revenue and deferred revenue at the time expenditures are incurred. This process will no longer be dependent solely on departmental requests for reimbursement. 2. Quarterly Review and Reconciliation: A new quarterly grant monitoring schedule will be established. As part of this process, the Accounting Department will review expenditure reports for all active grants, estimate receivable amounts, and ensure timely recognition of revenue in accordance with applicable accounting standards. 3. Formal Documentation and Workflow Procedures: The City will develop written procedures detailing the steps for monitoring grant expenditures, estimating receivables, reconciling recorded amounts to actual reimbursement submissions, and communicating with grant managing departments. 4. Departmental Training: The City will provide training to staff involved in grant management to ensure all departments understand the updated process and the importance of timely expenditure reporting. These corrective actions will strengthen internal controls, improve accuracy in financial reporting, and ensure compliance with federal grant reimbursement requirements. Anticipated Completion Date: Procedures will be drafted and implemented by June 30, 2026, with quarterly monitoring beginning immediately thereafter. Views of Responsible Officials: The City concurs with the auditors’ findings and recommendations.
In December 2026, managemetn worked with SBA representatives to transfer excess reserves from other SBA Loan Loss Reserve Fund (LLRF) balances to the fund with the deficiency. The matter has been resolved.
In December 2026, managemetn worked with SBA representatives to transfer excess reserves from other SBA Loan Loss Reserve Fund (LLRF) balances to the fund with the deficiency. The matter has been resolved.
Department will strengthen controls to ensure that the required award information is provided, once available. Certain information such as Federal Award Identification Number and Federal Transit Administration and National Highway Traffic Safety Administration award date are not available at the tim...
Department will strengthen controls to ensure that the required award information is provided, once available. Certain information such as Federal Award Identification Number and Federal Transit Administration and National Highway Traffic Safety Administration award date are not available at the time of contracting CDOT is working on a process to provide this information, once it is available in a publicly available format on CDOT’s website or on a subrecipient facing grant management site. We will add a note to the contract explaining where the information will be posted on our site when it becomes available. The Department will also identify staff requiring additional training on classification and coding for contractors vs. subrecipients.
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant com...
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant compliance is verified prior to payment. It also includes assessing the need for increased monitoring to ensure initial program reviews are complete and accurate. This remediation effort was finalized on June 30, 2025, following the September 2024 transaction in question. Additionally, the Department plans to review the remediation plan with all relevant staff again this season. This will ensure that all supporting documentation is thoroughly vetted and that expenditures comply with the applicable award period of performance.
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving in...
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving invoices for Highway Safety Cluster grants, with a specific focus on the period of performance. This training plan will be revisited and reviewed with all staff involved by April 2026.
The Department agrees with the recommendation. The Department will review, assess, and, where necessary, update existing procedures for FFATA reporting relating to the requirement that state subawards for $30,000+ be submitted within 30 days of committed budget. This will include ensuring that the c...
The Department agrees with the recommendation. The Department will review, assess, and, where necessary, update existing procedures for FFATA reporting relating to the requirement that state subawards for $30,000+ be submitted within 30 days of committed budget. This will include ensuring that the confirmation date is documented. This process will be a coordinated effort between the Office Transportation Safety (OTS) and the Center for Accounting. This will include updating our reconciliation process to include additional data, reviewing and updating reconciliation and review procedures as needed, and reconciling Grants awarded in prior fiscal years that are still active and ensuring they have been appropriately reported. The findings related to this recommendation are in part the result of a federal reporting system limitation, and a federal system conversion. The legacy reporting system, FSRS, had a system limitation, which prevented the full amount of the award being reported in the case of three awards. Additionally, this conversion resulted in some data conversion issues impacting one additional award.
The Department agrees with this finding and will provide any training needed to staff members to ensure that all components of the FFATA are completed accurately, timely and with proper reviews. This training will include leadership reviewing NHTSA/Federal guidelines and SAM.Gov training on FFATA re...
The Department agrees with this finding and will provide any training needed to staff members to ensure that all components of the FFATA are completed accurately, timely and with proper reviews. This training will include leadership reviewing NHTSA/Federal guidelines and SAM.Gov training on FFATA reporting and requirements, documenting controls and ensuring the approvers have access to all supporting schedules, forms and systems and that they understand the subawards, and process for late submissions if needed.
The Department agrees with the finding and will ensure that staff follow all internal policies and procedures to maintain accurate and complete FFATA reporting. To achieve this, staff will review existing procedures and make any necessary updates regarding report compilation. Additionally, we will r...
The Department agrees with the finding and will ensure that staff follow all internal policies and procedures to maintain accurate and complete FFATA reporting. To achieve this, staff will review existing procedures and make any necessary updates regarding report compilation. Additionally, we will review control points to ensure they are consistently followed and approved by the team supervisor and team manager.
The Department will continue to follow the current Policy and Procedure related to the Single Audit reviews and has allocated an individual to review the Single Audits. This includes issuing a management decision letter if required, in accordance with the timeline established in federal guidance.
The Department will continue to follow the current Policy and Procedure related to the Single Audit reviews and has allocated an individual to review the Single Audits. This includes issuing a management decision letter if required, in accordance with the timeline established in federal guidance.
CDPHE fiscal procedures have been updated to reflect changes to the reporting process, specifically noting the recent federal website change and adding the requirement of a secondary level of review. By July 31, 2026, all outstanding FFATA reports will be filed with the federal government and the mo...
CDPHE fiscal procedures have been updated to reflect changes to the reporting process, specifically noting the recent federal website change and adding the requirement of a secondary level of review. By July 31, 2026, all outstanding FFATA reports will be filed with the federal government and the monthly review process in the updated fiscal procedures will be implemented.
The Department will strengthen its internal controls over federal reporting by implementing policies and procedures that include a monitoring process to ensure that FFATA reporting occurs as required for subawards of $30,000 or more in SAM.gov by the end of the month following the month the subaward...
The Department will strengthen its internal controls over federal reporting by implementing policies and procedures that include a monitoring process to ensure that FFATA reporting occurs as required for subawards of $30,000 or more in SAM.gov by the end of the month following the month the subawards are made.
The Department will document and implement internal monitoring policies and procedures, including the performance of reconciliations of reports, to ensure that the required PR28 and Quarterly Performance Reports are accurate and complete. This will include maintaining documentation of evidence of th...
The Department will document and implement internal monitoring policies and procedures, including the performance of reconciliations of reports, to ensure that the required PR28 and Quarterly Performance Reports are accurate and complete. This will include maintaining documentation of evidence of the review and approval of each report prior to its submission to the federal government.
MSU Denver IT Security will update its written information security program to address the necessary requirements of the Gramm-Leach-Bliley Act. The WISP will be reviewed and updated at least once each year, with updates being based on risk assessments, audits, changes to the environment, and any in...
MSU Denver IT Security will update its written information security program to address the necessary requirements of the Gramm-Leach-Bliley Act. The WISP will be reviewed and updated at least once each year, with updates being based on risk assessments, audits, changes to the environment, and any incidents which indicate a need for changes to the WISP. The updated WISP will include existing policies as well as new policies that describe standards for: • Periodic inventory of data • Multi-Factor Authentication, Single Sign-On, and passwords • Assessment of applications developed by the institution • Testing our safeguards The updated WISP will be formally reviewed and approved by the Chief Financial Officer by June 30, 2026.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
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