Corrective Action Plans

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Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into inte...
Internal Control over Compliance and Compliance with Cash Management Requirements Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action Transition to interest-bearing accounts and move advance Federal balances into interest-bearing accounts. Also, establish a process to track interest earned on Federal advances and remit annually any interest above the $500 de minimis threshold to the federal agency per §200.305(b)(11), retaining records of calculation and remittance.
Internal Control over Compliance and Compliance with the Reporting Compliance Requirement Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action The results of the 2025 audit will be shared with appropriate EGPAF staff a...
Internal Control over Compliance and Compliance with the Reporting Compliance Requirement Contact: Aida Awaj Title: Assistant Controller Phone Number: 202-785-0072 Estimated Completion Date: August 31, 2026 Corrective Action The results of the 2025 audit will be shared with appropriate EGPAF staff and reinforced through training to ensure adequate attention and clear guidance on the FFATA reporting threshold and the requirement to file first-tier subaward reports in SAM.gov by the end of the month following the month in which the subaward is executed.
Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appro...
Internal Controls over Compliance and Compliance with the Period of Performance Compliance Requirement Contact: Katie Queen Dossinger Title: Chief Operating Officer Phone Number: 202-785-0072 Estimated Completion Date: Ongoing Corrective Action The results of the 2025 audit will be shared with appropriate PSI and EGPAF staff and reinforced through training to ensure adequate attention and clear guidance on the allowability of trailing costs and the unallowability of newly incurred costs.
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management ...
Recommendation: We recommend that the Authority develop, approve, and implement comprehensive written policies for federal fund spending that address cost allowability, procurement, approvals, documentation retention, subrecipient or vendor oversight, reimbursement requests, and periodic management review. In addition, the Authority should train relevant personnel on these policies and perform ongoing monitoring to confirm that federal expenditures are reviewed and documented in accordance with applicable grant requirements. Management’s Response: Management acknowledges the recommendation. The Authority will evaluate its existing processes and controls over the use of federal funds and consider whether additional written guidance and/or enhancements to current procedures are warranted to address, as applicable, cost allowability, procurement requirements, approval responsibilities, documentation and record retention, subrecipient or vendor oversight, reimbursement request preparation and review, and periodic management review of federal expenditures. Based on the results of this evaluation, the Authority will communicate any clarifications, reminders, and/or targeted training to relevant personnel involved in administering, approving, recording, or requesting reimbursement for federal expenditures, as deemed necessary. Management will also consider whether additional monitoring activities are warranted to help confirm that federal expenditures are reviewed, approved, and supported by appropriate documentation in accordance with applicable grant requirements.
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsib...
Finding No. 2025-003 – Late Filing of Single Audit Reporting Package Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Hospital will establish an annual audit readiness timeline working backward from the Uniform Guidance submission deadline (the earlier of thirty (30) calendar days after receipt of the auditors’ reports or nine months after the end of the audit period, June 30). The timeline will include target dates for the completion of year-end closing procedures, the delivery of auditor-requested schedules and supporting documentation, audit fieldwork, review of the draft report, and submission of the reporting package and Data Collection Form to the Federal Audit Clearinghouse in advance of the deadline. 2. Monthly closing discipline will be maintained throughout the fiscal year so that year-end balances, account reconciliations (including patient accounts receivable aging, the allowance for credit losses, and grants receivable), and audit support schedules are substantially complete at year end and available for timely delivery to the auditors. 3. The Chief Financial Officer will monitor the status of the audit timeline monthly beginning in October of each fiscal year, and any delay against the established milestones will require a documented recovery plan to return the process to schedule. 4. The Single Audit Reporting Package and Data Collection Form for the year ended September 30, 2025 will be submitted to the Federal Audit Clearinghouse immediately upon issuance of the final audit report. Anticipated Completion Date October 31, 2026
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J....
Finding No. 2025-002 – Failure to Properly Apply Current Federal Poverty Guidelines in the Sliding Fee Discount Program (SFDP) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Taken and Planned 1. Resolution of the two identified cases. The Hospital reviewed and resolved the two patient accounts identified in the audit sample in which an incorrect sliding fee discount percentage was applied: • In the first case, the discount applied resulted in a charge to the patient below the amount that corresponded under the correct Federal Poverty Guidelines discount tier, and a lower amount was collected from the patient. Management evaluated the account and determined not to retroactively bill the patient for the remaining difference, consistent with the Hospital’s mission and its policy of not creating barriers to care for patients eligible under the Sliding Fee Discount Program. • In the second case, the Hospital billed and collected from the patient an amount higher than the amount that corresponded under the correct discount tier. This case was resolved and the amount collected in excess of the correctly discounted amount was returned to the patient by check no. 95274, issued on May 29, 2026. Documentation of the refund is retained in the patient’s account file. 2. Questioned cost. The known questioned cost of $245.97 has been repaid and offset by the Hospital. Supporting documentation of the resolution is available for review by the awarding agency. 3. Current Federal Poverty Guidelines implementation. The Sliding Fee Discount Schedule will be updated to the current Federal Poverty Guidelines (FPG) issued annually by HHS, and a standing procedure will be established requiring that the updated schedule be approved and incorporated into the Hospital’s billing system (eClinicalWorks) within thirty (30) days of the annual publication of the FPG. 4. Review of sliding fee determinations. The review process over sliding fee discount determinations, which had previously been performed by the Billing Department and was later delegated to the information management staff, has been returned to the Billing Department to ensure that discounts are properly applied to patients in accordance with the Sliding Fee Discount Program policies and the updated fee schedule. 5. Strengthened internal controls. A secondary review control will be implemented under which a quarterly sample of new and renewed SFDP eligibility determinations will be re-verified by the Billing Department against the current FPG schedule, income documentation, and household size, with the results documented in a monitoring log subject to review by the Chief Financial Officer. 6. Training. Formal training on the SFDP policy, the current FPG schedule, and the related documentation requirements will be provided to all registration, billing, and eligibility staff, with attendance documented. Refresher training will be provided annually upon each FPG update. Anticipated Completion Date Items 1 and 2 – Completed. Items 3 through 6 – October 31, 2026.
Finding No. 2025-001 – Late Report Filing (SF-425) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Manag...
Finding No. 2025-001 – Late Report Filing (SF-425) Federal Program: Health Center Program Cluster, ALN 93.224 – U.S. Department of Health and Human Services (HHS) Contact Person Responsible for Corrective Action Guillermo J. Jiménez Ramos, Chief Financial Officer Views of Responsible Officials Management concurs with the finding. Corrective Action Planned 1. The Fiscal Department will implement a Federal Compliance Reporting Calendar covering all required federal financial reports, including the Federal Financial Report (SF-425) and Payment Management System (PMS) submissions, identifying for each report its due date, the individual responsible for its preparation, the reviewer, and the submission evidence to be retained. 2. Responsibility for the preparation of each SF-425 report will remain formally assigned to the Fiscal Department, under the oversight of the Chief Financial Officer (CFO). Each report will be subject to CFO review and approval prior to submission. Preparation of the reports will commence no later than thirty (30) days before the established due date, in accordance with internal control procedures and reporting timelines. 3. Automated reminders will be configured at thirty (30), fifteen (15), and five (5) days before each filing deadline, directed to both the preparer and the reviewer, to provide adequate oversight and prevent future delays. 4. Confirmation of each submission (PMS acknowledgment) will be retained and filed with the report workpapers as evidence of timely filing, and the status of federal reporting deadlines will be monitored monthly by the Chief Financial Officer. Anticipated Completion Date July 31, 2026
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Jenn Moses, Manager of Planning and Community Development Co...
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Jenn Moses, Manager of Planning and Community Development Corrective Action Planned: • Update FFATA reporting by June 25, 2026 • Implement new procedures for monthly review of FFATA reporting with multiple team members Anticipated Completion Date: July 31, 2026
2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Non...
2025-006: STUDENT MEAL APPLICATIONS Program: Child Nutrition Cluster Federal Assistance Listing Number: 10.553, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Questioned Costs: $-0- Type of Finding: Noncompliance (Other Matter), significant deficiency in internal control Compliance Requirement: E. Eligibility Condition: During our testing of eligibility determinations under the Child Nutrition Cluster, we selected 40 student meal applications for review. Of the 40 applications tested, two applications were incorrectly classified based on the information provided on the applications. Specifically, one application was approved as free when it should have been approved as reduced, and one application was approved as reduced when it should have been approved as paid based on applicable eligibility guidelines. Action planned in response to finding: The District will ensure nutrition applications are reviewed to determine they meet the appropriate classification criteria. In addition, applications will be reviewed and approved by someone other than the initial individual that is recording the classification type. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Edward Dickie, Business Manager.
The Finance Department staff will review all items prior to completing the report. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Finance Department staff will review all items prior to completing the report. Personnel responsible for implementation: Carmen Tsui, Grant Accountant Completion Date: June 30, 2026
The Housing Manager and Management Analyst/Grant Writer are collaboratively working to ensure FFATA reports are completed prior to disbursing funds to subawardees. Personnel responsible for implementation Vanessa Sedano, Housing Manager Completion Date: June 30, 2026
The Housing Manager and Management Analyst/Grant Writer are collaboratively working to ensure FFATA reports are completed prior to disbursing funds to subawardees. Personnel responsible for implementation Vanessa Sedano, Housing Manager Completion Date: June 30, 2026
June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, S...
June 25, 2026 Dear Cognizant or Oversight Agency for Audit: DePelchin Children’s Center (DePelchin) respectfully submits the following corrective action plan for the year ended December 31, 2025. Name and address of independent public accounting firm: Doeren Mayhew Assurance, 2600 North Loop West, Suite 600, Houston, TX 77092. The finding discussed below from the Schedule of Findings and Questioned Costs (the schedule) for the year ended December 31, 2025 is numbered consistently with the number assigned in the schedule. Federal Award Finding 2025-001 Corrective Action Plan: DePelchin has implemented an internal review process whereby a grant specialist on the evaluation team conducts a monthly review of all enrollments to verify that eligibility requirements, including priority characteristics and service area criteria, have been met. Program staff, evaluation staff, and data team members have been provided additional training on the applicable eligibility requirements and documentation standards. Additionally, DePelchin has implemented an annual cross-functional review process involving program leadership, evaluation staff, and fiscal representatives to review eligibility requirements and key contract provisions prior to the start of each fiscal year. This review is intended to ensure that any changes in program requirements are identified, communicated, and incorporated into program operations in a timely manner. Based on these corrective actions and enhanced monitoring procedures, DePelchin believes the risk of similar eligibility documentation issues has been substantially mitigated. Contact Person Responsible for Corrective Action: Mr. Brian Pate, Senior VP and CFO Anticipated Completion Date: The corrective action plan is anticipated to be completed by October 31, 2026. Respectfully submitted, Mr. Brian Pate Senior VP and CFO
Finding 2025-002 – Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action: The City is in the process of updating a...
Finding 2025-002 – Significant Deficiency and Noncompliance - Lack of Required Uniform Guidance Policies and Procedures Condition: The City did not update their federal policies and procedures to be in full compliance with Uniform Guidance. Corrective Action: The City is in the process of updating and adopting written policies and procedures that are in compliance with Uniform Guidance. Anticipated Completion Date: December 31, 2026 Responsbile Official: John Szymanski, City Manager
Finding 2025-005 - Untimely Release of Title IV Credit Balances (Significant Deficiency): Condition - During testing of student account activity, we identified that fourteen (14) out of sixty (60) sampled students had Title IV created credit balances that remained on their accounts for more than 14 ...
Finding 2025-005 - Untimely Release of Title IV Credit Balances (Significant Deficiency): Condition - During testing of student account activity, we identified that fourteen (14) out of sixty (60) sampled students had Title IV created credit balances that remained on their accounts for more than 14 days without being released to the student or parent. All refunds were eventually released to the students. Corrertive Action Plan The College experienced significant staff turnover within the business office. In addition, the College is undergoing conversion to a new Enterprise Resource Planning (ERP) system which affected its ability to complete some functions within a timely manner. A new bursar was hired in May 2026. Timely processing of student refunds was emphasized during her training. Going forward, student refunds will be released within 14 days after credit balances are reflected on student accounts." Completion Date - September 30, 2026 Responsible Party - Chief Financial Officer
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code with...
Federal Agency: U.S. Department of Education Federal Program: Student Financial Assistance Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-004 Corrective Action Plan: The identified conditions relate to students who experienced a change in status code within the Union College system specifically related to graduation and withdrawal dates. A report that includes status code changes will be reconciled with student status changes transmitted by the National Student Clearinghouse (NSC) to the National Student Loan Database System (NSLDS), and any necessary corrections will be made in the appropriate time frame. Timeline for Implementation of Corrective Action Plan: The corrective action plan was implemented at the end of the Spring 2026 term.
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal con...
Federal Agency: Various Federal Program: Research and Development Cluster Assistance Listing Number: Various Federal Award Numbers: Various Finding No.: 2025-002 Corrective Action Plan: To address the finding, the College will continue to implement a corrective action plan to strengthen internal controls over the application of indirect cost rates to federally funded awards. Although corrective actions were initiated following the prior year's finding, the College has identified opportunities to enhance the review and monitoring of indirect cost rate calculations to ensure consistent compliance with Uniform Guidance. Going forward, the accounting group, in collaboration with the Office of Sponsored Programs, will maintain the current federally negotiated indirect cost rates, apply approved rates to applicable awards, and perform periodic reviews to verify that the correct rates are consistently applied. Timeline for Implementation of Corrective Action Plan: The College will finalize written procedures governing the application and review of indirect cost rates, implement a documented review process for indirect cost calculations prior to posting, and provide guidance to employees responsible for grant accounting. These actions will be completed by September 30, 2026. Management will periodically monitor compliance to ensure indirect cost rates are applied accurately and in accordance with federal requirements.
Management has implemented procedures effective 7/1/2025 to ensure that reports are submitted timely and that any new filing deadlines will be documented and met without exception.
Management has implemented procedures effective 7/1/2025 to ensure that reports are submitted timely and that any new filing deadlines will be documented and met without exception.
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreeme...
View of Responsible Officials and Corrective Actions: Management agrees with the finding. Management will implement procedures to identify all federal awards expended, including funds passed through state and local governments. For each grant and contract, management will review the executed agreement and related funder documentation for indicators of federal funding, including an Assistance Listing Number, a federal award identification number, the originating federal agency, the pass-through entity identifying number, and references to the Uniform Guidance, and should confirm the federal funding status with the pass-through entity when it is not clear. Management will maintain a centralized listing of awards that is reconciled to the general ledger and reviewed for completeness in preparing the schedule of expenditures of federal awards. Contact Persons Responsible: Dr. Sharrone Ward, President and Chief Executive Officer Kim Shelton-Mamon, Vice President of Finance Completion Date: July 31,2026
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards...
2025-002 PROCUREMENT (repeat comment) Planned Corrective Action: LCCMH Management has taken actions to revise policies and procedures to ensure their alignment with federal regulations, as well as providing training regarding federal procurement requirements for the relevant personnel. The Standards Committee, which is responsible for regularly reviewing Policies and Procedures and approving or recommending changes, reviewed and approved the following policy revisions at its November 19, 2024 meeting to maintain compliance with federal regulation standards. 0.1.02.65 Provider Procurement and Best Value Purchasing 01.02.85 Procuring Employment Services Providers, Independent Contractors and Network Providers. The approved policies were also presented at the LCCMH Full Board meeting on November 21, 2024. All LCCMH Staff were advised on December 2, 2024, to review the revised policies and procedures. On April 22, 2025, SAMSHA provided LCCMH written notification identifying the 2023 citation for procurement as resolved. Responsible Party: Emma McQuillan, Chief Financial Officer Completion Date: 12/5/2024
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Correct...
Finding Number: 2025-002 Finding Title: Reporting – Federal Funding Accountability and Transparency Act (FFATA) Program: 14.218 Community Development Block Grants/Entitlement Grants 14.218 COVID-19 – Community Development Block Grants/Entitlement Grants Name of Contact Person Responsible for Corrective Action: Matthew Bower, George Hardgrove Corrective Action Planned: The City concurs with this finding. City has hired additional resources to perform review of subrecipient transactions. On a monthly basis, the new position will review system generated reports to timely capture reportable subrecipient transactions. Additionally, the City has an ongoing quarterly meeting with all grant managers. Training will be provided to grant managers to ensure proper identification of subrecipient contracts and proper entry into the SAM.gov system. Anticipated Completion Date: December 31, 2026
The Board of County Commissioners will ensure that the reports are accurate and reported in the proper period.
The Board of County Commissioners will ensure that the reports are accurate and reported in the proper period.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
The Board of County Commissioners will work with all County Officials to go over all grants and federal monies that the County receives to ensure that proper internal controls are implemented.
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compli...
We will work to implement a Risk Assessment plan over federal grants. We will implement controls to make sure we comply with grant requirements and that federal funds are expended in accordance with grant agreements and in a timely manner. We will ensure employees have the current and correct compliance supplement to work from.
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the...
The Town agrees with this finding. We understand that while the total project budget was correct, $324, 641 for the Park St. Sewer Main, the project was accidentally listed as a current expense instead of a past expense. Corrective Action Plan: To fix this and make sure it does not happen again, the Town will take the following steps: Before sending any future reports to the federal government, the Finance Department will match the report numbers directly to the Town's official accounting records (the general ledger). A second person in the finance department will review and sign off on the report before it is submitted. We will save copies of the accounting records and the signed approval forms to show future auditors. Planned Implementation Date of Corrective Action: September 1, 2026 Person Responsible for Corrective Action: Town Accountant/ Finance Director
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant ag...
Finding 2025-004 Inadequate System of Internal Controls over Benefit Limitation Condition: The Organization is required by the federal grant award to limit eligible client families to a maximum of eleven diapering supply "package" distributions per participating child over the course of the grant agreement period. While the program design includes efforts to control this requirement, the eligibility database lacks the capability to assign or track unique participant identifiers needed to reliably enforce this limit. Additionally, there is no documentation to demonstrate that processes related to benefit limits are periodically reviewed or monitored. Due to the nature of recordkeeping in this area, testing compliance is challenging. Although no instances of noncompliance were identified in the sample tested, the Organization has not implemented an adequate system of internal controls to ensure consistent compliance with this grant criterion. A new system was implemented in December 2025 which improved the deficiencies identified for the remainder of the year. Corrective Actions Taken or Planned: The new CRM, Pantry Soft will allow us to monitor and control benefit limitation. While not documented, the President and CEO did periodically review and monitor benefit eligibility and limits. We will begin documenting this procedure.
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