Corrective Action Plans

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Management Response and Corrective Action Plan City’s Response: The City concurs with the recommendation. Corrective Action Plan: The City’s finance department has taken over reporting duties and has ensured all reporting related to CSLFRF is done on a timely basis. Planned Implementation Date: Reso...
Management Response and Corrective Action Plan City’s Response: The City concurs with the recommendation. Corrective Action Plan: The City’s finance department has taken over reporting duties and has ensured all reporting related to CSLFRF is done on a timely basis. Planned Implementation Date: Resolved, implemented in December of 2024. Responsible Person: Director of Finance
Responsible Executive: CEO – Carmela Slivinski Implementation Status: Effective Immediately Full Implementation Date: No later than June 30, 2026 Finding — Compliance (Period of Performance) Significant Deficiency Condition: Auditor noted while testing period of performance, 1 of the 10 expenses rec...
Responsible Executive: CEO – Carmela Slivinski Implementation Status: Effective Immediately Full Implementation Date: No later than June 30, 2026 Finding — Compliance (Period of Performance) Significant Deficiency Condition: Auditor noted while testing period of performance, 1 of the 10 expenses recorded in June 2025 pertained to subsequent months outside of the contract period. Effect: One expense was included in the expenditure report under the incorrect grant period ending June 30, 2025. Cause: The Organization noted that this finding came about due to a clerical error. The bookkeeper inadvertently recorded a July invoice on June 30th and this led to an incorrect charge to the grant period ending June 30th. Recommendation: Auditor recommends management continue to perform a second review on the grant submission especially towards the end of the grant period. Management’s Response: Management concurs with the finding regarding deficiencies in grant period-of-performance compliance. Corrective Action Plan - Review existing Accounts Payable and Accounting Controls processes and revise as needed to ensure expenses are recorded as required. - Staff Training and Competency Development conducted annually to review accounting controls and ensure accounting personnel understand period of performance grant compliance requirements. - Ongoing Monitoring and Internal Compliance Review conducted periodically to ensure oversight of financial controls and grant compliance.
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of do...
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Deputy Director, Department of Public Health 2. Corrective action plan: DPH agrees with the finding and recommendation. VPDCP will develop and implement written procedures for the centralized and secure storage of documentation supporting grant deliverables and required progress reports. The procedures will include, at a minimum, the following: • Define required documentation, storage location, staff responsibilities, and retention requirements. • Require all supporting documentation to be maintained in a designated centralized repository and ensure documentation is complete, organized, and readily accessible for review. • Detail the steps during staff transitions that new staff must follow to access, maintain, and update grant-related documentation, ensuring consistency and completeness of records. VPDCP will perform periodic reviews of the centralized repository and formally document and sign-off on the reviews to verify that required documentation is maintained. 3. Anticipated implementation date: June 19, 2026
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Administrative Deputy, DCBA 2. Corrective action plan: DCBA concurs with the findings and the recommendation, however, the total expenditure amount of $5,917,341 is inclusive of expenditures from a different contract...
Views of Responsible Officials and Planned Corrective Action 1. Person responsible: Administrative Deputy, DCBA 2. Corrective action plan: DCBA concurs with the findings and the recommendation, however, the total expenditure amount of $5,917,341 is inclusive of expenditures from a different contract held by the same agency who was identified as a contractor and not a sub-recipient. As such, expenditures under that contract would not be subject to monitoring as set forth in 2 CFR § 200.332. Therefore, the total expenditures for the four (4) subrecipient agreements that are missing monitoring reports are $585,756. To address the finding, DCBA will establish a formal monitoring plan that will include a monitoring checklist, monitoring schedule, and a detailed tracking log to ensure timely monitoring of its subrecipients. DCBA will work with CEO and/or the Auditor-Controller to identify resources to implement ongoing monitoring of subrecipients, with clear documentation and reporting. Additionally, DCBA already implemented a risk assessment process to ensure an assessment of all subrecipients is completed at least once a year. This process will be formalized in writing. The process involves identifying risk areas, including reviewing financial stability, legal risks, capacity, and performance history. The assessment process uses a risk scoring model that rates organizations using a risk level scale between 1-5 that takes into consideration operating reserves, program and fundraising efficiency, and their ability to meet financial obligations. 3. Anticipated implementation date: September 30, 2026.
Recommendation: We recommend the College not disburse funds from the debt service reserve fund without the approval of USDA in accordance with the loan agreement. Action Taken: The USDA loan was paid in full on December 10, 2025.
Recommendation: We recommend the College not disburse funds from the debt service reserve fund without the approval of USDA in accordance with the loan agreement. Action Taken: The USDA loan was paid in full on December 10, 2025.
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement p...
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement procedures and controls to ensure pre-approval in accordance with the Uniform Guidance compliance requirements.
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement p...
Personnel Responsible For Corrective Action: Kelly Dobell, Controller, Square Watson, Chief Operations Officer, and Spencer Winn, Director of Food and Nutrition Services Anticipated Completion Date: June 30, 2026 Corrective Action Plan: Food and Nutrition Services along with Finance will implement procedures for review and reconciliation of lunch count data with claims reports in accordance with the Uniform Guidance.
Identifying Number: 2025-001 Finding: The Coalition erroneously identified certain federal grants as state funded grants on the Schedules. Contact Person Responsible for Corrective Action: Nicole Morella, Co-Executive Director and Adreinne Gantz, Co-Executive Director Corrective Action Planned: The ...
Identifying Number: 2025-001 Finding: The Coalition erroneously identified certain federal grants as state funded grants on the Schedules. Contact Person Responsible for Corrective Action: Nicole Morella, Co-Executive Director and Adreinne Gantz, Co-Executive Director Corrective Action Planned: The Coalition acknowledges past issues with properly separating federal and state grant funds. As of July 1, 2025, the Coalition began fully segregating overlapping grants in its accounting system to ensure accurate allocation and monitoring, including separating FY26 RPE federal and state funds. The Coalition will thoroughly review each award’s conditions and funding streams to ensure all funds are correctly classified in the general ledger and monitored throughout the grant by all staff involved in the implementation, monitoring and reporting on the grant. Before year-end, the Coalition will review all received funds to ensure they are accurately reported in the Schedules. Anticipated Completion Date: June 30, 2026.
Condition: The Organization paid out management fees in excess of allowable amount per the Management Agent’s Certification agreement. Planned Corrective Action: The excess management fees will be reversed out of the Corporation for the year ended December 31, 2026, thus adjusting the fees to the al...
Condition: The Organization paid out management fees in excess of allowable amount per the Management Agent’s Certification agreement. Planned Corrective Action: The excess management fees will be reversed out of the Corporation for the year ended December 31, 2026, thus adjusting the fees to the allowable amount. Management acknowledges noncompliance in the current year and is currently reviewing internal controls related to management fees going forward. Contact person responsible for corrective action: Michael McMillan, Director of Finance / President Anticipated Completion Date: 12/31/2026
Response to Finding 2025-001 Timely Filing of SF-425, Federal Financial Report (FFR) (Federal Award Finding) An SF-425 annual report, covering the period ending September 30th, is due within 90 days of the reporting period for each open Airport Improvement Program (AIP) that receives funding from th...
Response to Finding 2025-001 Timely Filing of SF-425, Federal Financial Report (FFR) (Federal Award Finding) An SF-425 annual report, covering the period ending September 30th, is due within 90 days of the reporting period for each open Airport Improvement Program (AIP) that receives funding from the Federal Aviation Administration (FAA). Prior to submission, Talbot County ensures the accuracy of each financial report by reconciling amounts between various sources, including vendor invoices, SF-271 forms, Talbot County’s ERP/accounting system, and the FAA’s web-based electronic invoicing and grant payment portal system (Delphi). While this multi-step verification process supports the accuracy of financial reports, it remains highly manual and is constrained by increasing workloads, limited resources, and a lean workforce. This challenge has intensified and become more apparent over the last few years due to the recent surge in the number of open and active AIPs. Further compounding the issue were delayed responses from the FAA and the Federal government shutdown that occurred from October 1, 2025 to November 12, 2025. During this 43-day period, Talbot County staff were unable to effectively communicate with the FAA to verify essential financial data necessary to complete the SF-425 reports. Auditee’s Corrective Action Plan: Talbot County’s corrective action plan focuses on evaluating the current workflow to identify bottlenecks (points of constraint) and opportunities to leverage technology and improve efficiency. Ultimately, a clearly defined grant process will be implemented that establishes roles, responsibilities, and expectations for staff. Increasing the frequency of grant tracking and reconciliation activities throughout the year will be a key component, as this will mitigate the potential for reporting delays and minimize the burden on staff when SF- 425 reports are due subsequent to the Federal fiscal year ending each September 30th. The improved grant procedures will expand the role of Talbot County’s Finance Office and allow for the consistent timely filing of SF-425 reports. This is an evolving process that will show marked improvement for the 2026 Single Audit. Sincerely, Martha Darling Sparks Finance Director
Condition: Of the 40 students selected for enrollment reporting testing, 2 students did not have their status change updated appropriately and 3 students did not have their Classification of Instructional Programs (CIP) code updated appropriately. Planned Corrective Action: The Director of Student F...
Condition: Of the 40 students selected for enrollment reporting testing, 2 students did not have their status change updated appropriately and 3 students did not have their Classification of Instructional Programs (CIP) code updated appropriately. Planned Corrective Action: The Director of Student Financial Services now oversees enrollment reporting to the third-party servicer. The director reviews enrollment reporting to the third party and also reviews reporting to the third-party servicer to ensure accurate and timely reporting to NSLDS. Contact person responsible for corrective action: Callie Zake, Director of Student Financial Aid Anticipated Completion Date: June 19, 2026
Finding 1191736 (2025-004)
Material Weakness 2025
Finding 2025-004 Federal Departments: Corporation for National and Community Service Assistance Listing #: 17.274 Internal Controls Material Weakness Category of Finding – Procurement, Suspension, and Debarment Finding Summary: There was no observable control documentation to directly indicate that ...
Finding 2025-004 Federal Departments: Corporation for National and Community Service Assistance Listing #: 17.274 Internal Controls Material Weakness Category of Finding – Procurement, Suspension, and Debarment Finding Summary: There was no observable control documentation to directly indicate that a search for suspension and debarment was performed on vendors. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: Our Executive Director and Controller developed an updated procurement policy that went into place July 1, 2024. Our Operations Manager did not follow the policy. This staff member is no longer with the organization. We have implemented new training for managers and directors about the procurement policy to ensure proper execution going forward. Anticipated Completion Date: July 1, 2025
Finding 1191734 (2025-003)
Material Weakness 2025
Finding 2025-003 Significant Deficiency Medical Billing Revenue Recognition Internal Controls Finding Summary: Regular reconciliation between the medical billing system and the accounting system was not conducted throughout the year, leading to a significant discrepancy between the end of year trail...
Finding 2025-003 Significant Deficiency Medical Billing Revenue Recognition Internal Controls Finding Summary: Regular reconciliation between the medical billing system and the accounting system was not conducted throughout the year, leading to a significant discrepancy between the end of year trail balance and the billing software report. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We are developing formal procedures to include monthly reconciliation between accounting and billing systems. Anticipated Completion Date: March 31, 2026
Finding 1191716 (2025-002)
Material Weakness 2025
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting ...
Finding 2025-002 Material Weakness Inadequate Documentation and Training for CECL Calculation Process Finding Summary: The staff member responsible for the CECL calculation left during FY25. The replacement staff member did not have adequate understanding of the prior calculations or the supporting workpapers. Therefore, the CECL adjustment was not recorded at the beginning of the audit and required multiple attempts before a reasonable estimate was determined and recorded. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: We will capture detailed documentation of the CECL calculation process, including training and detailed written procedures. Anticipated Completion Date: January 1, 2026
Finding 1191698 (2025-001)
Material Weakness 2025
Finding 2025-001 Material Weakness Limited Segregation of Duties Over Cash Receipts Finding Summary: The person responsible for opening the mail, preparing the deposit summary, and depositing funds was granted full access to the accounting software, including the ability to enter, modify, and delete...
Finding 2025-001 Material Weakness Limited Segregation of Duties Over Cash Receipts Finding Summary: The person responsible for opening the mail, preparing the deposit summary, and depositing funds was granted full access to the accounting software, including the ability to enter, modify, and delete transactions. While it is not this person’s responsibility to record deposits in the accounting system, they have the ability to do so. Responsible Individuals: Jill Johnson, Executive Director Corrective Action Plan: Our process has been updated to ensure the person opening mail, preparing the deposit summary, and depositing funds do not have access to the accounting software. Anticipated Completion Date: January 1, 2026
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and document...
Management’s Plan for Corrective Action: Management agrees with the finding and plans to implement procedures to ensure timely submission of required performance reports. We will ensure that the grant administrator develops processes for a reporting calendar, preparing required reports, and documenting submission. Management expects these procedures to be implemented beginning in the next reporting cycle. Management has subsequently completed and submitted all of the required performance reports to remedy the identified deficiency.
Finding no.: 2025-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse...
Finding no.: 2025-003 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The monthly deposits to the replacement reserve account have been reinstated after the lapse which was due to a period of transition of management in the property management department. The funding processes have been reestablished and procedures are in place to ensure there are no unplanned lapses in funding the reserve going forward. Anticipated completion date: February 2026
Finding no.: 2025-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2025-001 will serv...
Finding no.: 2025-002 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The improvements in processes mentioned in the plan to address Fining no. 2025-001 will serve to accelerate closing procedures and help the audit to be completed on schedule allowing for the required calculation and deposit of the residual receipt reserve funds within the required time frame. Anticipated completion date: October 2026
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvement...
Finding no.: 2025-001 Contact person(s) responsible: Kymberly Horner, Executive Director for PCRI and Matthew Wrigley, Accounting Financial and Audit Manager for Cascade Management Corrective action planned: The closing of books and preparation for audit procedures is being addressed via improvements in internal controls related to property accounting, month and year end closing procedures which include a new property management accounting software package. It is also being addressed via the hiring of more experienced staff during fiscal year 2024-2025. The organization anticipates that these improvements will allow for the audit to be completed within the required timeframe in the upcoming cycle. Anticipated completion date: October 2026
Condition: Of the 40 students selected for enrollment reporting, the College did not update the student enrollment information for 3 students accurately. Planned Corrective Action: The College will modify its process and update its documented procedures to include periodically running an Enrollment ...
Condition: Of the 40 students selected for enrollment reporting, the College did not update the student enrollment information for 3 students accurately. Planned Corrective Action: The College will modify its process and update its documented procedures to include periodically running an Enrollment Reporting Graduated/Withdrawn Report from NLSDS and review for accuracy and make timely corrections, if necessary. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: June 30, 2026
Condition: The College did not have appropriate segregation of duties in place to ensure the reporting to COD is being reviewed by an individual separate from the process of preparing the reconciliations. Planned Corrective Action: The College will modify its process and update its documented proced...
Condition: The College did not have appropriate segregation of duties in place to ensure the reporting to COD is being reviewed by an individual separate from the process of preparing the reconciliations. Planned Corrective Action: The College will modify its process and update its documented procedures to include an appropriate review of the reconciliation by an individual separate from the process of preparing the reconciliations. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: June 30, 2026
Condition: The College did not provide notifications to certain students related to direct loan disbursements. Planned Corrective Action: The Director of Financial Aid will work with our information technology department to ensure the criteria used for triggering the notification emails is correct a...
Condition: The College did not provide notifications to certain students related to direct loan disbursements. Planned Corrective Action: The Director of Financial Aid will work with our information technology department to ensure the criteria used for triggering the notification emails is correct and capturing all the necessary students. Additionally, an exception report will be created to identify students who have not been sent the notification email for the financial aid department to review and then send the appropriate notification. The department procedures will be updated to reflect these changes in process. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: March 31, 2026
Condition: Out of 60 students tested for return to Title IV, we identified 4 students whose calculations were performed outside of the required time frame. Planned Corrective Action: The College will work with its Director of Financial Aid to ensure the semester end procedures include steps to ident...
Condition: Out of 60 students tested for return to Title IV, we identified 4 students whose calculations were performed outside of the required time frame. Planned Corrective Action: The College will work with its Director of Financial Aid to ensure the semester end procedures include steps to identify those students who unofficially withdrew. Once the students are identified, individuals with appropriate skills and knowledge will be able to determine if a return of Title IV calculation is necessary and appropriately return any funds, as necessary. Contact person responsible for corrective action: Director of Financial Aid Anticipated Completion Date: March 31, 2026
Finding: 2025-001 Reimbursable federal grant revenue Responsible Person: Cecilia Frerotte Title: Contract CFO Phone Number: 617-261-8186 Anticipated Completion Date: June 30, 2026 Corrective Action: Management will enhance grant review and reconciliation procedures to ensure that reimbursable expend...
Finding: 2025-001 Reimbursable federal grant revenue Responsible Person: Cecilia Frerotte Title: Contract CFO Phone Number: 617-261-8186 Anticipated Completion Date: June 30, 2026 Corrective Action: Management will enhance grant review and reconciliation procedures to ensure that reimbursable expenditures incurred under cost-reimbursement grants are properly recognized as contribution revenue and federal expenditures in the appropriate period. These procedures will include a grant-by-grant reconciliation of reimbursement requests, refundable advances, award terms, general ledger balances, amounts reported on the Schedule of Expenditures of Federal Awards (SEFA) and amounts reported in all other grant-related compliance reports, as applicable. Management will also formalize and expand supervisory review and approval controls over all grant compliance reporting and year end financial reporting, including the SEFA. In addition, the Board plans to increase the size of the Audit Committee to include members with substantial experience in auditing and grant program oversight. The Audit Committee will meet regularly with both the external auditors and the outsourced accounting firm to provide enhanced governance and oversight of grant accounting and compliance matters.
Contact Person – Sue Chase, Superintendent Corrective Action Plan – The District should implement policies and procedures to ensure only allowable activities/costs are being charged against grants. Completion Date – March 31, 2026
Contact Person – Sue Chase, Superintendent Corrective Action Plan – The District should implement policies and procedures to ensure only allowable activities/costs are being charged against grants. Completion Date – March 31, 2026
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