Corrective Action Plans

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control standards outlined in 2 CFR 200.303.
control standards outlined in 2 CFR 200.303.
Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health...
Corrective Action Plan – Material Weakness & Material Noncompliance (Single Audit) Entity Name: Froedtert ThedaCare Health (FTCH) Corrective Action Plan For the Fiscal Year Ended June 30, 2025 Finding 2025-001 – Material Noncompliance (Major Federal Program) Federal Program U.S. Department of Health and Human Services – National Institutes of Health (NIH) – Cancer Control ALN: 93.399 Finding Description The audit identified material weakness and material noncompliance with federal program requirements related to payroll, fringe benefits and indirect costs. Specifically, FTCH did not comply with NIH Salary Cap requirements, which resulted in questioned costs that were quantitatively and qualitatively material. Cause of the Finding FTCH did not apply the NIH salary cap limitations correctly during the period under review. Corrective Action Planned • The Entity will take the following corrective actions to address the material noncompliance:  Performing a comprehensive review of all FTCH grants, both under consideration and currently active, to determine whether a salary cap limitation applies. Where applicable, management will confirm that the salary cap is being consistently and accurately applied in accordance with governing requirements. Any discrepancies identified have been or will be corrected in a timely manner.  Enhancing pre-award and pre-submission compliance controls through updates to grant review procedures and compliance checklists. These updates are designed to ensure that grants subject to salary cap limitations are clearly flagged and that salary calculations are reviewed and documented prior to submission and award acceptance.  Providing targeted training for staff involved in grant administration, budgeting, payroll processing, and financial reporting to ensure consistent understanding and application of salary cap requirements and related internal control procedures.  Conducting periodic internal monitoring reviews of salary charges to federal awards to assess ongoing compliance, validate the effectiveness of internal controls, and identify potential issues before they result in noncompliance. Results of these reviews will be documented, and corrective actions implemented as appropriate. Personnel Responsible: SVP Finance Anticipated Completion Date: May 31, 2026 Status of Corrective Action Corrective action has been initiated and will be completed within the stated timeframe. Management Certification Management certifies that the corrective actions described above are accurate, appropriate, and will be implemented as represented. ____________________ Matt Partridge SVP Finance April ___, 2026
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations We concur that the Corporation did not maintain the property in good repair and condition. S3800-130 Response Indicator Agree S3800-140 Completion Date 12/31/2025 S3800-150 Response The Corporation has addressed...
S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations We concur that the Corporation did not maintain the property in good repair and condition. S3800-130 Response Indicator Agree S3800-140 Completion Date 12/31/2025 S3800-150 Response The Corporation has addressed the exigent health and safety issues. S3800-160 Contact Person First Name Jimmy S3800-180 Contact Person Last Name Wilson
Item: 2025-002 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-002 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Subrecipeint Monitoring Criteria: A Pass-Through Entity (PTE) is required to monitor the activities of subrecipients as necessary to ensure that the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals (2 CFR 200.332(d) through (f)). In addition to procedures identified as necessary based upon the evaluation of subrecipient risk or specifically required by the terms and conditions of the award, subaward monitoring must include the following: (a) reviewing financial and programmatic (performance and special reports) required by the PTE, (b) following-up and ensuring that the subrecipient takes timely and appropriate action on all deficiencies pertaining to the federal award provided to the subrecipient from the PTE detected through audits, on-site reviews, and other means, and (c) issuing a management decision for audit findings pertaining to the federal award provided to the subrecipient from the PTE as required by 2 CFR 200.521. Condition: The Foundation did not complete the required subrecipient monitoring related to review of subrecipient Single Audits and financial statements. Specifically, we noted no evidence that the Foundation verified whether certain subrecipients met the Single Audit threshold under 2 CFR 200.501 or obtained the subrecipients’ Single Audit reporting packages from the Federal Audit Clearinghouse. Additionally, the Foundation did not obtain or document a review of the subrecipients’ audited financial statements (or other financial information) to inform the subrecipient risk assessment under 2 CFR 200.332(b). Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: For the current audit period, the Foundation has obtained the missing single audit reports and financial statements and is in the process of completing and documenting the required reviews, updating subrecipient risk ratings and performing any necessary follow-up or management decisions by April 30, 2026. Additionally, the Foundation will establish formal written procedures to comply with 2 CFR 200.332(b), (d), and (f), 2 CFR 200.501, and 2 CFR 200.521, including clear steps and timelines for verifying Single Audit applicability, obtaining and reviewing Single Audit reports, and issuing management decisions when applicable. Lastly, the Foundation will provide periodic training to finance and program staff on subrecipient monitoring requirements under the Uniform Guidance.
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2...
Item: 2025-001 Assistance Listing Number: 17.280 Program: WIOA Dislocated Worker National Reserve Demonstration Grants Federal Agency: U.S. Department of Labor Pass-Through Agencies: n/a Contract/Pass-Through Grantor Identifying Number: 23A60YP000003 Award Year: September 30, 2023 to September 30, 2026 Compliance Requirement: Reporting - FFATA Criteria: The Federal Funding Accountability and Transparency Act (FFATA), as implemented by OMB at 2 CFR Part 170, requires prime recipients of federal awards to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). Condition: The Foundation did not complete the required FFATA reporting in FSRS for applicable first-tier subawards. Name of Contact Person Steve Zylstra, President & CEO Phone Number: (602) 422-9447 Anticipated Completion Date: July 31, 2026 Views of Responsible Officials and Corrective Actions: The Foundation has corrected missed FFATA reporting by submitting outstanding subaward information to FSRS as of February 2026. Additionally, the Foundation will establish and document a FFATA reporting policy that defines the FFATA threshold and timing requirements. The Foundation will also assign clear responsibility for FFATA compliance and implement a monthly reconciliation of subaward obligations to FSRS submissions. Lastly, the Foundation will provide periodic training to grants, procurement, and finance staff on FFATA requirements and FSRS processes.
Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management will monitor security deposit refunds in order to ensure refunds meet the Regulatory Agreement requirements.
Management acknowledges noncompliance in the current fiscal year and has taken measures to improve internal controls over compliance. Management will monitor security deposit refunds in order to ensure refunds meet the Regulatory Agreement requirements.
Finding 2025-002: Comments on the Finding and Each Recommendation: During the year ended December 31, 2025, one of the twenty-four resident files selected for testing under the OMB Compliance Supplement were unable to be located by the Agent. The Agent should review resident files completed by the F...
Finding 2025-002: Comments on the Finding and Each Recommendation: During the year ended December 31, 2025, one of the twenty-four resident files selected for testing under the OMB Compliance Supplement were unable to be located by the Agent. The Agent should review resident files completed by the Former Agent to ensure that all resident files include all properly executed and documented resident eligibility forms and ensure that these files are maintained at the Property for a minimum of three years. Action(s) taken or planned on the finding: The Agent concurs with the finding and the recommendation. The Agent will review resident files completed by the Former Agent to ensure that all resident files include all properly executed and documented resident eligibility forms and ensure that these files are maintained at the Property for a minimum of three years.
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Ow...
Finding 2025-001: Comments on the Finding and Each Recommendation: The Former Agent did not obtain a HUD approved Project Owner's/Management Agent's Certification (Form HUD-9839-B) and the Property paid unapproved management fees to the Former Agent. The Agent should obtain a HUD-approved Project Owner's/Management Agent's Certification. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. Management of the property transitioned to the Agent on June 1, 2025 and the Agent received a HUD-aproved Project Owner's/Management Agent's Certification for the Property.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
FINDING 2025-003: Title I Eligibility Response: To ensure all records are correctly filed and maintained, the district is establishing new protocols for documenting Title eligibility.
This finding is due to the Township not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Township’s engineer has searched the state procurement office webpage to check if any vendor for a federal project...
This finding is due to the Township not having control procedures in place for ensuring contractors performing work on federal projects were not suspended or debarred. Subsequently, the Township’s engineer has searched the state procurement office webpage to check if any vendor for a federal project is on the debarment list, which they are not. In the future, the Township will have controls in place to ensure that vendors are not debarred or suspended from federal funding awards. The person responsible for the corrective action is the Supervisor. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is the Board will review implement controls to ensure that vendors are not suspended, debarred, or otherwise excluded.
This finding is due to the Township not having formal written policies in place required by Uniform Guidance. The Township is now aware that these policies are required and will adopt all necessary policies. The Township does not believe that there were any actual nonallowable costs or transactions ...
This finding is due to the Township not having formal written policies in place required by Uniform Guidance. The Township is now aware that these policies are required and will adopt all necessary policies. The Township does not believe that there were any actual nonallowable costs or transactions because of the lack of written policies as required by Uniform Guidance. The Township will adopt all necessary policies to be in compliance. The person responsible for the corrective action is the Supervisor. The anticipated completion date of the corrective action plan is before the end of the 2026 fiscal year. The plan for adherence is that the Board will review all proposed policies and adopt them, the Board will also monitor any changes to policy requirements to ensure that they are in compliance in the future.
Corrective Action: Management agress with the finding. Due to the federal government shutdown and the temporary suspension of HUD operations, approval for one replacement reserve withdrawal could not be obtained prior to disbursement. The withdrawal was necessary to maintain essential project operat...
Corrective Action: Management agress with the finding. Due to the federal government shutdown and the temporary suspension of HUD operations, approval for one replacement reserve withdrawal could not be obtained prior to disbursement. The withdrawal was necessary to maintain essential project operations during the lapse in rental assistance payments. Management has since resumed compliance with all HUD approval requirements and will enhance documentation and contingency planning to address similar circumstances in the future. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agent's procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: Management agrees with the finding. Management acknowledges that the withdrawal exceeded the amount approved by HUD and is reviewing internal procedures to ensure replacement reserve withdrawals comply with HUD approval requirements. Mangement will coordinate with HUD to resolve t...
Corrective Action: Management agrees with the finding. Management acknowledges that the withdrawal exceeded the amount approved by HUD and is reviewing internal procedures to ensure replacement reserve withdrawals comply with HUD approval requirements. Mangement will coordinate with HUD to resolve the unapproved portion of the withdrawal and take corrective action as necessary. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson , Chief Financial and Operating Officer.
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in acco...
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they document and maintain tenant files in accordance with HUD and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson , Chief Financial and Operating Officer.
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certification...
Corrective Action: The Organization agrees with the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing, documenting, and retaining certifications in accordance with applicable regulations. Ownership periodically reviews the agents' procedures to ensure that they document and maintain tenant files in accordance with HUD and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a tra...
Corrective Action: The Organization agrees with the finding and has continued to implement strategies to address the finding. To address this finding, ownership has moved its portfolio, with the exception of one project, to third party property managers as of January 1, 2026. These agents have a track record of completing certifications on time and in accordance with applicable regulations. Ownership periodically reviews the agent's procedures to ensure that they complete tenant files on time and have routine internal audits of tenant files to ensure compliance with HUD regulations. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Corrective Action: Management agress with the finding. Due to the federal government shutdown and the temporary suspension of HUD operations, approval for one replacement reserve withdrawal could not be obtained prior to disbursement. The withdrawal was necessary to maintain essential project operat...
Corrective Action: Management agress with the finding. Due to the federal government shutdown and the temporary suspension of HUD operations, approval for one replacement reserve withdrawal could not be obtained prior to disbursement. The withdrawal was necessary to maintain essential project operations during the lapse in rental assistance payments. Management has since resumed compliance with all HUD approval requirements and will enhance documentation and contingency planning to address similar circumstances in the future. Proposed completion date: Management has begun the corrective action and is expected to have additional internal controls in place by December 31, 2026. Name of contact person: Jennifer Anderson, Chief Financial and Operating Officer
Special Provisions: Rent Reasonableness Federal Agency: Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: January 1, 2025 – December 31, 2025 Compliance Requirement Section: Special Provisions Type of ...
Special Provisions: Rent Reasonableness Federal Agency: Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Assistance Listing Number: 14.871 Award Period: January 1, 2025 – December 31, 2025 Compliance Requirement Section: Special Provisions Type of Finding: Material Weakness in Internal Control Over Compliance and Other Matters Recommendation: The agency should update its rent reasonableness procedures to ensure: • Rental comparison data is current and regularly refreshed; • Comparable non-assisted units are consistently used; and • Staff are trained on proper rent reasonableness documentation and review standards. The agency should also review a sample of recent rent reasonableness determinations to ensure corrective actions are fully implemented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority has taken the following steps to correct the finding: • Updated and refreshed rent reasonableness software data to reflect current market rents. • Configured and are using the software to require selection of comparable non assisted units. • Revisee procedures to document software generated rent reasonableness results in tenant files. • Train staff on correct use of the rent reasonableness software and regulatory requirements. • Conduct supervisory reviews of software based determinations for compliance. Name of the contact person responsible for corrective action: Karen Young, Finance Director Planned completion date for correct action plan: The corrective action plan has already been implemented and will be corrected before December 31, 2026.
Management plans to revamp procedures to ensure that the reports are filed in a timely manner in the future.
Management plans to revamp procedures to ensure that the reports are filed in a timely manner in the future.
Management's Views and Corrective Action Plan: Re: Response to finding 2025-001 2025-001 - RETURN OF TITLE IV FUNDS Cluster: Student Financial Assistance Cluster Sponsoring Agency: Department of Education Award Name: Federal Direct Student Loans Program ALN Number: 84.268 Award Period: 2024-2025 Pas...
Management's Views and Corrective Action Plan: Re: Response to finding 2025-001 2025-001 - RETURN OF TITLE IV FUNDS Cluster: Student Financial Assistance Cluster Sponsoring Agency: Department of Education Award Name: Federal Direct Student Loans Program ALN Number: 84.268 Award Period: 2024-2025 Pass-through Entity: Not applicable Management concurs with the finding. To prevent future delays, we plan to stabilize staffing, increase oversight, and improve workflow efficiency: 1. Increase staffing Following the audit recommendation to maintain consistent staffing, the Graduate School of Education and Psychology’s (GSEP) Financial Aid Office will: • Prioritize hiring by expediting the recruitment and onboarding of full-time Financial Aid positions to fill existing vacancies within the GSEP Financial Aid office. • Cross-train staff and establish a backup schedule where multiple staff members are trained on the Return to Title IV (R2T4) process and can assist during peak withdrawal periods and unexpected staff vacancies. 2. Increase oversight To ensure compliance, the GSEP Financial Aid Office will improve the R2T4 log, tracking every student withdrawal and term cancelation from the date of determination and add internal oversight at the 30-day mark to ensure the 45-day deadline is met. A manager will complete a secondary review of all R2T4 calculations to ensure accuracy and compliance. 3. Improve workflow efficiency To alleviate the high volume of inquiries that contributed to processing backlogs, GSEP is exploring partnering with CollegeVine, a third-party technology solution, to implement school-specific AI agents. With CollegeVine handling routine inquiries via chat and phone, the Financial Aid staff will be able to focus on compliance-oriented tasks. IMPLEMENTATION TIMELINE Increase staffing: Clear existing R2T4 backlog. (Completion: May 1, 2026) Increase staffing: Cross-training Financial Aid staff and implement contingency plan. (Completion: June 1, 2026) Increase staffing: Fill all GSEP Financial Aid vacancies. (Estimated Completion: June 1, 2026) Increase oversight: Implement additional monitoring, reconciliation, and compliance checks. (Completion: June 1, 2026) Workflow efficiency: Implement CollegeVine AI Agents. (Estimated Completion: Undetermined- pending approval) CONCLUSION By stabilizing our workforce and leveraging additional efficiencies, GSEP will ensure that R2T4 processing is prioritized and completed within the 45-day regulatory timeframe. CONTACT FOR THIS PLAN: Jillian Doyle Robinson Director of Student Financial Services Pepperdine Graziadio Business School & Graduate School of Education and Psychology Jillian.Doyle@pepperdine.edu 310-568-5578
The Nutrition Services management team has established an internal schedule to ensure visits are done in a timely and compliant manner.
The Nutrition Services management team has established an internal schedule to ensure visits are done in a timely and compliant manner.
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