Corrective Action Plans

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Equipment Inventory Controls - R&D - UM - The University of Montana - Missoula will establish a system-level inventory monitoring process by generating an annual listing from the Banner system to identify all departments required to perform inventories. This listing will serve as the official invent...
Equipment Inventory Controls - R&D - UM - The University of Montana - Missoula will establish a system-level inventory monitoring process by generating an annual listing from the Banner system to identify all departments required to perform inventories. This listing will serve as the official inventory checklist and will be used to track and verify inventory completion. The University will continue to use the dedicated staff member responsible for capital asset management and will perform physical inventories every two years to verify asset existence and ensure all capital assets are properly tagged. Responsible Party - Rachel Buswell, Controller, University of Montana - Missoula Target Implementation Date - 3/31/2027
Noncompliant FFATA Reports - Medicaid - DPHHS - The Montana Department of Public Health and Human Services agrees that internal control deficiencies existed in its Federal Funding Accountability and Transparency Act (FFATA) subaward reporting processes during fiscal years 2024 and 2025, and that ins...
Noncompliant FFATA Reports - Medicaid - DPHHS - The Montana Department of Public Health and Human Services agrees that internal control deficiencies existed in its Federal Funding Accountability and Transparency Act (FFATA) subaward reporting processes during fiscal years 2024 and 2025, and that instances of noncompliance occurred. The department has implemented additional internal controls and has corrected the Medicaid FFATA reports. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 7/1/2025
Inadequate HAP Reconciliation Controls - HVC - Commerce - The Montana Department of Commerce has provided additional staff training to ensure housing assistance payments are issued timely, even though the error rate was less than one percent. Responsible Party - Ingrid Mallo, Chief Financial Officer...
Inadequate HAP Reconciliation Controls - HVC - Commerce - The Montana Department of Commerce has provided additional staff training to ensure housing assistance payments are issued timely, even though the error rate was less than one percent. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/19/2026
Inadequate Inspection Controls - HVC - Commerce - The Montana Department of Commerce implemented the United States Department of Housing and Urban Development’s new inspection protocol on July 1, 2026. This protocol will ensure staff are able to perform the required inspections. Responsible Party - ...
Inadequate Inspection Controls - HVC - Commerce - The Montana Department of Commerce implemented the United States Department of Housing and Urban Development’s new inspection protocol on July 1, 2026. This protocol will ensure staff are able to perform the required inspections. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 9/18/2025
Inadequate HAPPY System Access Controls - HVC - Commerce - The Montana Department of Commerce began conducting user access reviews during the audit period. The department’s Chief Information Officer updated the Access Control Policy and distributed it to all employees. Staff received training on acc...
Inadequate HAPPY System Access Controls - HVC - Commerce - The Montana Department of Commerce began conducting user access reviews during the audit period. The department’s Chief Information Officer updated the Access Control Policy and distributed it to all employees. Staff received training on access control requirements on May 28, 2026. The department plans to obtain a new vendor to replace the HAPPY system by October 2028. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 10/31/2028
Inadequate Field Agent Payment Controls - HVC - Commerce - The Montana Department of Commerce has updated its processes to ensure that contract limits are reviewed prior to payments being issued and that contract amendments are pursued when needed. Responsible Party - Ingrid Mallo, Chief Financial O...
Inadequate Field Agent Payment Controls - HVC - Commerce - The Montana Department of Commerce has updated its processes to ensure that contract limits are reviewed prior to payments being issued and that contract amendments are pursued when needed. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/24/2026
Inadequate HQS Inspection Controls - HVC - Commerce - The Montana Department of Commerce has updated its inspection procedures to clearly outline requirements, including annual reexaminations. While the department may have lacked documentation of certain monthly reports, both the fiscal year 2024 an...
Inadequate HQS Inspection Controls - HVC - Commerce - The Montana Department of Commerce has updated its inspection procedures to clearly outline requirements, including annual reexaminations. While the department may have lacked documentation of certain monthly reports, both the fiscal year 2024 and fiscal year 2025 Section 8 Management Assessment Program Indicator 12 inspection reviews received all available points. The department is also transitioning to the National Standards for the Physical Inspection of Real Estate (NSPIRE) model for inspections. Staff completed training on June 16, 2026, and have begun using the federal inspection checklist to ensure compliance with current standards. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 9/18/2025
Inadequate FASS Reporting Controls - HVC - Commerce - The Montana Department of Commerce has developed procedures for the Financial Assessment Subsystem (FASS) reports to ensure they are complete and accurate and that the reviews of these reports are sufficiently documented. Responsible Party - Ingr...
Inadequate FASS Reporting Controls - HVC - Commerce - The Montana Department of Commerce has developed procedures for the Financial Assessment Subsystem (FASS) reports to ensure they are complete and accurate and that the reviews of these reports are sufficiently documented. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/20/2026
Inaccurate Management System Reports - HVC - Commerce - The Montana Department of Commerce implemented a process in fiscal year 2025 to ensure the completeness and accuracy of monthly Voucher Management System reports. The issues occurred during fiscal year 2024, and no issues were present in fiscal...
Inaccurate Management System Reports - HVC - Commerce - The Montana Department of Commerce implemented a process in fiscal year 2025 to ensure the completeness and accuracy of monthly Voucher Management System reports. The issues occurred during fiscal year 2024, and no issues were present in fiscal year 2025. The department will continue using these established processes to maintain accuracy and support ongoing compliance. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/20/2025
Noncompliant Waiting List Selections - HVC - Commerce - The Montana Department of Commerce identified that errors related to data entry delays for paper applications were caused by a training issue. This issue was addressed with the current Waiting List Coordinator, and training was provided to prev...
Noncompliant Waiting List Selections - HVC - Commerce - The Montana Department of Commerce identified that errors related to data entry delays for paper applications were caused by a training issue. This issue was addressed with the current Waiting List Coordinator, and training was provided to prevent future occurrences. As part of the updated process, the Waiting List Coordinator confirms data entry dates for paper applications before finalizing selections from the waiting list. In addition, the department created separate waiting lists for the ModRehab program to further reduce the potential for errors. Responsible Party - Ingrid Mallo, Chief Financial Officer, Montana Department of Commerce Target Implementation Date - 8/18/2026
Noncompliant FFATA Reports - Nutrition - OPI - The Montana Office of Public Instruction does not concur with the portions of the finding related to historical reporting issues that were fully resolved in the prior audit, including the deletion of historical reports and resubmission of final versions...
Noncompliant FFATA Reports - Nutrition - OPI - The Montana Office of Public Instruction does not concur with the portions of the finding related to historical reporting issues that were fully resolved in the prior audit, including the deletion of historical reports and resubmission of final versions. Earlier discrepancies resulted from concurrent reports within the federal reporting system, which caused amounts to duplicate. Federal partners verbally confirmed the system correction, and SAM.gov was updated at the beginning of fiscal year 2026. These issues were attributable to federal system functionality rather than to the Montana Office of Public Instruction, and reporting was completed as directed. The Office concurs with the portion of the finding involving discrepancies associated with prior‑period adjustments. After awards were liquidated and closed, the Office submitted final reports using complete expenditure data. Subsequent adjustments created differences between the Office’s internal records and federal reporting. For ALN 10.582, the Office concurs with the finding but does not agree that the Office is responsible. SAM.gov did not recognize the Federal Award Identification Number, preventing submission of required reports. This issue was later identified as a broader system problem affecting agencies nationwide. To address the recommendation, the Office will update internal FFATA guidance to ensure continued compliance with federal requirements. Documentation will be retained, and reconciliations will verify values reported in both USAspending and SAM.gov. These actions strengthen internal controls and support timely, accurate reporting. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Inadequate Physical Inventory Procedures - Nutrition - OPI - The Montana Office of Public Instruction partially concurs with this finding. The 1,000 cases of beef arrived on June 12 for the next fiscal year, while the physical inventory count occurred on June 3. The order had been entered into MAPS ...
Inadequate Physical Inventory Procedures - Nutrition - OPI - The Montana Office of Public Instruction partially concurs with this finding. The 1,000 cases of beef arrived on June 12 for the next fiscal year, while the physical inventory count occurred on June 3. The order had been entered into MAPS before the count, but the product had not yet arrived at the warehouse. When MAPS reporting was run after June 12, during verification, the beef appeared in the system even though it was not present during the physical count. The product was distributed during the following school year. This discrepancy was due solely to timing between delivery, system entry, and the inventory count. Because of staff turnover, the employee entering inventory into MAPS was not aware that items should only be entered once they are physically received. The invoice was entered before delivery, while inventory was being performed, creating a short‑term difference between the MAPS count and the actual inventory. This was a training issue, and staff have now been instructed on correct inventory procedures. Responsible Party - April Grady, Chief Financial Officer, Montana Office of Public Instruction Target Implementation Date - 12/31/2026
Noncompliant FFATA Reports - CCDF - DPHHS - The Montana Department of Public Health and Human Services partially concurs. The department agrees that internal control deficiencies existed in its subaward reporting processes under the Federal Funding Accountability and Transparency Act (FFATA) during ...
Noncompliant FFATA Reports - CCDF - DPHHS - The Montana Department of Public Health and Human Services partially concurs. The department agrees that internal control deficiencies existed in its subaward reporting processes under the Federal Funding Accountability and Transparency Act (FFATA) during fiscal years 2024 and 2025, and that instances of noncompliance occurred. The department does not concur with the quantified extent of the exceptions, including report counts and reporting figures. The department has been unable to replicate the amounts noted and did not receive sufficient detail, as outlined in 2 CFR 200.516(b), to fully understand the specific errors identified. In response to a prior audit recommendation, the department implemented corrective actions to strengthen its internal controls and review processes. These actions included enhanced oversight and the identification and correction of duplicate and inaccurate records. Many of these duplication issues originated from data quality challenges within the former federal reporting system. When the federal reporting system transitioned to the System for Award Management in state fiscal year 2026, many of those data quality concerns were eliminated. The department corrected most of the duplicated and inaccurate records that migrated from the former system to the new one. The department also enhanced its internal controls and revised its policies and procedures for reporting under FFATA. Responsible Party - Brenda Crawford, Internal Control and Compliance Officer, Montana Department of Public Health and Human Services Target Implementation Date - 7/23/2025
Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supe...
Controls over Reporting Recommendation: The City should strengthen its internal controls over federal reporting by establishing formal procedures to monitor reporting deadlines, assigning responsibility for report preparation and review, maintaining a reporting calendar, and performing periodic supervisory reviews to ensure all required reports are submitted accurately and timely. Management Response: Management concurs with the recommendation. The Management Analyst will ensure accurate and timely grant reporting. Anticipated Completion Date: September 30, 2026 Responsible Party: GIna Sherman, Management Analyst
Suspesion and Debarment Recommendation: The City should perform SAM checks for all vendors or contracors prior to entering into covered transactions and retain docuentation of these processes. Management Response: Management concurs with the finding. As part of the federal grant award process, City ...
Suspesion and Debarment Recommendation: The City should perform SAM checks for all vendors or contracors prior to entering into covered transactions and retain docuentation of these processes. Management Response: Management concurs with the finding. As part of the federal grant award process, City Management will ensure SAM checks are performed prior to contracting with vendors. Anticipated Completion Date: Septembe 30, 2026 Responsibnle Party: Gina Sherman, Management Analyst
Views of Responsible Officials: Management agrees with the finding. Management identified the VAT overcharge prior to the audit and requested a refund from the staffing agency. The staffing agency issued a credit of approximately $200,000 in 2026. Management identified approximately $40,000 that cou...
Views of Responsible Officials: Management agrees with the finding. Management identified the VAT overcharge prior to the audit and requested a refund from the staffing agency. The staffing agency issued a credit of approximately $200,000 in 2026. Management identified approximately $40,000 that could have been allocated back to certain affected awards. However, because some awards were closed, actual credits or adjustments program expenses and budgets were not applied. Management will enhance its review process over staffing agency invoices and vendor credits to ensure costs and related credits are reviewed for allowability, allocability, and proper award-level treatment. Name and Title of Responsible Officials: Oliver Rivers, Chief Operating Officer and Deniz Sarkinovic, Senior Director of Compliance Anticipated Completion Date: September 30, 2026
Finding 2025-003 Federal Agency name: Department of Housing and Urban Development Pass-Through Entity: Governor’s Office of Economic Development and Moody County Assistance Listing Number: 14.228 Program Name: Community Development Block Grant Finding Summary: The property records listing had no for...
Finding 2025-003 Federal Agency name: Department of Housing and Urban Development Pass-Through Entity: Governor’s Office of Economic Development and Moody County Assistance Listing Number: 14.228 Program Name: Community Development Block Grant Finding Summary: The property records listing had no formal review or approval in place. Additionally, there was no formally documented physical inventory of property that was purchased with federal award monies within the last two years. Corrective Action Plan: When the auditors asked for a physical inventory of property bought with federal funds, we gave them a complete list in June 2026, within five business days. That showed our property records were accurate and on hand. We are now adding a formal review and approval step for the property list, and we will keep it current with the information 2 CFR 200.313(d)(1) requires: a description, the identification number, the funding source and Federal Award Identification Number (FAIN), the title holder, the date and cost of purchase, the federal share, and the location, use, condition, and disposition of each item. We will take a physical inventory of federally funded property at least every two years and match it against the records. We have assigned a staff member to keep the property records current and to document the reviews and inventory counts. Responsible Individuals: Jody Hernandez, Chief Executive Officer; Tim Dietz, Chief Financial Officer Anticipated Completion Date: Inventory provided in June 2026. The review and approval process and the two-year inventory schedule will be in place by July 2026
2025-003 – WRITTEN POLICIES AND PROCEDURES REQUIRED BY THE UNIFORM GUIDANCE (REPEAT) Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): •...
2025-003 – WRITTEN POLICIES AND PROCEDURES REQUIRED BY THE UNIFORM GUIDANCE (REPEAT) Corrective Action Plan: Management developed written policies and procedures related to federal awards, which were formally adopted by the City Council at the June 18, 2025 Council meeting. Responsible Party(ies): • City Council • City Manager • Deputy City Manager / Finance Director Anticipated Completion Date: June 18, 2025.
2025-003 Finding – Material Weakness in Internal Controls over Compliance Responsible official: Patti Lawrence, Accounting Manager Context and Cause: The Organization has a documented fiscal policy; however the policy does not include procedures that cover specific compliance attributes associated w...
2025-003 Finding – Material Weakness in Internal Controls over Compliance Responsible official: Patti Lawrence, Accounting Manager Context and Cause: The Organization has a documented fiscal policy; however the policy does not include procedures that cover specific compliance attributes associated with federal award requirements. 2 CFR 200.303 requires the recipient to establish, document, and maintain effective internal control over federal awards. Recommendation: It was recommended the Organization develop, document, and implement policies and procedures that address the recent guidance regarding applicable federal compliance requirements. Corrective Action Planned: The Organization has engaged a CPA firm as a 3rd party CFO service and accounting department. The firm is helping develop written policies over federal award attributes. Implementation date: October 31, 2026
Type of Finding: Significant deficiency in compliance and internal control over compliance over invoice requests for reimbursement. View of Responsible Officials: Management accepts this finding. Review and approval of reimbursement requests is a significant internal control to ensure the agency is ...
Type of Finding: Significant deficiency in compliance and internal control over compliance over invoice requests for reimbursement. View of Responsible Officials: Management accepts this finding. Review and approval of reimbursement requests is a significant internal control to ensure the agency is requesting appropriate reimbursement from our funders. Corrective Action: Management is now requiring all invoice requests to have a cover sheet that will show proof of review. This process will be implemented across all divisions.
Planned Corrective Action: The next subsequent Project and Expenditure report to be filed for this program will include the expenditures incurred for the period of 1/1/2025-3/31/2025 that were previously unreported. A second person will review subsequent reports for this program for accuracy prior t...
Planned Corrective Action: The next subsequent Project and Expenditure report to be filed for this program will include the expenditures incurred for the period of 1/1/2025-3/31/2025 that were previously unreported. A second person will review subsequent reports for this program for accuracy prior to submission to reduce the risk of non-compliance with program rules. Anticipated Completion Date: April 30th, 2026 Person Responsible for Corrective Action: Patrick Luddy (Director of Finance, Town of Swampscott, MA) Patrick Luddy
The EBR Head Start Program follows the established financial policies, procedures, and approval processes administered through the City of Baton Rouge and Parish of East Baton Rouge. EBR Head Start does not maintain a separate set of finance procedures independent of the City-Parish. Rather, the pro...
The EBR Head Start Program follows the established financial policies, procedures, and approval processes administered through the City of Baton Rouge and Parish of East Baton Rouge. EBR Head Start does not maintain a separate set of finance procedures independent of the City-Parish. Rather, the program operates within the existing City-Parish framework. These processes include the review, approval, and monitoring of activities necessary to support compliance with applicable Federal requirements. The finding identified an opportunity for the Head Start Program to demonstrate how it applies and maintains evidence of these existing controls within the department. The Department of Transportation and Drainage will assess and improve its current guidelines and procedures for ensuring record-keeping compliance with all applicable federal requirements. Although currently being enforced, these remedies will include the following processes: Ensure applicable federal statute requirements are included in the contract advertisement, proposal and bid documents; Identifying and documenting when a contract can be sole sourced; Collecting and storing compliance documentation before, during and after contract execution; Internal audit for compliance; and additional controls identified during discussions between the Department of Transportation and Drainage and its consultants. While internal controls were informally in place for Airport, the department-wide documentation demonstrating the design and operating effectiveness of controls was not formalized. To address this and ensure full compliance with 2 CFR 200.303, management has initiated the following corrective actions: Development and formal adoption of comprehensive, written policies and procedures that explicitly define internal controls over each applicable compliance requirement, utilizing recognized frameworks such as COSO or the Green Book; Implementing a centralized or coordinated approach for maintaining internal control documentation to ensure consistency and guarantee that evidence of control activities is readily accessible; Establish a process for periodic reviews to verify that all applicable compliance documentation is complete, current, and aligned with federal requirements; Relevant staff and departmental personnel will undergo training on these formalized policies to reinforce expectations for documenting internal controls in accordance with Uniform Guidance. The Department of Environmental Services will assess and improve its current guidelines and procedures for documenting internal controls over federal awards and ensuring compliance with applicable federal requirements. These improvements will include developing formal department-level procedures, identifying and maintaining required compliance documentation, establishing consistent record-retention practices, periodically reviewing documentation for completeness and accuracy, providing guidance to appropriate staff, and implementing any additional controls identified as necessary to comply with 2 CFR Part 200.303. Expected Implementation Date: December 2026 Contact person: Kelly LeDuff, Executive Director/Community Development, Federal Programs & Outreach Mike Edwards, Director of Aviation, Baton Rouge Metropolitan Airport Fred Raiford, Director, Transportation and Drainage Adam Smith, Director, Environmental Services
Although currently being enforced by the Department of Transportation and Drainage, current guidelines and procedures will be reassessed and improved upon to ensure record-keeping compliance with BABA and any other applicable federal acts moving forward. These remedies will include the following: Tr...
Although currently being enforced by the Department of Transportation and Drainage, current guidelines and procedures will be reassessed and improved upon to ensure record-keeping compliance with BABA and any other applicable federal acts moving forward. These remedies will include the following: Trimble Unity Construct (TUC) software will continue to be used as a repository for all relevant construction project documentation; Compliance certification letters must be submitted and approved through the established construction submittal workflow process, or other future processes, in TUC for applicable BABA materials; A specific field for BABA compliant documentation will now be required to ensure that a pay item or any of its components satisfy BABA requirements prior to completing a material submittal process; Guidance that certification letters must be provided for review concurrently with material submittals will be provided to Construction Document Controls staff; Continue to maintain the BABA compliance tracking document for internal record-keeping and for federal internal audits at an established interval based upon the duration or cost of the contract. This will be executed by a designated audit review team established by the Department of Transportation and Drainage through use of audit checklists based on specific grant requirements. Any deficiencies discovered during the audit will be communicated through a Grant Compliance Remediation Plan with deadline identified for corrections. In order to bring the documentation into compliance for construction materials installed on active grants, the Department of Transportation and Drainage proposes to perform the following immediate actions: Update the current BABA log to include additional information not already captured for materials, installed and expected, the status of each item’s compliance letter, if the letter contains the required five criteria and where the letter is stored; Hold an initial BABA regroup meeting with the contractor to discuss materials installed, materials expected, and status letters for all items, with subsequent bi-weekly meetings to address any identified deficiencies; and review all letters, currently stored and to be received, submitted by the Prime Contractor into TUC to ensure the letters contain the five criteria required for federal compliance and enter the conformity into the BABA log. Expected Implementation Date: December 2026 Contact person: Fred Raiford, Director, Transportation and Drainage
2025-009 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation ...
2025-009 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University reviewed its awarding and reconciliation processes following the identified discrepancy between COD and the institutional ledger, which resulted from packaging based on an earlier ISIR transaction without confirming the most recent ISIR data. To address this, the University has partnered with FA Solutions and implemented enhanced controls within Regent, including system checks to flag updated ISIR information and require confirmation of the most current transaction prior to packaging.Additionally, reconciliations and related reporting provided by FA Solutions will be reviewed for accuracy and completeness. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 3/31/2026
2025-008 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University should implement formal review procedures to document that the Cash Management reconciliation and drawdown reviews are bei...
2025-008 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University should implement formal review procedures to document that the Cash Management reconciliation and drawdown reviews are being performed to correct errors in a timely manner and to minimize the likelihood of errors going undetected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University performs cash management reconciliation and drawdown reviews; however, formal documentation of these reviews has not been consistently maintained. To address this, the University is implementing formal review procedures that include documented evidence of reconciliation and drawdown review activities. As part of this process, reconciliations and drawdowns prepared by FA Solutions will be reviewed by the Financial Aid Office for accuracy and completeness prior to submission and reporting. These procedures will be formalized within a standardized SOP, which will outline review timelines, responsibilities, and required documentation to ensure errors are identified and resolved in a timely manner and to reduce the risk of discrepancies going undetected. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 4/30/2026
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