Corrective Action Plans

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2025-018 PROCUREMENT HIGHER EDUCATION POLICY COMMISSION (HEPC), BLUEFIELD STATE UNIVERSITY (BSU) Assistance Listing Number: Various – Research & Development Cluster Higher Education Policy Commission (HEPC) response: HEPC maintains procurement policies consistent with state law, which is one of the ...
2025-018 PROCUREMENT HIGHER EDUCATION POLICY COMMISSION (HEPC), BLUEFIELD STATE UNIVERSITY (BSU) Assistance Listing Number: Various – Research & Development Cluster Higher Education Policy Commission (HEPC) response: HEPC maintains procurement policies consistent with state law, which is one of the three allowable criteria recognized in 2 CFR §200.320(a)(1)(iv) for establishing a micro purchase threshold of up to $50,000. A Self-Certification letter will be developed and maintained by April 30, 2026, while formally defining micro-purchase thresholds applied to federal awards. This selfcertification letter will be retained as part of our procurement documentation and will provide how the micro-purchase threshold was determined and applied in accordance with 2 CFR §200.320(a)(1)(iv). Bluefield State University (BSU) response: Beginning in FY 2026, the BSU Controller and Director of Purchasing will review the criteria recognized in 2 CFR §200.320(a)(1)(iv) for establishing a micro purchase threshold of up to $50,000. These requirements will be presented to the Board of Governors before June 30, 2026.
2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to m...
2024-014 SPECIAL TESTS AND PROVISIONS - HEALTH AND SAFETY REQUIREMENTS DEPARTMENT OF HUMAN SERVICES (DOHS) Assistance Listing Number: 93.575/93.596 The Quality Assurance specialists have established a plan of action for each Regulation Unit (Child Care Licensing Unit and Family Child Care Unit) to maintain continual monitoring of conducted Annual Unannounced Monitoring Visits required under 45 CFR §98.42(b)(2)(i)(B). Within the tracking spreadsheet, detailed information is input from our documentation system PATH COGNOS Report PCC-PLI 1080. Information includes Provider Name, Provider Number, Provider Type, Specialist Name, and columns for visits conducted and visits not yet conducted. To provide an overall year-to-date calculation of monthly totals/percentages, a Yearly Summary tab is included in the spreadsheet for a quick reference analysis to provide an additional method of tracking visits. As the monthly totals and percentages change, the data updates on the monthly tabs and the Yearly Summary tab. Program Managers have implemented individual efforts to track visits conducted by specialists. The PCC-PLI 1080 report is distributed twice per month by PM II to each Program Manager for review. Specialists have been instructed to include completed annual unannounced monitoring visits on monthly report data, which can then be compared with the PCC-PLI-1080 reports. Additionally, a tracking system has been implemented that requires specialists to pre-plan annual unannounced visits for the 2026 calendar year to ensure visits are completed.
2025-021 SUBRECIPIENT MONITORING DEPARTMENT OF AGRICULTURE (DOA) Assistance Listing Number: 93.103 Management concurs with this finding. For current subawards, contents will be reviewed for required elements and subrecipients informed of any missing elements with documentation of this communication ...
2025-021 SUBRECIPIENT MONITORING DEPARTMENT OF AGRICULTURE (DOA) Assistance Listing Number: 93.103 Management concurs with this finding. For current subawards, contents will be reviewed for required elements and subrecipients informed of any missing elements with documentation of this communication kept within subaward files. For future subawards, the Department of Agriculture will create a checklist based on 2 CFR 200.332 (b)(1) to use in review of new agreements (one checklist per funding source), including section citations for the required elements.
2025-019 SUSPENSION AND DEBARMENT HIGHER EDUCATION POLICY COMMISSION Assistance Listing Number: 47.076 This finding was previously identified during the FY 2024 audit. Since the original finding, HEPC has addressed and resolved this issue by strengthening its internal controls and procedures. On Mar...
2025-019 SUSPENSION AND DEBARMENT HIGHER EDUCATION POLICY COMMISSION Assistance Listing Number: 47.076 This finding was previously identified during the FY 2024 audit. Since the original finding, HEPC has addressed and resolved this issue by strengthening its internal controls and procedures. On March 31, 2025, HEPC updated policies and procedures that established and maintain effective control over federal awards. The update established a threshold for identifying covered transactions and provides clear guidance on conducting suspension and debarment searches in SAM.gov for those transactions. The update also provided additional steps for documentation required to assess whether a vendor is excluded or disqualified if not in SAM.gov. The instances noted in this finding happened before the corrective action plan was implemented. Management believes the updated processes and procedures are effective.
2025-009 REPORTING SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE, OTHER MATTERS OFFICE OF THE GOVERNOR (GO) Assistance Listing Number: 21.027 The GO fully believes that its documentation and support for obligations and expenditures incurred under its SLFRF funding is available and appro...
2025-009 REPORTING SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE, OTHER MATTERS OFFICE OF THE GOVERNOR (GO) Assistance Listing Number: 21.027 The GO fully believes that its documentation and support for obligations and expenditures incurred under its SLFRF funding is available and appropriate to support all items, though recognizes there were challenges and delays in its ability to provide the information to our auditors due to miscommunications and need to coordinate across multiple agencies. That said, the GO recognizes that certain errors were noted in the amounts reported in the quarterly expenditure reports and is committed to enhancing its processes going forward. In particular, as the new administration has had a chance to become more familiar with the reporting processes and its relationship with the third-party firm responsible for assisting the State’s creation and submission of its expenditure reporting. In particular, the GO will ensure that each quarterly expenditure report includes a clearly defined project schedule that allows ample time for the full review and confirmation of information and data included prior to the report’s due date. Additionally, the third-party firm has added additional resources to support the reporting periods and developed new templates to better track and summarize the information aggregated across all agencies spending SLFRF funds to better enable review and identification of any errors or questions.
2025-006 REPORTING – FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA) DEPARTMENT OF ENVIRONMENTAL PROTECTION (DEP) Assistance Listing Number: 15.252 The finding states that the DEP did not report subaward information in accordance with reporting requirements. Specifically, two reports sel...
2025-006 REPORTING – FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA) DEPARTMENT OF ENVIRONMENTAL PROTECTION (DEP) Assistance Listing Number: 15.252 The finding states that the DEP did not report subaward information in accordance with reporting requirements. Specifically, two reports selected for testing were not reported in a timely manner. Based on the previous year’s finding, DEP implemented standard operating procedures on January 24, 2024, to ensure compliance with the FFATA reporting requirements. DEP concurs that the two reports found to be in noncompliance were, in fact, submitted after the required deadline. This oversight was primarily due to the understaffing of the Sub Grants Unit at the time these reports were to be submitted. DEP currently has sufficient standard operating procedures to ensure compliance with FFATA reporting. DEP will temporarily reassign staff responsibilities to ensure reporting compliance timelines are met until the current vacancy in the Sub Grants Unit can be filled to provide additional support to the existing staff.
2025-005 REPORTING – FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA) DEPARTMENT OF EDUCATION (DOE) Assistance Listing Numbers: 10.553/10.555/10.556/10.559/10.582 During FY 2025, the FFATA reporting system changed from the FSRS site to SAM.gov. Many transactions that were originally enter...
2025-005 REPORTING – FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT (FFATA) DEPARTMENT OF EDUCATION (DOE) Assistance Listing Numbers: 10.553/10.555/10.556/10.559/10.582 During FY 2025, the FFATA reporting system changed from the FSRS site to SAM.gov. Many transactions that were originally entered into the FSRS site did not transfer over and had to be re-entered into SAM.gov, making those entries appear late. In addition, we had trouble getting the SAM.gov site to accept our FFATA entries. DOE worked with SAM.gov customer support to eventually get the issues resolved, but this also resulted in late reporting. Subsequent to the systematic issues being resolved, all FFATA reports have been completed timely and will continue to be reported timely going forward.
2025-002 - Timeliness of Federal Funding Accountability and Transparency Act Reporting Auditor Description of Condition and Effect. The City completed its FFATA reporting after the reporting deadline of 30 days. As a result of this condition, the City did not comply with the requirements of the Unif...
2025-002 - Timeliness of Federal Funding Accountability and Transparency Act Reporting Auditor Description of Condition and Effect. The City completed its FFATA reporting after the reporting deadline of 30 days. As a result of this condition, the City did not comply with the requirements of the Uniform Guidance to complete FFATA reporting in a timely manner. Auditor Recommendation. We recommend that the City complete FFATA reporting requirements in a timely manner. Corrective Action. Management concurs with the finding. The City will complete FFATA reporting requirements in a timely manner going forward. Responsible Person. Deb Chubb - Community Development Block Grant Manager Anticipated Completion Date. June 30, 2026
Views of Responsible Officials: Management acknowledges the audit finding related to the Federal Funding Accountability and Transparency Act of 2006 (FFATA) Reporting and appreciates the opportunity to address this matter. Everstand does have an established procedure for consistent reporting of subr...
Views of Responsible Officials: Management acknowledges the audit finding related to the Federal Funding Accountability and Transparency Act of 2006 (FFATA) Reporting and appreciates the opportunity to address this matter. Everstand does have an established procedure for consistent reporting of subrecipient activities as required under FFATA regulations. However, the lack of a clearly defined responsibility for this task resulted in non-compliance. Management recognizes this gap and is committed to implementing corrective measures to ensure full compliance moving forward.
Views of Responsible Officials: Management acknowledges the audit finding related to Subrecipient Monitoring and appreciates the opportunity to address this matter. We recognize the importance of robust monitoring procedures to ensure compliance with Federal requirements and mitigate risk. Although ...
Views of Responsible Officials: Management acknowledges the audit finding related to Subrecipient Monitoring and appreciates the opportunity to address this matter. We recognize the importance of robust monitoring procedures to ensure compliance with Federal requirements and mitigate risk. Although procedures exist for verifying SAM.gov registration (suspension/debarment status) and obtaining audited financial statements from subgrantees, these procedures were not documented or codified in the Caminos Nacional Policy Manual. Pre-award risk assessments have been conducted informally without a formal determination of risk, and protocols surrounding risk assessment were inadequately documented, resulting in inconsistent implementation.
Views of Responsible Officials: Management acknowledges the findings related to Payroll Allocation, and Training & Compliance, as outlined in the recent audit report. We appreciate the recommendations provided and are committed to implementing corrective actions to strengthen compliance, improve pay...
Views of Responsible Officials: Management acknowledges the findings related to Payroll Allocation, and Training & Compliance, as outlined in the recent audit report. We appreciate the recommendations provided and are committed to implementing corrective actions to strengthen compliance, improve payroll allocation accuracy, and enhance staff knowledge of grant management requirements.
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the ...
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting. The District will consider implementing a detailed grant tracking sheet to ensure the general ledger expenditures agree to the expenses reported to ISBE by grant. Anticipated Date of Completion: June 30, 2026
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the ...
Condition: It was noted that there was an inconsistency when comparing the general ledger to what was reported on the expenditure reports. Recommendation: We recommend that steps are taken, including oversight by a second employee, to reconcile the general ledger to the expenditure reports, and the expenditure reports against the budget items before submitting. Management Response: The District will add a verification process to reconcile the general ledger to the budget and expenditure reports before submitting. The District will consider implementing a detailed grant tracking sheet to ensure the general ledger expenditures agree to the expenses reported to ISBE by grant. Anticipated Date of Completion: June 30, 2026
Condition: The Organization lacked adequate controls to ensure reviews were performed by a different individual than the one responsible for preparing monthly financial reporting, calculations of per-unit activity, and requests for reimbursement. Planned Corrective Action: 1. Standardization of Fina...
Condition: The Organization lacked adequate controls to ensure reviews were performed by a different individual than the one responsible for preparing monthly financial reporting, calculations of per-unit activity, and requests for reimbursement. Planned Corrective Action: 1. Standardization of Financial Reporting Workflow: A formal segregation of duties for all federal and pass-through reimbursement requests and financial reports has been implemented. Effective immediately, the individual responsible for accumulating cost data and calculating per-unit activity (preparer) is prohibited from being the reviewer. 2. Implementation of Approval Process: All reports must now be submitted by the preparer to the designated reviewer for approval via email prior to submission. An approval response from the reviewer is required prior to submission to the awarding agency. 3. Staff Training: All grants management and accounting personnel have been briefed on the requirements of 2 CFR 200.303, specifically regarding the necessity of documented internal controls to provide reasonable assurance of compliance. Contact person responsible for corrective action: Erin Nordmann (Controller) Chiyoko Yokota (Chief Financial Officer) Anticipated Completion Date: Fully Corrected
Condition: The Organization lacked adequate controls to ensure the SEFA was complete and accurate. Planned Corrective Action: 1. Federal Award Classification Review: Federal versus non-federal classification will be reviewed by the program manager, Director of Internal Control, and CFO based on the ...
Condition: The Organization lacked adequate controls to ensure the SEFA was complete and accurate. Planned Corrective Action: 1. Federal Award Classification Review: Federal versus non-federal classification will be reviewed by the program manager, Director of Internal Control, and CFO based on the executed agreement. Any reclassification will require documented CFO approval. 2. Annual Cross-System Reconciliation: An annual reconciliation between the contract management system and the general ledger will be performed to ensure all federal awards are captured for SEFA reporting. 3. SEFA Format Standardization: The SEFA preparation schedule will be reverted to a prior-year rollover format that retains carryforward data and enables year-over-year comparison to improve completeness review and anomaly detection. 4. General Ledger Tagging Controls: General ledger dimensional tagging has been enhanced so federally funded activity is automatically identified and included in the preliminary SEFA. 5. Independent SEFA Review: The SEFA will undergo documented independent review and approval by the CFO prior to auditor submission, consistent with 2 CFR 200.303. Contact person responsible for corrective action: Ian Kile (Director of Internal Controls and Analysis) Chiyoko Yokota (Chief Financial Officer) Anticipated Completion Date: Fully Corrected
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report fir...
2025-001 – Federal Funding Accountability and Transparency Act (FFATA) Reporting Auditor Description of Criteria, Condition, and Effect: Under the requirements of the Federal Funding Accountability and Transparency Act, direct recipients of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Direct recipients must report key data elements by registering through the FSRS and reporting subaward data through that system. Direct recipients that are awarded a federal grant are required to file a FFATA sub-award report by the end of the month following the month in which the prime awardee awards any sub-grant equal to or greater than $30,000. The City did not submit the required key data elements through the FSRS reporting system as required by the Uniform Guidance and as a result has not completed the appropriate sub-award reporting that is required for direct recipients. Auditor Recommendation: We recommend that the City review its procedures for FFATA reporting through FSRS and ensure that all key data elements are reported timely moving forward. Corrective Action: Upon discovery of the issue in November 2025, City staff corrected the noncompliance by submitting the required report to the appropriate reporting system/entity. To prevent recurrence, management has strengthened internal controls over FFATA reporting and Single Audit preparation by (1) adding review and verification steps, (2) communicating expectations with key personnel, and (3) explicitly assigning submission responsibility to a designated submitter who is independent of the individual(s) responsible for monitoring compliance. These control enhancements are expected to identify and prevent similar deficiencies and, based on implementation to date, appear to be operating effectively. Responsible Person: Jason Denton, Controller Anticipated Completion Date: June 30, 2026
The College agrees with the finding. While many GLBA-required safeguards are operationally in place, documentation and a formal enterprise risk assessment have not been fully completed. The College will engage a qualified third party to perform a comprehensive GLBA-aligned risk assessment using a re...
The College agrees with the finding. While many GLBA-required safeguards are operationally in place, documentation and a formal enterprise risk assessment have not been fully completed. The College will engage a qualified third party to perform a comprehensive GLBA-aligned risk assessment using a recognized framework such as NIST. Based on the results, the College will document identified risks, existing safeguards, and remediation plans. Additionally, the College will formalize and update its Written Information Security Program, including policies addressing vendor management, user access controls, data transmission and destruction, change management, and data inventory. Policies will be reviewed and approved through the College’s governance process. Responsible Party: Kyle Brown, Executive Director of Technology, Jamestown Community College, kylebrown@sunyjcc.edu, 716.338.1118 Anticipated Completion Date: August 31, 2026
FA 2025-001 Strengthen Controls over Employee Compensation Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Allowable Costs/Cost Principles Significant Defici...
FA 2025-001 Strengthen Controls over Employee Compensation Compliance Requirement: Internal Control Impact: Compliance Impact: Federal Awarding Agency: Pass-Through Entity: Assistance Listing Number and Title: Federal Award Number: Questioned Costs: Allowable Costs/Cost Principles Significant Deficiency Nonmaterial Noncompliance U.S. Department of Education Georgia Department of Education 84.027 - Special Education Cluster Grant to States 84.173 - Special Education Cluster Preschool Grants H027A230073 (Year: 2024), H027A240073 (Year: 2025), H173A240081 (Year: 2025) $1,283 Description: The policies and procedures of the School District were insufficient to provide adequate internal controls over the employee compensation process as it relates to the Special Education Cluster. Corrective Action Plans: The District concurs with the finding and is committed to strengthening internal controls. While the identified discrepancies were isolated, we recognize the need for enhanced reconciliation during personnel transitions. The Human Resources and Finance departments will enhance our review process. This pre-payroll validation step will ensure that all salary adjustments and position changes align with Board authorized pay documentation prior to disbursement. Estimated Completion Date: 3/31/2026 Contact Person: Julie Wiley, Chief Financial Officer Telephone: 229-316-1878 Email: juliewiley@lowndes.k12.ga.us
Finding 2025-003 See response to finding 2025-001.
Finding 2025-003 See response to finding 2025-001.
Condition: The controls in place to review the final grant packet, including the grant draw-down template and the drawdown invoice detail, prior to final processing of the drawdown were not operating as designed. Planned Corrective Action: Treasury will work with PMM and DCC departments to out-line ...
Condition: The controls in place to review the final grant packet, including the grant draw-down template and the drawdown invoice detail, prior to final processing of the drawdown were not operating as designed. Planned Corrective Action: Treasury will work with PMM and DCC departments to out-line a process to ensure accurate reporting of eligible expenses when invoices are re-viewed for compliance with grant program requirements. The process will be documented and adhered to once agreed by all departments. A review process for the final drawdown submission will also be adopted to ensure costs that are identified as ineligible are appro-priately excluded from the final submission. Contact person responsible for corrective action: Sr. Grants Manager Anticipated Completion Date: 06/30/2026
Since the prior audit period, management has taken steps to review and revise OFB’s procurement policy and procedures, in alignment with federal procurement standards. Finance will continue implementing the corrective actions and establishing the internal controls to ensure adherence to the policy, ...
Since the prior audit period, management has taken steps to review and revise OFB’s procurement policy and procedures, in alignment with federal procurement standards. Finance will continue implementing the corrective actions and establishing the internal controls to ensure adherence to the policy, retaining documentation of the procurement process to demonstrate compliance. These recent and planned improvements will enhance transparency, strengthen accountability, and reduce compliance risk, ensuring a more efficient and well-documented procurement process that supports the organization’s long-term financial integrity and operational effectiveness. The anticipated completion date remains June 30, 2026.
Since the prior audit period, management has taken steps to establish procedures and internal controls to ensure consistent application, billing, and reporting of indirect cost rates across all federal awards. Such steps include defining and documenting roles and responsibilities for applicable staf...
Since the prior audit period, management has taken steps to establish procedures and internal controls to ensure consistent application, billing, and reporting of indirect cost rates across all federal awards. Such steps include defining and documenting roles and responsibilities for applicable staff members during each phase of the grants management lifecycle, as well as implementing procedures and tools to ensure compliance with subrecipient monitoring requirements. These steps involve multiple levels of review for accurate and consistent application of indirect cost rates. Finance will continue implementing the corrective actions necessary to achieve effective controls over compliance with indirect cost rate requirements. Policy and procedures on allowable and allocable costs will be drafted to clearly document how direct and indirect costs will be billed to federal awards. Training will be provided to relevant staff members to ensure accurate implementation and ongoing compliance. These actions will improve our ability to manage indirect costs effectively and ensure compliance with federal requirements. The anticipated completion date remains June 30, 2026.
Since the prior audit period, management has taken steps to develop and implement a time and effort reporting system that meets federal documentation standards, such as activating the electronic timekeeping system to track actual work performed and testing adoption of reporting procedures across dep...
Since the prior audit period, management has taken steps to develop and implement a time and effort reporting system that meets federal documentation standards, such as activating the electronic timekeeping system to track actual work performed and testing adoption of reporting procedures across departments and teams. Finance will continue implementing the corrective actions necessary to establish an effective and compliant time and effort reporting system, including providing training for employees and regularly monitoring for effective system utilization. These actions will strengthen internal controls and ensure personnel costs are accurately recorded and appropriately allocated. The anticipated completion date remains June 30, 2027.
Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by...
Corrective Action Plan for Finding 2025-001 We are in receipt of the Finding Required to be reported by the Uniform Guidance regarding the Reporting Compliance Requirement. Management agrees with the finding. The discrepancy in current-year reporting resulted from a computational oversight caused by a formula error within the reporting templates. Where possible, we will add automated check figures to the reporting spreadsheets to validate data accuracy and strengthen internal review procedures. Jamie Moore, Accounting Manager, will be responsible for ensuring this is accomplished. The correction action plan will be implemented by September 30, 2026.
Finding 2025-004: Reporting – Owner – Certified Submission Management Response Management agrees with the finding. REAC submission was late because year – end accounting records were not done in time. Corrective Action Plan 1. Establish a Closing Calendar and Compliance Calendar • Year-end data dead...
Finding 2025-004: Reporting – Owner – Certified Submission Management Response Management agrees with the finding. REAC submission was late because year – end accounting records were not done in time. Corrective Action Plan 1. Establish a Closing Calendar and Compliance Calendar • Year-end data deadlines • Dates for draft and final financials • REAC submission due date 2. Coordination with Fee Accountant • Schedule year-end preparation work earlier • Fee Accountant set a deadline for LHA to provide supporting documents IMPLEMENTATION TIMELINE: PRIOR TO NEXT FISCAL YEAR-END.
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