Corrective Action Plans

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Views of Responsible Officials and Corrective Action Plan Each Return of Title IV calculation will be supported by verifiable supporting reports or information demonstrating the number of calendar days used in the calculation. During the annual New Year Roll, all date fields will be manually reviewe...
Views of Responsible Officials and Corrective Action Plan Each Return of Title IV calculation will be supported by verifiable supporting reports or information demonstrating the number of calendar days used in the calculation. During the annual New Year Roll, all date fields will be manually reviewed to ensure default system values are appropriate and consistent with the academic calendar. This information will be reviewed by supervisory personnel independent of the staff member preparing the dates and calculations.
Condition Found The Council did not submit quarterly reports to NHTSA within the required timeframe as stipulated under federal grant requirements. The reports were only provided in September 2025 after the Council became aware of the obligation and coordinated with the Contracting Officer’s Represe...
Condition Found The Council did not submit quarterly reports to NHTSA within the required timeframe as stipulated under federal grant requirements. The reports were only provided in September 2025 after the Council became aware of the obligation and coordinated with the Contracting Officer’s Representative (COR) to submit all past-due reports retroactively. Corrective Action Plan Onboarding Enhancement: Develop and implement a standardized onboarding checklist for new program managers that includes all federal reporting requirements. Compliance Monitoring: Establish quarterly internal compliance reviews to verify timely submission of required reports. Communication Protocol: Formalize communication with government agency to confirm reporting expectations at the start of each contract year. Training: Provide annual compliance training for program managers and relevant staff on federal reporting obligations. Responsible Person for Corrective Action Plan Keith Radeke, Chief Financial Officer Implementation Date of Corrective Action Plan December 18, 2025
Section III Federal Award Findings and Questioned Costs Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care),) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Grants for New and Expanded...
Section III Federal Award Findings and Questioned Costs Health Center Program (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care),) Grants for New and Expanded Services Under the Health Center Program, COVID-19 Grants for New and Expanded Services Under the Health Center Program Federal Assistance Listing Numbers: 93.224 and 93.527 Item 2025 002 – Special Tests Recommendation The Center should establish a system of internal controls to ensure that all slide fee discounts are properly calculated based on family size and income. Repeat Finding Yes Action Taken The Finance Department will take the following steps to enhance the slide fee discounts process: 1. Policy Revision: the health center will revise its Sliding Fee Discount Policy to ensure alignment with HRSA requirements, including accurate discount calculation methodologies, annual updates to the sliding fee scale, and proper utilization of NextGen system functionality to support implementation 2. Staff Training: the health center will provide comprehensive training to all relevant staff on the revised Sliding Fee Discount Policy and procedures. 3. Training will emphasize correct discount calculations, required documentation, and income verification processes. A recurring training program will be implemented to ensure ongoing compliance for both new hires and existing employees. 3. Retrospective Review: the health center will conduct a retrospective review of patient files for the current fiscal year to confirm that all sliding fee discounts are appropriately supported by required documentation. Any identified discrepancies will be corrected in a timely manner. 4. Ongoing Monitoring: the health center will establish monthly internal audits of sliding fee discount determinations to monitor compliance. Audit results will be documented and reviewed by management to ensure corrective actions are taken as needed. Responsible Party: Chief Financial Officer Target Completion Date: 04/30/2026 If the Cognizant or Oversight Agency for Audit has questions regarding this plan, please call: Javier Vallejo, CFO at (314)-482-0915. Sincerely yours, Javier Vallejo Chief Financial Officer
Management agrees with the auditor’s finding 2025-01 Subrecipient Monitoring – Audit Verification. The following action will be taken to ensure that the Subrecipient complies with the single audit requirement: • The Finance Director, Kristie Howell, will correspond with the Subrecipient, Grassy Pond...
Management agrees with the auditor’s finding 2025-01 Subrecipient Monitoring – Audit Verification. The following action will be taken to ensure that the Subrecipient complies with the single audit requirement: • The Finance Director, Kristie Howell, will correspond with the Subrecipient, Grassy Pond Water Company, to clearly state the single audit requirement and due dates. • Cherokee County will request written correspondence from the subrecipient, outlining their course of action and timeline to complete the single audit. • Cherokee County will follow-up with Grassy Pond Water Company on a bi-weekly basis until the 2024 single audit has been submitted, and monthly to ensure that the 2025 audit is being completed as well. • All correspondence will be documented.
FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Procurement: For two vendors, the School Corporation did not obtain price or rate quotes as required. The School Corporation did not maintain documentation to support the rational...
FINDING 2025-001 Finding Subject: Child Nutrition Cluster - Procurement and Suspension and Debarment Summary of Finding: Procurement: For two vendors, the School Corporation did not obtain price or rate quotes as required. The School Corporation did not maintain documentation to support the rationale and justification to limit competition, and there was no documentation of the history of the Procurement which would include the rationale for the method of procurement, the selection of the vendor, and the basis for price. Suspension and Debarment: Two vendors were identified for which the School Corporation was required to verify the suspension and debarment status, however no such verification could be provided for audit. Contact Person Responsible for Corrective Action: Food Service Director, Joshua Deck Contact Phone Number and Email Address: (812) 649-2591 / josh.deck@sspencer.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: Procurement: The Food Service Director will maintain a binder/Google Drive folder with documentation of price and/or rate quotes and documentation of the attempts made from at least three vendors that fall within the small purchase threshold. If price and/or rate quotes cannot be obtained from at least three vendors, documentation of the reasoning will be maintained. Suspension and Debarment: The Food Service Director will ensure that all vendors are not suspended or debarred by either ensuring the suspension and debarment verbiage is included in the contracts, providing a clause to the vendor to sign that they are not suspended or debarred, or checking the SAM.gov website. Documentation of these records will be maintained for audit. Anticipated Completion Date: Effective FY 2025/2026
Audit Finding Reference: 2025-002 – Title I Grants to Educational Agencies (LEAs) – ALN #84.010 Planned Corrective Action: For FY26, the Academy has implemented a process to ensure procurement of approval signatures on Semi-Annual Time Certification Forms, which will demonstrate a review has been pe...
Audit Finding Reference: 2025-002 – Title I Grants to Educational Agencies (LEAs) – ALN #84.010 Planned Corrective Action: For FY26, the Academy has implemented a process to ensure procurement of approval signatures on Semi-Annual Time Certification Forms, which will demonstrate a review has been performed over salary allocations. Name of Contact Person: Bob Haynes Interim Controller Bobhaynes@achievementfirst.org Anticipated completion date: December 9, 2025
Audit Finding Reference: 2025-002 – Title I Grants to Educational Agencies (LEAs) – ALN #84.010 Planned Corrective Action: For FY26, the Academy has implemented a process to ensure procurement of approval signatures on Semi-Annual Time Certification Forms, which will demonstrate a review has been pe...
Audit Finding Reference: 2025-002 – Title I Grants to Educational Agencies (LEAs) – ALN #84.010 Planned Corrective Action: For FY26, the Academy has implemented a process to ensure procurement of approval signatures on Semi-Annual Time Certification Forms, which will demonstrate a review has been performed over salary allocations. Name of Contact Person: Bob Haynes Interim Controller Bobhaynes@achievementfirst.org Anticipated completion date: December 9, 2025
For FY26, the Academy has implemented a process to ensure procurement of approval signatures on Semi-Annual Time Certification Forms, which will demonstrate a review has been performed over salary allocations.
For FY26, the Academy has implemented a process to ensure procurement of approval signatures on Semi-Annual Time Certification Forms, which will demonstrate a review has been performed over salary allocations.
Federal grants ended in FY 2025. If we receive federal reimbursement grants in the future, we will develop a better process so this does not occur.
Federal grants ended in FY 2025. If we receive federal reimbursement grants in the future, we will develop a better process so this does not occur.
Catholic Charities had implemented procedures to ensure that monthly expenditure reports were filed by the required deadline of the 15th day of the following month. In the following fiscal year, all grant reports were submitted on time, with the exception of the first few months of the beginning of ...
Catholic Charities had implemented procedures to ensure that monthly expenditure reports were filed by the required deadline of the 15th day of the following month. In the following fiscal year, all grant reports were submitted on time, with the exception of the first few months of the beginning of the grant year when the required reporting templates were not yet available from the administering agency. These programs have since been closed; therefore, no ongoing corrective action or monitoring is required.
2025-007 – Medical Assistance Program – Activities Allowed and Allowable Costs/Cost Principles – The District is aware of the licensing requirements and will attempt to compile the information necessary in the future. Responsible Official – Karl Morrin, District Administrator Anticipated Completion ...
2025-007 – Medical Assistance Program – Activities Allowed and Allowable Costs/Cost Principles – The District is aware of the licensing requirements and will attempt to compile the information necessary in the future. Responsible Official – Karl Morrin, District Administrator Anticipated Completion Date – This finding is expected to be resolved for the 2026 annual financial report.
Views of Responsible Officials and Planned Corrective Action
Views of Responsible Officials and Planned Corrective Action
The Division has since initiated the annual risk assessments on subrecipients and expects to complete the risk assessments by December 31, 2025.
The Division has since initiated the annual risk assessments on subrecipients and expects to complete the risk assessments by December 31, 2025.
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: CLA recommends reviewing and updating key IT/financially relevant organization-wide policies and procedures on an annual basis. CLA also recommends the Organization review the institution's written information security pr...
Student Financial Aid Cluster – Assistance Listing No. Various Recommendation: CLA recommends reviewing and updating key IT/financially relevant organization-wide policies and procedures on an annual basis. CLA also recommends the Organization review the institution's written information security program and ensure that a qualified individual (i.e. CIO, CISO, ISO) has been identified to enforce and monitor GLBA compliance. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: During the audit period, the University experienced significant employee turnover within the Information Technology department, which contributed to delays in the review and update of key IT and financially relevant policies and procedures. A new Chief Information Officer (CIO) has since been hired and has begun addressing the gaps noted in the finding. Under the CIO’s leadership, the University is actively reviewing and updating organization-wide IT policies, procedures, and the written information security program. The CIO is also assuming responsibility for enforcing and monitoring GLBA compliance going forward. Name(s) of the contact person(s) responsible for corrective action: John Honchell, CIO Planned completion date for corrective action plan: May 31, 2026
FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA) - Procurement Contact Person Responsible for Corrective Action: Samantha Berrier Contact Phone Number and Email Address: 219-962-2909, sberrier@rfcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description o...
FINDING 2025-001 Finding Subject: Special Education Cluster (IDEA) - Procurement Contact Person Responsible for Corrective Action: Samantha Berrier Contact Phone Number and Email Address: 219-962-2909, sberrier@rfcsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The offices of the Northwest Indiana Special Education Cooperative (NISEC), on behalf of River Forest Community School Corporation, its member school, has implemented a corrective action plan to ensure that the proper methodology for procurement is followed. Additionally, a system of internal controls has been established to ensure that vendors are procured using the required methods. The Northwest Indiana Special Education Cooperative created a corrective action plan to develop procedures to obtain bids when any vendor will exceed the simplified acquisition threshold. As part of this corrective action plan they have included procedures to follow if a noncompetitive procurement would be applicable. These procedures include documenting the rationale for using this alternative method and requesting approval from the Board of School Trustees when doing so. Anticipated Completion Date: October 9th, 2024
Criteria: HUD requires the Organization to maintain fidelity bond coverage of at least two months' cash collections Cause: Following completion of the 2025 Mark-to-Market process for HRCA Housing for Elderly Inc., we failed to update our fidelity bond coverage to reflect the revised requirements. Ac...
Criteria: HUD requires the Organization to maintain fidelity bond coverage of at least two months' cash collections Cause: Following completion of the 2025 Mark-to-Market process for HRCA Housing for Elderly Inc., we failed to update our fidelity bond coverage to reflect the revised requirements. Action Plan: Once the finding was identified, we immediately contacted our insurance broker and requested an increase to the fidelity bond coverage. The bond has since been raised to a $2M limit, and the updated policy became effective on 11/14/25. Going forward, the fiscal team will incorporate an annual verification of bond coverage into its routine monitoring procedures to ensure timely updates after significant organizational or regulatory changes. In addition, we are implementing an internal audit component to enhance our review of all HUD requirements. This added oversight will help mitigate future risk and ensure continued compliance with all applicable regulations.
HACP has implemented the following corrective actions: Continued oversight of two current inspectors to ensure compliance with HQS and federal regulations; Retention of a Compliance Coordinator to oversee inspection processes and documentation; implementation of improved documentation standards rela...
HACP has implemented the following corrective actions: Continued oversight of two current inspectors to ensure compliance with HQS and federal regulations; Retention of a Compliance Coordinator to oversee inspection processes and documentation; implementation of improved documentation standards related to inspections, re-inspections, and abatements; Regular file audits conducted by the ED or Deputy Director to verify timely rescheduling and enforcement of rent abatements.
HIV Formula Care Grant (AL93.917) - Significant Deficiency 2025-001 Management agrees with the finding and will enhance the current processes. Subsequent to year end, management created a tool to ensure all elements of program income, as well as related expenses incurred, are properly tracked, repor...
HIV Formula Care Grant (AL93.917) - Significant Deficiency 2025-001 Management agrees with the finding and will enhance the current processes. Subsequent to year end, management created a tool to ensure all elements of program income, as well as related expenses incurred, are properly tracked, reported, and utilized in accordance with federal requirements. Additionally, written policies are being drafted to reflect these procedures. Implementation is expected by January 31, 2026.
The grant accounting team will create grant abstracts summarizing compliance requirements and key dates. These will then be added to the accounting department’s comprehensive checklist to ensure proper reporting guidelines are met on time. This will be completed by December 31, 2025 The grant accoun...
The grant accounting team will create grant abstracts summarizing compliance requirements and key dates. These will then be added to the accounting department’s comprehensive checklist to ensure proper reporting guidelines are met on time. This will be completed by December 31, 2025 The grant accounting Team will submit information on first-tier subawards to SAM.gov for eligible grants by December 31, 2025.
Morrow County respectfully submits the following corrective action plan in response to deficiencies reported in our audit of the fiscal year ended June 30, 2025. The audit was completed by the independent auditing firm SingerLewak, LLP and reported the deficiency listed below. SIGNIFICANT DEFICIENCY...
Morrow County respectfully submits the following corrective action plan in response to deficiencies reported in our audit of the fiscal year ended June 30, 2025. The audit was completed by the independent auditing firm SingerLewak, LLP and reported the deficiency listed below. SIGNIFICANT DEFICIENCY 2025-001 Late Submission of Required Reports Criteria: The recipient or subrecipient must submit financial reports as required by the Federal award. Reports submitted annually by the recipient or subrecipient must be due no later than 90 calendar days after the reporting period. Reports submitted quarterly or semiannually must be due no later than 30 calendar days after the reporting period. Condition: The County did not submit the required financial reports timely. Cause: The County was unaware of the requirement to submit a financial report for this award. Effect or potential effect: Agency monitoring over the award is unable to be performed. Questioned Costs: None Recommendation: We recommend the County establish internal controls that would ensure compliance with the criteria noted above. The County acknowledges the significant deficiency identified in the 2025 audit related to late submission of required reports. Management has reviewed its existing controls and procedures to identify the point of failure and has implemented changes to ensure proper review of grant requirements and timely filing of reports occur.
Finding #2025-001: Comments on the Finding and Each Recommendation: The Corporation received a reimbursement from the reserve for replacements, as approved by HUD, for $17,400 for HVAC services based on a proposal during the year ended September 30, 2025; however the proposal was never accepted and ...
Finding #2025-001: Comments on the Finding and Each Recommendation: The Corporation received a reimbursement from the reserve for replacements, as approved by HUD, for $17,400 for HVAC services based on a proposal during the year ended September 30, 2025; however the proposal was never accepted and the scheduled repairs never incurred. At September 30, 2025, the $17,400 had not been deposited back into the reserve for replacements. Management should transfer $17,400 from the operating account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. On November 6, 2025, management transferred $17,400 from the operating account to the reserve for replacements.
Finding 2025-001 Reporting – Annual Reporting Criteria: Education Stabilization Fund (ESF) grantees must submit an annual performance report with data on expenditures, planned expenditures, subrecipients, and uses of funds, including mandatory reservations. Local Education Agencies submit data to th...
Finding 2025-001 Reporting – Annual Reporting Criteria: Education Stabilization Fund (ESF) grantees must submit an annual performance report with data on expenditures, planned expenditures, subrecipients, and uses of funds, including mandatory reservations. Local Education Agencies submit data to the state education agencies. Key line items must include expenditures by category, object code, and allocations to schools. Audit Recommendation: We recommend management of the District review processes related to reporting for the ESF and establish appropriate internal controls to ensure all reporting requirements are met. Corrective Action Planned: The District will review, update and train staff on the process and internal controls related to reporting for the ESF to ensure compliance with the reporting requirements. Person(s) Responsible: Matthew Keyes, Superintendent ad interim Anticipated Completion Date: December 31, 2025
Finding 2025-001: Required Services to Eligible Participants Name of Contact Person: TRIO Talent Search Beeville Project Director, Ruby Hernandez Corrective Action: The College has corrected this issue by requiring staff to submit bimonthly student contact reports through Blumen within five business...
Finding 2025-001: Required Services to Eligible Participants Name of Contact Person: TRIO Talent Search Beeville Project Director, Ruby Hernandez Corrective Action: The College has corrected this issue by requiring staff to submit bimonthly student contact reports through Blumen within five business days following each reporting period. This process ensures consistent and well-documented outreach to students while strengthening the accuracy and completeness of program records. Under the leadership of the new TRIO Talent Search Beeville Director, the system is now fully operational and demonstrating compliance, with supervisory oversight in place to prevent future occurrences. This reporting practice has been standardized and implemented across all four TRIO programs. Proposed Completion Date: 11/01/2025 Anticipated Completion Date: Completed
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at September 30, 2024 in the amount of $642,483 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required res...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at September 30, 2024 in the amount of $642,483 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on June 9, 2025.
Finding During the federal award audit, it was noted that while the District followed procurement guidelines and procedures in the DJB Federal Procurement Policy, it does not have an established suspension and debarment procedure. Condition The District currently lacks a documented process to verify...
Finding During the federal award audit, it was noted that while the District followed procurement guidelines and procedures in the DJB Federal Procurement Policy, it does not have an established suspension and debarment procedure. Condition The District currently lacks a documented process to verify that vendors and subrecipients are not suspended or debarred from doing business with federal agencies. Criteria Under 2 CFR 200.214, non-federal entities are prohibited from entering into contracts or subawards with parties that are suspended or debarred from participation in federal programs. Cause The absence of a formal written procedure to verify vendor status prior to award or contract execution. Effect Without a documented procedure, there is a risk that contracts could be awarded to suspended or debarred entities, resulting in noncompliance with federal regulations. Corrective Action The District will formally adopt a Suspension and Debarment Verification Procedure that outlines the required process for verifying all vendors and subrecipients before entering into any contract funded by federal awards. Staff will verify suspension and debarment status by checking the System for Award Management (SAM.gov) prior to contract execution and will maintain documentation of verification in the procurement file. The Business Services Department will complete training on the new procedure and documentation requirements. Responsible Party: Business Manager Completion Date: Procedure adoption and staff training by December 31, 2025
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