Corrective Action Plans

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2025-001. Payroll (Allowable Costs/Cost Principles) United States Department of Education, Passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States: IDEA Part B ALN: 84.027 Condition: Subpart I, 2 CFR §200.430 of the Uniform Guidance require...
2025-001. Payroll (Allowable Costs/Cost Principles) United States Department of Education, Passed-through New York State Department of Education: Special Education Cluster Special Education Grants to States: IDEA Part B ALN: 84.027 Condition: Subpart I, 2 CFR §200.430 of the Uniform Guidance requires that charges to “Federal awards for salaries and wages must be based on records that accurately reflect the work performed.” The documentation should support the distribution of the employee’s compensation among specific activities if employees work on more than one Federal award, or a Federal award and non-Federal award. The preparation of payroll verification forms, or periodic certifications or the equivalent is the most effective way to comply with this requirement. During the current year, it was noted that in some instances, the District’s payroll verification forms did not accurately reflect the actual allocation that was charged to the grant in order to comply with Subpart I, 2 CFR §200.430. Planned Corrective Action: The District acknowledges the finding and will thoroughly review and maintain the payroll verification forms to ensure each employee’s salary, or other forms of compensation, charged to the grant corresponds to the federal program to which the employees’ earnings were allocated, based on time and effort, in compliance with Subpart I, 2 CFR §200.430. Anticipated Completion Date: June 30, 2026
The City acknowledges the internal control deficiencies related to the tracking, recording, and monitoring of grant receivables, related revenue and deferred revenue, and the timely preparation of reimbursement requests for federal and state grants. Management recognizes that the current process, wh...
The City acknowledges the internal control deficiencies related to the tracking, recording, and monitoring of grant receivables, related revenue and deferred revenue, and the timely preparation of reimbursement requests for federal and state grants. Management recognizes that the current process, which relies heavily on individual departments to initiate reimbursement activity, has resulted in delays and incomplete financial reporting. To address the issue, the City will implement the following corrective actions: 1. Centralized Grant Monitoring Process: The Accounting Department will assume responsibility for proactively identifying and recording grant receivables and associated revenue and deferred revenue at the time expenditures are incurred. This process will no longer be dependent solely on departmental requests for reimbursement. 2. Quarterly Review and Reconciliation: A new quarterly grant monitoring schedule will be established. As part of this process, the Accounting Department will review expenditure reports for all active grants, estimate receivable amounts, and ensure timely recognition of revenue in accordance with applicable accounting standards. 3. Formal Documentation and Workflow Procedures: The City will develop written procedures detailing the steps for monitoring grant expenditures, estimating receivables, reconciling recorded amounts to actual reimbursement submissions, and communicating with grant managing departments. 4. Departmental Training: The City will provide training to staff involved in grant management to ensure all departments understand the updated process and the importance of timely expenditure reporting. These corrective actions will strengthen internal controls, improve accuracy in financial reporting, and ensure compliance with federal grant reimbursement requirements. Anticipated Completion Date: Procedures will be drafted and implemented by June 30, 2026, with quarterly monitoring beginning immediately thereafter. Views of Responsible Officials: The City concurs with the auditors’ findings and recommendations.
In December 2026, managemetn worked with SBA representatives to transfer excess reserves from other SBA Loan Loss Reserve Fund (LLRF) balances to the fund with the deficiency. The matter has been resolved.
In December 2026, managemetn worked with SBA representatives to transfer excess reserves from other SBA Loan Loss Reserve Fund (LLRF) balances to the fund with the deficiency. The matter has been resolved.
Estacada School District submits this Corrective Action Plan in response to audit finding SA-2025-02, included in the District’s audit report for the fiscal year ended June 30, 2025, related to the Child Nutrition Cluster federal programs. Finding SA-2025-02 – Significant Deficiency Federal Program:...
Estacada School District submits this Corrective Action Plan in response to audit finding SA-2025-02, included in the District’s audit report for the fiscal year ended June 30, 2025, related to the Child Nutrition Cluster federal programs. Finding SA-2025-02 – Significant Deficiency Federal Program: 10.553, 10.555, 10.559 Child Nutrition Cluster Condition: NSLP reimbursement claims were submitted without consistent evidence of independent review and documentation prior to submission. Cause: Staffing turnover and workload demands contributed to inconsistent review practices. Recommendation: Assign an individual other than the preparer to review NSLP reimbursement claims prior to submission and retain documentation of the review. Corrective Action Plan The District has implemented procedures requiring all NSLP reimbursement claims to be reviewed and approved by an individual independent of the preparer prior to submission. A standardized review and documentation process has been implemented to ensure review is consistently completed and retained with claim submission records. Written procedures and cross-training will continue to support consistency and continuity. Implementation Date Corrective actions were implemented during in July 2025 and are currently in place as of February 2026.
Department will strengthen controls to ensure that the required award information is provided, once available. Certain information such as Federal Award Identification Number and Federal Transit Administration and National Highway Traffic Safety Administration award date are not available at the tim...
Department will strengthen controls to ensure that the required award information is provided, once available. Certain information such as Federal Award Identification Number and Federal Transit Administration and National Highway Traffic Safety Administration award date are not available at the time of contracting CDOT is working on a process to provide this information, once it is available in a publicly available format on CDOT’s website or on a subrecipient facing grant management site. We will add a note to the contract explaining where the information will be posted on our site when it becomes available. The Department will also identify staff requiring additional training on classification and coding for contractors vs. subrecipients.
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant com...
The Department agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated to implement updated reviews and controls. This implementation involves reviewing current processes to ensure supporting documentation is vetted and grant compliance is verified prior to payment. It also includes assessing the need for increased monitoring to ensure initial program reviews are complete and accurate. This remediation effort was finalized on June 30, 2025, following the September 2024 transaction in question. Additionally, the Department plans to review the remediation plan with all relevant staff again this season. This will ensure that all supporting documentation is thoroughly vetted and that expenditures comply with the applicable award period of performance.
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving in...
The Colorado Department of Transportation (CDOT) agrees with the recommendation. The Center for Accounting (CFA) and the Office of Transportation Safety (OTS) have coordinated on its implementation. The Department has assessed and updated training for staff responsible for reviewing and approving invoices for Highway Safety Cluster grants, with a specific focus on the period of performance. This training plan will be revisited and reviewed with all staff involved by April 2026.
The Department agrees with the recommendation. The Department will review, assess, and, where necessary, update existing procedures for FFATA reporting relating to the requirement that state subawards for $30,000+ be submitted within 30 days of committed budget. This will include ensuring that the c...
The Department agrees with the recommendation. The Department will review, assess, and, where necessary, update existing procedures for FFATA reporting relating to the requirement that state subawards for $30,000+ be submitted within 30 days of committed budget. This will include ensuring that the confirmation date is documented. This process will be a coordinated effort between the Office Transportation Safety (OTS) and the Center for Accounting. This will include updating our reconciliation process to include additional data, reviewing and updating reconciliation and review procedures as needed, and reconciling Grants awarded in prior fiscal years that are still active and ensuring they have been appropriately reported. The findings related to this recommendation are in part the result of a federal reporting system limitation, and a federal system conversion. The legacy reporting system, FSRS, had a system limitation, which prevented the full amount of the award being reported in the case of three awards. Additionally, this conversion resulted in some data conversion issues impacting one additional award.
The Department agrees with this finding and will provide any training needed to staff members to ensure that all components of the FFATA are completed accurately, timely and with proper reviews. This training will include leadership reviewing NHTSA/Federal guidelines and SAM.Gov training on FFATA re...
The Department agrees with this finding and will provide any training needed to staff members to ensure that all components of the FFATA are completed accurately, timely and with proper reviews. This training will include leadership reviewing NHTSA/Federal guidelines and SAM.Gov training on FFATA reporting and requirements, documenting controls and ensuring the approvers have access to all supporting schedules, forms and systems and that they understand the subawards, and process for late submissions if needed.
The Department agrees with the finding and will ensure that staff follow all internal policies and procedures to maintain accurate and complete FFATA reporting. To achieve this, staff will review existing procedures and make any necessary updates regarding report compilation. Additionally, we will r...
The Department agrees with the finding and will ensure that staff follow all internal policies and procedures to maintain accurate and complete FFATA reporting. To achieve this, staff will review existing procedures and make any necessary updates regarding report compilation. Additionally, we will review control points to ensure they are consistently followed and approved by the team supervisor and team manager.
The Department will continue to follow the current Policy and Procedure related to the Single Audit reviews and has allocated an individual to review the Single Audits. This includes issuing a management decision letter if required, in accordance with the timeline established in federal guidance.
The Department will continue to follow the current Policy and Procedure related to the Single Audit reviews and has allocated an individual to review the Single Audits. This includes issuing a management decision letter if required, in accordance with the timeline established in federal guidance.
CDPHE fiscal procedures have been updated to reflect changes to the reporting process, specifically noting the recent federal website change and adding the requirement of a secondary level of review. By July 31, 2026, all outstanding FFATA reports will be filed with the federal government and the mo...
CDPHE fiscal procedures have been updated to reflect changes to the reporting process, specifically noting the recent federal website change and adding the requirement of a secondary level of review. By July 31, 2026, all outstanding FFATA reports will be filed with the federal government and the monthly review process in the updated fiscal procedures will be implemented.
The Department of Local Affairs (Department) agrees with the recommendation to strengthen internal controls over the financial management of federal Coronavirus Capital Projects Fund grant expenditures and the accuracy and completeness of the Exhibit K1, Schedule of Federal Assistance. The Departmen...
The Department of Local Affairs (Department) agrees with the recommendation to strengthen internal controls over the financial management of federal Coronavirus Capital Projects Fund grant expenditures and the accuracy and completeness of the Exhibit K1, Schedule of Federal Assistance. The Department will develop a corrective action plan that includes enhanced procedures for the performance of year-end estimates/accruals. The Department will create and implement staff training for staff that are responsible for preparing and reviewing the estimates/accruals, the Exhibit K1, grant transactions and enhancements.
The Department will strengthen its internal controls over federal reporting by implementing policies and procedures that include a monitoring process to ensure that FFATA reporting occurs as required for subawards of $30,000 or more in SAM.gov by the end of the month following the month the subaward...
The Department will strengthen its internal controls over federal reporting by implementing policies and procedures that include a monitoring process to ensure that FFATA reporting occurs as required for subawards of $30,000 or more in SAM.gov by the end of the month following the month the subawards are made.
The Department will document and implement internal monitoring policies and procedures, including the performance of reconciliations of reports, to ensure that the required PR28 and Quarterly Performance Reports are accurate and complete. This will include maintaining documentation of evidence of th...
The Department will document and implement internal monitoring policies and procedures, including the performance of reconciliations of reports, to ensure that the required PR28 and Quarterly Performance Reports are accurate and complete. This will include maintaining documentation of evidence of the review and approval of each report prior to its submission to the federal government.
The Department will complete and communicate formalized IT procedures to staff and IT service providers for IT general control activities for MyUI+ by April 2026.
The Department will complete and communicate formalized IT procedures to staff and IT service providers for IT general control activities for MyUI+ by April 2026.
The Department will implement Part B of the confidential finding.
The Department will implement Part B of the confidential finding.
The Department will implement Part A of the confidential finding.
The Department will implement Part A of the confidential finding.
The Department will implement Part B of the confidential finding.
The Department will implement Part B of the confidential finding.
MSU Denver manages enrollment reporting within the Office of the Registrar. We develop a schedule each calendar year and semester with NSC to identify scheduled reporting dates for each term in alignment with critical semester dates (start, end, drop, etc.). In Fiscal Year 2025, there was a technica...
MSU Denver manages enrollment reporting within the Office of the Registrar. We develop a schedule each calendar year and semester with NSC to identify scheduled reporting dates for each term in alignment with critical semester dates (start, end, drop, etc.). In Fiscal Year 2025, there was a technical issue in which we had to work with our ERP vendor, Ellucian, to provide a solution. The Office of the Registrar will strengthen its internal controls to ensure enrollment changes are reported within the required 60-day timeline.
MSU Denver IT Security will update its written information security program to address the necessary requirements of the Gramm-Leach-Bliley Act. The WISP will be reviewed and updated at least once each year, with updates being based on risk assessments, audits, changes to the environment, and any in...
MSU Denver IT Security will update its written information security program to address the necessary requirements of the Gramm-Leach-Bliley Act. The WISP will be reviewed and updated at least once each year, with updates being based on risk assessments, audits, changes to the environment, and any incidents which indicate a need for changes to the WISP. The updated WISP will include existing policies as well as new policies that describe standards for: • Periodic inventory of data • Multi-Factor Authentication, Single Sign-On, and passwords • Assessment of applications developed by the institution • Testing our safeguards The updated WISP will be formally reviewed and approved by the Chief Financial Officer by June 30, 2026.
The Colorado State University and Colorado State University – Pueblo campuses will strengthen their internal controls to ensure enrollment changes are reported within the required 60-day timeline for newly enrolled students. Additionally, the Colorado State University and Colorado State University –...
The Colorado State University and Colorado State University – Pueblo campuses will strengthen their internal controls to ensure enrollment changes are reported within the required 60-day timeline for newly enrolled students. Additionally, the Colorado State University and Colorado State University – Pueblo campuses will improve the documentation provided as part of compliance testing as both students referenced within the finding were unique situations. In both instances referenced, additional context was not provided during compliance testing for both students that was not captured on the provided National Student Loan Data System Campus Enrollment Details webpage that showed the appearance of reporting an enrollment status change outside of the 60-day requirement. For the Colorado State University, the student was reported with an effective date of the beginning of the Fall 2024 Semester but did not complete verification procedures until February 2025 and was then disbursed the Fall 2024 portion of their Pell Grant. For Colorado State University – Pueblo, the student was reported with an effective date of the beginning of the Fall 2024 Semester, but corrections were required on the student’s FAFSA before federal student financial aid could be disbursed. The campuses will improve documentation provided during compliance testing for when these unique situations with enrollment reporting occur.
The Department agrees to strengthen its internal controls over Medicaid eligibility to ensure compliance with federal and state regulations. Colorado will continue its approved Centers for Medicare and Medicaid mitigation plan to ensure that eligibility is determined on an individual rather than a h...
The Department agrees to strengthen its internal controls over Medicaid eligibility to ensure compliance with federal and state regulations. Colorado will continue its approved Centers for Medicare and Medicaid mitigation plan to ensure that eligibility is determined on an individual rather than a household basis. The Department will continue to conduct ex parte reviews to determine eligibility for all household members based on available information. Those members identified as eligible at ex parte will be approved, regardless if others in the household continue to need verifications or are no longer eligible. The Department is currently working on a permanent system change for CBMS that will only send out renewal forms for individuals not eligible through the ex parte process, with implementation by December 2026.
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, reco...
The Department of Health Care Policy and Financing has examined rate maintenance practices since FY2024 to determine the best course of action to strengthen internal controls to subsequently develop formal policies and procedures. The Waiver and Fee Schedule Rates section will develop a formal, recorded training and corresponding training materials based on current, informal processes on completion of the rate update form to be submitted to the Department's fiscal agent, Gainwell Technologies. Since FY2024, the Waiver and Fee Schedule Rates section has implemented a multilevel secondary review process prior to any rate change submission to ensure accuracy in rate update submissions. The Rates section has also worked closely with other internal partners to formalize informal update processes for quality assurance and maintenance of a minimal error percentage. The Rates section has also implemented a post-implementation data analysis review of all rate update submissions to ensure the update was implemented as directed and expected to ensure accountability on behalf of the Department's fiscal agent Gainwell Technologies. The Rates section is currently in process of documenting and formalizing all rate update processes and policies for future training and process maintenance.
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring ...
The Department agrees with the recommendation and will strengthen internal controls over Children’s Basic Health Plan eligibility determinations to ensure compliance with federal and state regulations. The Department will issue formal Management Decision Letters to the identified counties requiring Department-approved Corrective Action Plans. These plans will be required to address root causes related to income documentation, application of correct income thresholds, and compliance with CBHP eligibility requirements, including any necessary training or guidance for county and Medical Assistance site caseworkers. The Department will review, approve, and monitor corrective actions to ensure deficiencies are addressed.
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