Corrective Action Plans

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Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" two (2) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will...
Condition: During the compliance testing of the Uniform Guidance "Special Tests and Provisions - Sliding Fee Discounts" two (2) selections out of a sample size of forty (40) used the incorrect calculation of income from the proof of income and applied the incorrect sliding fee. Plan: Management will ensure that all information is collected and input into the billing system correctly in order to avoid patients getting charged incorrect amounts for services. Anticipated Date of Completion: March 31, 2026. Name of Contact Person: Lori Sanson, CFO. Management's Response: Management is implementing weekly chart auditing of encounters from the prior week. These reviews will include a review of the client's financial information which includes assessment of the sliding fee scale paperwork completed, whether we have obtained proof of income, if the sliding fee was entered into the billing system, if the sliding fee adjustments are applied, if payment was collected, insurance information, and the client's balance. These audits will be sent to front office staff for corrections (if needed) or the CFO for review on a monthly basis. In addition, MCPHC Supervisors will obtain a monthly report of the clients that have not turned in proof of income in order to proactively reach out either by phone, email or mail and attempt to obtain the information.
FINDING 2025-001 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Leeanne Koeneman Contact Phone Number and Email Address: Leeanne.Koeneman@nacs.k12.in.us; 260-637-8768 Views of Responsible Officials: We concur with...
FINDING 2025-001 Finding Subject: Child Nutrition Cluster – Procurement and Suspension and Debarment Contact Person Responsible for Corrective Action: Leeanne Koeneman Contact Phone Number and Email Address: Leeanne.Koeneman@nacs.k12.in.us; 260-637-8768 Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation will design and implement a proper system of internal controls and procedures to ensure there are appropriate procurement procedures for goods and services and contractors and subrecipients, as appropriate, are not suspended, debarred, or otherwise excluded prior to entering any contracts or subawards. This process will include obtaining vendor certifications and/or verification through SAM.gov, with two independent individuals reviewing and confirming the completeness and accuracy of the documentation. Certification will be initialed and retained in the procurement file. Anticipated Completion Date: January 26, 2026 INDIANA STATE
PLANNED CORRECTIVE ACTION - The Davis-Bacon Act requirements to submit weekly payroll certification will be included in all contract language for federally funded projects as well as on our purchase orders. The finance department will continued to follow up with vendors to ensure payroll certificati...
PLANNED CORRECTIVE ACTION - The Davis-Bacon Act requirements to submit weekly payroll certification will be included in all contract language for federally funded projects as well as on our purchase orders. The finance department will continued to follow up with vendors to ensure payroll certifications are collected before invoice payments are made. ANTICIPATED COMPLETION DATE - February 13, 2026 RESPONSIBLE CONTACT PERSON - Shannon Rodriguez, CFO
Name of Contact Person: Robin M. West, Assistant County Manager/Chief Financial Officer Corrective Action/Management Response: Davie County Health and Human Services staff will review documentation supporting claims entered into the NC Fast Enterprise Program Integrity (“EPI”) system for accuracy an...
Name of Contact Person: Robin M. West, Assistant County Manager/Chief Financial Officer Corrective Action/Management Response: Davie County Health and Human Services staff will review documentation supporting claims entered into the NC Fast Enterprise Program Integrity (“EPI”) system for accuracy and completeness. The supervisor reviews all 1682 forms for accuracy and quality control prior to entering the claim into NCFAST. The cases identified in error were the result of training and processing issues related to a former employee. DSS will properly train employees and address any future processing issues immediately through quality control procedures. Proposed Completion Date: Immediately and ongoing.
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We ...
FINDING 2025-007 Finding Subject: BRIC: Building Resilient Infrastructure and Communities – Internal Controls Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: This grant was fully expended in 2024. Going forward, the current treasurer will work closely with the grant administrator, whether within corporation or an outside source, when compiling all claims, disbursements and reporting for any given project, including BRIC programs. Internal controls will be incorporated at the Corporation level for future grants that use an outside Grant Administrator. Anticipated Completion Date: 2/16/2026
FINDING 2025-006 Finding Subject: COVID-19 - Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding...
FINDING 2025-006 Finding Subject: COVID-19 - Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: When the current treasurer was hired, the ESSER III grant was at the end of the grant cycle. The learning loss aspect was discovered toward the end of the funding. In the future, breakdowns of grant funding will be understood by the treasurer and used as a guide for expenditures, helping the grant administrators keep on track with the grant budget. In addition, internal controls will be designed to ensure compliance with requirements of grant programs, such as a secondary review by another staff member who understands the program requirements. Anticipated Completion Date: 2/16/2026
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding ...
FINDING 2025-005 Finding Subject: COVID-19 - Education Stabilization Fund - Reporting Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Internal controls for reimbursement requests will include necessary documentation of expenditures from the accounting program attached to the reimbursement form for all grants. Each reimbursement request will be checked and approved by two school employees. The treasurer will keep the packet until funds are received and receipted and then the packet, with the receipt, will be filed in two places; the respective grant folder and in the monthly receipt folder. Anticipated Completion Date: 2/16/2026
FINDING 2025-004 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@s...
FINDING 2025-004 Finding Subject: Title I Grants to Local Educational Agencies - Special Tests and Provisions - Annual Report Card, High School Graduation Rate Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: When removing students from the graduation cohort, files will be kept in two places. One will be a file of all transfers/removals from the cohort. That same information will be filed in each students’ file. These files will be kept at the high school. An internal control will be developed that will ensure that the proper documentation is retained. Anticipated Completion Date: 2/16/2026
FINDING 2025-003 Finding Subject: Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the f...
FINDING 2025-003 Finding Subject: Title I Grants to Local Educational Agencies – Eligibility Contact Person Responsible for Corrective Action: Lana Hamilton Contact Phone Number and Email Address: 812-883-4437, ext. 1005, lhamilton@salemschools.us Views of Responsible Officials: We concur with the finding Description of Corrective Action Plan: Due to continued turnover in the Title I administrator position, application details have not been mastered. The treasurer and current Title I administrator are continuing to learn the process through guidance from our DOE Title I specialist and what we have learned from this audit. We will continue to work together on applying for future Title I grants and for the necessary implementation of the current Title I grant. Internal control over the processes will be developed and implemented, and will be notated with a “reviewed by” signature and date. Anticipated Completion Date: 2/16/2026
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Report training has been implemented and will continue on an ongoing basis to ensure compliance. We will implement periodic spot checks to prevent this issue from recurring and to ensure that all s...
Incorrect Enrollment Reporting to National Student Loan Data System (NSLDS) Planned Corrective Action: Report training has been implemented and will continue on an ongoing basis to ensure compliance. We will implement periodic spot checks to prevent this issue from recurring and to ensure that all students are properly enrolled each semester. Person Responsible for Corrective Action Plan: Registrar, Elena Majerowicz Anticipated Date of Completion: Already Implemented
Late Return of Title IV Funds Calculations Planned Corrective Action: We have implemented a document processing system in collaboration with our third-party administrator and the Student Accounts Office to ensure that funds required to be returned as part of the R2T4 process are processed on time. P...
Late Return of Title IV Funds Calculations Planned Corrective Action: We have implemented a document processing system in collaboration with our third-party administrator and the Student Accounts Office to ensure that funds required to be returned as part of the R2T4 process are processed on time. Person Responsible for Corrective Action Plan: Giselle Atenco, Director of Financial Aid Anticipated Date of Completion: Already Implemented
Need Analysis Planned Corrective Action: System-generated notifications have been implemented within our student information system to flag any academic year changes or required reviews. In addition, a periodic review process of student award packages has been established to ensure funds are awarded...
Need Analysis Planned Corrective Action: System-generated notifications have been implemented within our student information system to flag any academic year changes or required reviews. In addition, a periodic review process of student award packages has been established to ensure funds are awarded accurately and in accordance with applicable awards. Person Responsible for Corrective Action Plan: Giselle Atenco, Director of Financial Aid Anticipated Date of Completion: Already Implemented
Internal control deficiencies: See Finding 2025-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is not ...
Internal control deficiencies: See Finding 2025-001 Recommendation: The District should review the operating procedures of the District offices to obtain the maximum internal control possible under the circumstances utilizing currently available staff. While we do recognize that the District is not large enough to permit a segregation of duties for effective internal controls, we believe it is important the Board be aware that this condition does exist. Action Taken: Management is cognizant of this limitation and will implement additional procedures where possible.
Finding 2025 – 001: Restatement to Net Position Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct leased capital assets, buildings, land improvements and equipment categories of capital assets that were improperly recorded in prior years. Pl...
Finding 2025 – 001: Restatement to Net Position Condition: During audit fieldwork, our testing resulted in a restatement of net position in order to correct leased capital assets, buildings, land improvements and equipment categories of capital assets that were improperly recorded in prior years. Plan: The District and Assistant Superintendent will implement internal controls to properly capital assets on a timely basis prior to audit fieldwork. Anticipated Date of Completion: Fiscal Year 2026 Name of Contact Person: Steve Miller, Assistant Superintendent Management Response: The District brought in a new firm for fixed asset inventory purposes in 2025 and is implementing training for staff to assist in proper coding of purchases to reduce the need to make adjusting journal entries after year end.
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. As of the date of the audit report, the math coach has renewed and obtained an active State of Florida teaching certification. Management has implemented procedures to monitor certification expiration ...
Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding. As of the date of the audit report, the math coach has renewed and obtained an active State of Florida teaching certification. Management has implemented procedures to monitor certification expiration dates and verify certification status prior to charging payroll costs to Title I and other federally funded programs.
Finding 2025 – 001: Restatement to Fund Balance/Net Position Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct retainage payable and capital assets that were improperly recorded in prior years. Plan: The City will implement effective interna...
Finding 2025 – 001: Restatement to Fund Balance/Net Position Condition: During audit fieldwork, our testing resulted in a restatement of fund balance in order to correct retainage payable and capital assets that were improperly recorded in prior years. Plan: The City will implement effective internal controls in order to provide an accurate assessment of reporting requirements. This implementation of improved controls would result in the appropriate recognition for financial reporting requirements Anticipated Date of Completion: June 30, 2026 Name of Contact Person: Elizabeth Hannan, CFO/HR Director Management Response: Management acknowledges this comment and will work to implement and correct by the anticipated date of completion noted above.
Views of Responsible Officials and Planned Corrective Actions – While the Financial Aid Office does have two personnel reviewing each R2T4 calculation, the same was not done with the online calendars setup in COD. The Director will now review each online calendar before they are utilized. The Office...
Views of Responsible Officials and Planned Corrective Actions – While the Financial Aid Office does have two personnel reviewing each R2T4 calculation, the same was not done with the online calendars setup in COD. The Director will now review each online calendar before they are utilized. The Office of Financial Aid performed a review of the population of 672 students, noting an incorrect amount of funds was returned to the Department of Education for 32 of those students. The College has corrected and sent back the additional funds that the students were not eligible to receive.
Views of Responsible Officials and Planned Corrective Actions– The National Student Clearinghouse (NSC) Graduation Status submission calendar will be updated to reflect the necessary reporting timeline. NSC graduation status submission reports will be completed after verification of graduation requi...
Views of Responsible Officials and Planned Corrective Actions– The National Student Clearinghouse (NSC) Graduation Status submission calendar will be updated to reflect the necessary reporting timeline. NSC graduation status submission reports will be completed after verification of graduation requirements and credentialing are completed in Jenzabar by the Registrar's Office. Submission of graduation status to NSC will occur after each academic session and semester, to capture both traditional and non-traditional conferrals.
Grant Accounting Finding 2025-006 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities did not have adequate internal controls in place to ensure that the administrative costs were appro...
Grant Accounting Finding 2025-006 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities did not have adequate internal controls in place to ensure that the administrative costs were appropriately billed as allowed under uniform guidance. Corrective Action Plan: CCSPM will adhere to uniform guidance specific to Administrative Expenses ensuring Administrative Expenses plus Indirect Expenses are no more than 10% of the total award over the grant period. Adherence will be monitored as part of an expanded monthly secondary review process across Continuum of Care grants. Responsible Individuals: Mary Ammer, Senior Director of Accounting and Finance and Grant Accountants: Jen Goeppinger and Ashley Feldick. Anticipated Completion Date: Adherence will be met by the end of the current grant period or end of FY26 (6.30.26), whichever is sooner for each currently active Continuum of Care grant.
Grant Accounting Finding 2025-005 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities did not have adequate internal controls in place to ensure that the de minimis rates were appropria...
Grant Accounting Finding 2025-005 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities did not have adequate internal controls in place to ensure that the de minimis rates were appropriately billed as allowed under uniform guidance. Corrective Action Plan: CCSPM will adhere to uniform guidance specific to de minimis rates ensuring Indirect Expenses are no more than allowable percentage of eligible total expenses over the grant period. Adherence will be monitored as part of an expanded monthly secondary review process across Continuum of Care grants. Responsible Individuals: Mary Ammer, Senior Director of Accounting and Finance and Grant Accountants: Jen Goeppinger and Ashley Feldick. Anticipated Completion Date: Allowable de minimis rates will be met by the end of the current grant period or end of FY26 (6.30.26), whichever is sooner for each currently active Continuum of Care grant.
Grant Accounting Finding 2025-004 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Radias Health* Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities’ internal controls did not operate as designed, which resulted ...
Grant Accounting Finding 2025-004 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Radias Health* Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities’ internal controls did not operate as designed, which resulted in transactions not being reviewed timely or the review process not being formally documented and maintained. Corrective Action Plan: CCSPM is expanding the monthly secondary review of Continuum of Care grants to include matching grant requirements, de minimis rates and administrative expenses to ensure compliance with uniform guidance. The expanded review process will include the evidencing of each criteria reviewed. A senior member of the Accounting Team will perform the review. Responsible Individuals: Mary Ammer, Senior Director of Accounting and Finance and Grant Accountants: Jen Goeppinger and Ashley Feldick. Anticipated Completion Date: A secondary review of each Continuum of Care grant will be performed under these expanded criteria for the period of 7.25-12.25 and monthly beginning with January 2026 and thereafter. *The Radias Health pass-through ended early in FY2025. The correction action outlined above will be applied across existing active Continuum of Care grants.
Procurement Finding 2025-003 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Radias Health Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities did not have adequate internal controls in place to ensure that the p...
Procurement Finding 2025-003 Federal Agency Name: Department of Housing and Urban Development Pass‐Through Entity: Radias Health Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities did not have adequate internal controls in place to ensure that the processes laid out in their procurement policy regarding the process of obtaining quotes to support procurement and testing vendors for suspension and debarment were followed. Corrective Action Plan: Catholic Charities is enhancing procurement oversight and compliance by centralizing procurement documentation, strengthening review and approval controls, and increasing management oversight. Procurement records will be centrally maintained and made accessible to the Accounting and Compliance Departments, in order to support monitoring and audit readiness. Updated training and standardized compliance tools are in the process of implementation, to reinforce consistent application of federal procurement requirements. In addition, Catholic Charities is strengthening vendor oversight through a centralized vendor management process that ensures ongoing monitoring for suspension and debarment. The Compliance Department already runs regular debarment/suspension checks against all vendors engaged in any form of agreement (e.g., contract, grant, MOU, amendment, etc.) but has no visibility to vendors not tied to an agreement. To solve this, the Compliance Department will request a report from the Accounting Department, which lists all vendors paid and will run debarment and suspension checks. All new vendors will be reviewed prior to engagement, and existing vendors will be reviewed on a recurring basis using this report. Responsible Individuals: Primary: Carys Church, Procurement Manager Secondary: Elizabeth Knight, Chief Compliance Officer; Mary Ammer, Sr. Director of Accounting and Finance Anticipated Completion Date: April 2026
Finding 2025-002 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities’ internal controls did not operate as designed, which resulted in rent reasonableness tests not being reviewed befor...
Finding 2025-002 Federal Agency Name: Department of Housing and Urban Development Assistance Listing Number: 14.267 Program Name: Continuum of Care Finding Summary: Catholic Charities’ internal controls did not operate as designed, which resulted in rent reasonableness tests not being reviewed before the rent was paid. Corrective Action Plan: The Senior Division Director (now VP of Housing) issued the Rent Reasonableness Policy (Scattered Sites) on May 14, 2025. This policy was approved by the CEO on June 3, 2025, and was disseminated to all applicable staff via the Learning Management System (Bridge). Staff are required to read and electronically sign acknowledgement of every policy sent to them via Bridge. Managers in the Scattered Site program were trained on the policy and procedure in July 2025. To ensure compliance with this policy, the VP of Housing will audit all client files at least twice annually. The first audit is scheduled for March 11, 2026. Results of the internal audit will be shared with the Compliance Department for further assessment and action. Responsible Individuals: Kristen Brown, Vice-President of Housing Anticipated Completion Date: March 31, 2026
Reference Number: 2025-002. Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds. Assistance Listing Number: 21.027. Federal Agency: U.S. Department of the Treasury. Pass-Through Entity: City of Los Angeles, Economic and Workforce Development Department (EWDD). Federal Award Numb...
Reference Number: 2025-002. Federal Program Title: Coronavirus State and Local Fiscal Recovery Funds. Assistance Listing Number: 21.027. Federal Agency: U.S. Department of the Treasury. Pass-Through Entity: City of Los Angeles, Economic and Workforce Development Department (EWDD). Federal Award Number and Year: C-145793; FY 2025. Category of Finding: Reporting. Management acknowledges that one (1) monthly fiscal report submitted to the City of Los Angeles, EWDD, was not submitted on or before the fifteenth (15th) day of the following month. The management will ensure that the Accounting Department will strengthen its report submission process by working closely with the City of Los Angeles, EWDD to help finalize the contracts efficiently and be able to submitthe monthly fiscal reports by the 15th of the following month, in accordance with the contract. Anticipated Completion Date: March 16, 2026 Tito Maturan, Director of Finance and Technology (213) 355-5300
Reference Number: 2025-001 Federal Program Title: National Dislocated Worker Grant Program. Assistance Listing Number: 17.277 Federal Agency: U.S. Department of Labor, Employee and Training Administration. Pass-Through Entity: City of Los Angeles, Economic and Workforce Development Department (EWDD)...
Reference Number: 2025-001 Federal Program Title: National Dislocated Worker Grant Program. Assistance Listing Number: 17.277 Federal Agency: U.S. Department of Labor, Employee and Training Administration. Pass-Through Entity: City of Los Angeles, Economic and Workforce Development Department (EWDD). Federal Award Number and Year: C-200956; FY2025. Category of Finding: Reporting. Management acknowledges that one (1) monthly fiscal report submitted to the City of Los Angeles, EWDD, was not submitted on or before the fifteenth (15th) day of the following month. The management will ensure that the Accounting Department will strengthen its report submission process by working closely with the City of Los Angeles, EWDD to help finalize the contracts efficiently and be able to submit the monthly fiscal reports by the 15th of the following month, in accordance with the contract. Anticipated Completion Date: March 16, 2026 Tito Maturan, Director of Finance and Technology
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