Corrective Action Plans

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o The required timing for responding to NSLDS roster files; and
o The required timing for responding to NSLDS roster files; and
o The steps for making corrections when errors are identified.
o The steps for making corrections when errors are identified.
These actions are either already underway or will be implemented in the current fiscal year to fully resolve the finding and ensure ongoing compliance with the Federal Enrollment Reporting requirements.
These actions are either already underway or will be implemented in the current fiscal year to fully resolve the finding and ensure ongoing compliance with the Federal Enrollment Reporting requirements.
Name: Steven Aguilar
Name: Steven Aguilar
Title: Financial Aid Director
Title: Financial Aid Director
Anticipated Completion Date:
Anticipated Completion Date:
Context and Cause – During the year ended June 30, 2025, a severance payment was issued to an employee that worked on more than one federal program. The payment was an allowable cost, but was not allocated across the other federal programs based on time and effort per their policy. While internal co...
Context and Cause – During the year ended June 30, 2025, a severance payment was issued to an employee that worked on more than one federal program. The payment was an allowable cost, but was not allocated across the other federal programs based on time and effort per their policy. While internal controls and procedures have been established for payroll expenses, the procedures were bypassed when processing the severance payment. It should be noted that the employee spent the majority of their time on the program the severance was allocated to, and the transaction was isolated. Recommendation – The Organization should follow establish written policies and procedures for allocation of costs. Allocation spreadsheets currently used for the allocation of payroll should be used for all payroll related costs. Action Taken: OMEP will utilize standard allocation procedures for all payroll related payments going forward. Responsible parties: Controller. Anticipated completion date: June 30, 2026.
Context and Cause – During the year ended June 30, 2025, OMEP entered into four first-tier subawards greater than $30,000 under AL number 11.611. The auditor tested one of these subawards, noting that the award was not yet reported under the Federal Funding Accountability and Transparency Act to the...
Context and Cause – During the year ended June 30, 2025, OMEP entered into four first-tier subawards greater than $30,000 under AL number 11.611. The auditor tested one of these subawards, noting that the award was not yet reported under the Federal Funding Accountability and Transparency Act to the Federal Subaward Reporting System (FSRS). Per further inquiry, all of the first-tier subawards were yet to be reported to the FSRS. OMEP was aware of the FFATA reporting requirements, but the reporting was not made timely. Internal controls were not adequately designed, and procedures were not in place to track and report first-tier subawards within the time frame required by federal requirements. Recommendation – The Organization should establish written policies and procedures for reporting first-tier subawards. Action Taken: OMEP will add a fiscal policy, that includes a documented review of first tier subawards, to ensure they are input to the FSRS no later than the last day of month that follows the initial obligation to the sub awardee. Responsible parties: Controller. Anticipated completion date: June 30, 2026.
Audit Finding Number: 2025-001 – Cash Management Agency: Public Housing Capital Fund Responsible Person, Title: Stephanie Schmutzer, Accountant Completion date: 7/1/2025 Agency Response: Concur Corrective Action Plan: Management concurs with the recommendation to implement timely LOCCS fundings that...
Audit Finding Number: 2025-001 – Cash Management Agency: Public Housing Capital Fund Responsible Person, Title: Stephanie Schmutzer, Accountant Completion date: 7/1/2025 Agency Response: Concur Corrective Action Plan: Management concurs with the recommendation to implement timely LOCCS fundings that coincides with our normal accounting cycle when receiving Capital Funds in the future.
Corrective Action Plan 2025-001: We acknowledge the overaward of Direct Subsidized Loans and underaward of Unsubsidized Loans for both students identified in the finding. Based on the guidance in Volume 8, Chapter 3 of the 2024-2025 Federal Student Aid Handbook which states “If you discover that a s...
Corrective Action Plan 2025-001: We acknowledge the overaward of Direct Subsidized Loans and underaward of Unsubsidized Loans for both students identified in the finding. Based on the guidance in Volume 8, Chapter 3 of the 2024-2025 Federal Student Aid Handbook which states “If you discover that a student received Direct Subsidized Loan funds in excess of financial need after the student is no longer enrolled for the loan period, you are not required to take any action to eliminate the excess subsidized loan amount.” We have not adjusted the student’s loan awards given the identification of the overaward took place after the end of the loan period for each student. As the University has closed after August 15, 2025, no additional actions are considered necessary. Completion Date: August 2025 Contact Person: Ann Spall, Chief Financial Officer
SA-2025-01 - SIGNIFICANT DEFICIENCY FINDING: During our testing of Title 1 disbursements, we noted there were multiple purchases shipped directly to a private residence without receipt of the products at the District office. All disbursements should be shipped to District property for accountability...
SA-2025-01 - SIGNIFICANT DEFICIENCY FINDING: During our testing of Title 1 disbursements, we noted there were multiple purchases shipped directly to a private residence without receipt of the products at the District office. All disbursements should be shipped to District property for accountability, tracking and ensuring compliance with federal regulations. When supplies are shipped to private residences, there exists the increased likelihood of errors and fraud. AUDITOR RECOMMENDATION: We recommend all disbursements be shipped to District property. PLAN OF ACTION AND TIMEFRAME FOR IMPLEMENTATION: The district acknowledges the finding and has already met with the Title 1 Coordinator and the District purchasing clerk immediately after the exit meeting with the auditors to ensure this does not occur again effective this 2025-2026 school year.
Finding 1174308 (2025-001)
Material Weakness 2025
Responsible Parties: Janet Payne, Human Services Director Ashley Lantz, Department of Social Services Director Finding 2025-001, Medicaid Program - Significant Deficiency-Eligibility Response/Corrective Action: Findings: During the FY26 Single Audit of Medicaid, it was determined that the Union Coun...
Responsible Parties: Janet Payne, Human Services Director Ashley Lantz, Department of Social Services Director Finding 2025-001, Medicaid Program - Significant Deficiency-Eligibility Response/Corrective Action: Findings: During the FY26 Single Audit of Medicaid, it was determined that the Union County Medicaid program has deficiencies in the areas of oversight, income and deduction calculations, self employment income, self attestation, and internal controls related to 2nd party review corrections. Root Cause: It has been determined that staffing issues as well as deficiencies in training, due to vacancies on the training team, and lack of supervisor oversight due to span of control contributed to these deficiencies. Corrective Action: Due the the preliminary findings of the Single Audit, Union County Medicaid has already begun working on corrective actions. We have completed the following actions: • When an error is determined on an internal or external 2nd party review, the worker has 2 days to complete the correction. Once corrections are completed, the worker is to notify the supervisor that it has been completed. Supervisors are given 2 days to review the corrections. This is being added to our 2nd party review sheet for tracking effective 2/1. Initial tracking will be available once all February 2nd party reviews are completed. • Updates to our training are currently in progress for both new and seasoned staff. We anticipate these updates to be completed mid-February 2026 with training being completed by May 31, 2026 with all Medicaid staff. • Division Manager began monthly meetings with Medicaid leadership in November 2025. Monthly meetings focus on previous month’s 2nd party review findings and training needs as a way to ensure ongoing training needs are properly addressed. Corrective action currently in process includes the following: • Training on audit findings will be conducted by May 31, 2026. Pre and post assessments will be given to determine effectiveness of training. All staff will sign a statement of attendance and understanding upon the completion of trainings. Training topics will include income, self-employment income and deductions, self attestation, notices, and proper documentation. • Continuing education training will be completed monthly. Trainings will vary from month to month and will focus on common errors found in 2nd party reviews. Sessions will be conducted in small groups to allow better communication and more one on one time between the trainers and staff. Continuing education training will begin by May 31, 2026. • - Supervisors will continue to conduct 2nd party reviews to assess comprehension and adherance to Medicaid policy. Each month, beginning March 2026, Division Manager will receive a report from CQI to ensure that the 2 day correction and review mandate is being adhered to. It is important to note that the Medicaid Program Manager position is now vacant. The position will be filled as quickly as possible, and the Division Manager is currently taking over all roles of the Program Manager. Union County will implement the Corrective Action Plan by June 30, 2026.
Finding #2025-001 – Significant Deficiency and Other Noncompliance. Condition and context: Of the sample of 25 payroll transactions tested (pay amount for an employee for a pay period) for the Special Education Cluster (IDEA), seven transactions were under-charged to the grant as compared to the tim...
Finding #2025-001 – Significant Deficiency and Other Noncompliance. Condition and context: Of the sample of 25 payroll transactions tested (pay amount for an employee for a pay period) for the Special Education Cluster (IDEA), seven transactions were under-charged to the grant as compared to the timesheet, for a total of $1,001, and two transactions were over-charged for a total of $1,559. The net amount over-charged to the grant of the sample tested was $558. Recommendation: SWWF should establish written policies and procedures and provide training to its employees on the policies and procedures for allocating salaries in accordance with Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, §200.430. Planned corrective action: Policy and procedures for the allocation of payroll costs to the appropriate program in accordance with Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, §200.430 will be drafted within the next 15 days. Training of all employees affected will be completed within 15 days of that. Monthly monitoring will be conducted by the Associate Superintendent of Federal Programs, and quarterly by the Chief Financial Officer, to ensure the plan is effective. The Director of Human Resources will ensure all parties are notified of new hires. Our corrective action plan includes: 1) Coverage Plan: We currently have a policy and procedure in place, and have the Associate Superintendent of Federal Grants and the HR Director overseeing the submission of required documents. PARs are submitted semiannually by single-funded personnel and monthly by multi-funded personnel. Once the Associate Superintendent of Federal Programs reviews PARs, WebSmart should be notified, via the ticketing system, if there is a need to update allocations. Note: During the final months of the fiscal year, the Director of the SE Co-op resigned, resulting in a brief lapse in review while training was underway. During the fiscal year, we had a Desk Review where the allocations did not necessarily match what was paid out. The auditor said that so long as the program did not overcharge the federal fund (which it did not), we could allocate to the other non-federal fund. The issue was not to overcharge the federal fund, which we did not. 2) Process Improvement: The notification to Websmart to update allocations will be added to the SWWF procedures. Training is completed within 10 days of the procedure updates. Training will occur before their first payroll, for new employees, by the Associate Superintendent of Federal Programs. 3) Monitoring & Review: In addition to the Associate Superintendent of Federal Programs’ monthly review, the Chief Financial Officer will review allocations quarterly to ensure accuracy. 4) Communication Plan: All employees involved in Time and Effort reporting will be provided with the updated procedures by the Associate Superintendent of Federal Programs. The Director of Human Resources will ensure all appropriate personnel are notified when a new employee begins. Responsible officer: Judyjane Witte, Chief Financial Officer. Estimated completion date: January 31, 2026.
Finding: 2025-001 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Under 34 CFR 690.63 and 685.200, institutions must calculate Pell grant and federal direct...
Finding: 2025-001 Federal Agency Name: U.S. Department of Education Assistance Listing Number(s): 84.007, 84.033, 84.038, 84.063, and 84.268. Program Name: Student Financial Assistance Cluster Finding Summary: Under 34 CFR 690.63 and 685.200, institutions must calculate Pell grant and federal direct loan awards based on the student’s eligible enrollment status, cost of attendance, expected family contribution (EFC) or student aid index (SAI), satisfactory academic progress, and other Title IV eligibility requirements. Institutions are required to ensure award amounts are accurate and supported by the documentation in the students’ file. During testing of 60 students, it was found that two students who were not awarded the correct amount of Pell, one student who was not awarded the correct amount of federal direct loans, and two students who received subsidized direct loans however did not meet the requirements to receive the need-based aid. Responsible Individuals: Kella Helyer, Director of Financial Aid Corrective Action Plan: Management agrees with this finding. Banner reports have been modified to ensure that all students who are over gross need and over unmet need are captured in the report for the counseling team to review and update as needed. Anticipated Completion Date: February 16, 2026
Corrective action planned: During the audit review, questions were raised regarding compensatory and personal leave balances. Management notes that the amounts identified were processed through the Authority’s payroll system (ADP) and supported by existing leave balances, board-approval policy chang...
Corrective action planned: During the audit review, questions were raised regarding compensatory and personal leave balances. Management notes that the amounts identified were processed through the Authority’s payroll system (ADP) and supported by existing leave balances, board-approval policy changes, and documented role assignments. The Executive Director held acting, assistant, deputy, and executive leadership roles during the periods referenced, as documented by personnel status forms and Board actions. These roles include on-call and after-hours responsibilities impacting availability and leave usage. Management’s review identified that leave balances were influenced by payroll system configuration, transitions to PTO approved by the Board, and subsequent board-approved leave adjustments. Upon identification of discrepancies, records were corrected where appropriate. Management will coordinate with the Authority’s payroll provider (ADP) to review system configuration and ensure leave balances carry forward accurately in accordance with approved policy, further strengthening internal controls and documentation consistency. In addition, management is undertaking a broader review of personnel policies and procedures. Management anticipates presenting proposed updates to the Board of Commissioners, including elimination of compensatory time for executive-level staff and clarification of compensation and availability expectations to improve administrative clarity going forward. Management believes these actions will strengthen internal controls, enhance transparency, and reduce the risk of future misinterpretation of leave and compensation practices. Contact person: Amanda Koehn, Executive Director. Anticipated completion date: Management anticipates completion of corrective actions by February 18, 2026, including implementation of payroll system review with ADP and Board approval of policy revisions eliminating comp time. Final written policy updates through Nelrod are anticipated to be completed no later than March 31, 2026, subject to vendor processing timelines.
FINDING 2025-001 Subject: Child Nutrition Cluster (CNC) - Internal Controls Federal Agency: Department of Education Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Pass-Through Entity...
FINDING 2025-001 Subject: Child Nutrition Cluster (CNC) - Internal Controls Federal Agency: Department of Education Federal Program: School Breakfast Program, National School Lunch Program, Summer Food Service Program for Children Assistance Listing Number: 10.553, 10.555, 10.559 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Activities Allowed or Unallowed, Allowable Costs - Cost Principles Audit Finding: Significant Deficiency Condition: An effective internal control system was not in place at the School Corporation in order to ensure compliance with requirements related to the grant agreement and the Activities Allowed or Unallowed, Allowable Costs - Cost Principles compliance requirements. Context: During testing payroll disbursements charged to CNC grants, we noted: One selection in a sample of 40 for which the employee was paid above their contracted hourly rate. One selection in a sample of 40 for which the contract sheet for fiscal year 2025 did not include an accurate breakdown for cafeteria employees employed for less than one year and employees employed more than one year. Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: Management will ensure controls surrounding salary/hour rate schedules are implemented/enhanced and that rate changes are properly reviewed when instituted. Responsible Party and Timeline for Completion: Betty Huddleston, July 1, 2026
Management agrees with the finding. The Health System has implemented the policy titled, Alameda Health System Reports Policies – SUD Program, to ensure program earmarking requirements and proper documentation is retained to evidence fulfilled requirements. Management will continue to refine interna...
Management agrees with the finding. The Health System has implemented the policy titled, Alameda Health System Reports Policies – SUD Program, to ensure program earmarking requirements and proper documentation is retained to evidence fulfilled requirements. Management will continue to refine internal data collection processes to sufficiently monitor earmarking requirements.
Management agrees with the finding. The Health System has implemented the policy and procedures over the program to ensure that required reports are prepared and reviewed by separate individuals. Documentation is maintained by the program to evidence preparation and review processes and timely filin...
Management agrees with the finding. The Health System has implemented the policy and procedures over the program to ensure that required reports are prepared and reviewed by separate individuals. Documentation is maintained by the program to evidence preparation and review processes and timely filing of the annual report. Management will continue to refine internal processes to ensure quarterly and annual reports are filed timely.
FINDING 2025-002 Procurement and Suspension and Debarment Management’s or Department’s Response: Management agrees. Views of Responsible Officials and Corrective Action: SCRRA has implemented the use of the checklist for all the required documents associated with a procurement. The checklist include...
FINDING 2025-002 Procurement and Suspension and Debarment Management’s or Department’s Response: Management agrees. Views of Responsible Officials and Corrective Action: SCRRA has implemented the use of the checklist for all the required documents associated with a procurement. The checklist includes all applicable documents required to complete a procurement and communicated to the contractors. Name of Responsible Person: Cynthia Minix Implementation Date: June 30, 2026
Finding 1174221 (2025-004)
Material Weakness 2025
Finding 2025-004 U.S. Department of Agriculture Federal Financial Assistance Listing/ALN #10.855 Distance Learning and Telemedicine Grants Federal Award #IA0714-BI17 2025 Procurement, Suspension and Debarment Material Noncompliance and Material Weakness in Internal Controlover Compliance Criteria: U...
Finding 2025-004 U.S. Department of Agriculture Federal Financial Assistance Listing/ALN #10.855 Distance Learning and Telemedicine Grants Federal Award #IA0714-BI17 2025 Procurement, Suspension and Debarment Material Noncompliance and Material Weakness in Internal Controlover Compliance Criteria: Uniform Guidance and 2 CFR §§ 200.318 through 200.326 establish the procurement standards that non-federal entities (other than states) must follow when expending federal awards. These standards require non-federal entities to maintain written procurement policies and procedures that ensure full and open competition, use of appropriate procurement methods based on dollar thresholds, and inclusion of required contract provisions as outlined in Appendix II to Part 200. Condition: The Hospital does not have a written procurement policy that conforms to the procurement standards under Uniform Guidance and 2 CFR §§ 200.318 through 200.326. In addition, testing of the Hospital’s only procurement transaction during the audit period disclosed the following instances of noncompliance: The procurement method used was not in accordance with Uniform Guidance requirements, as the contract amount exceeded the simplified acquisition threshold and a sealed bid or other allowable competitive procurement method was not obtained. The executed contract did not include all required contract provisions as prescribed by Appendix II to 2 CFR Part 200. Planned Corrective Action: Management is aware of the deficiency of internal control over the procurement, suspension and debarment direct and material requirement and subsequent to fiscal year end has implemented a formal procurement policy. Planned Completion Date: June 30, 2026 Person Responsible: Denise Hook, Chief Financial Officer
The Sliding fee determination will be reviewed by the front desk staff thoughtfully daily to ensure the proper charge to the patient. We have redeveloped our front office patient registration flow. Once the patient is screened and determined to be eligible for the Sliding Fee program by the front of...
The Sliding fee determination will be reviewed by the front desk staff thoughtfully daily to ensure the proper charge to the patient. We have redeveloped our front office patient registration flow. Once the patient is screened and determined to be eligible for the Sliding Fee program by the front office/enrollment department, the patient will complete the Sliding Fee application and Self‑Declaration of Income and Family Size. The front office/enrollment department verifies/signs the application, determines what scale the patient qualifies for, and verifies with our practice management system. The Front Office/enrollment department will upload documents into the patient's chart in eCW and contact the billing department at extension 1907. The Lead Biller will review all uploaded documents and approve the Sliding Fee in real time. All Sliding Fee applications must be reviewed by billing before the patient leaves the clinic.
Corrective Action Plan FYE 6/30/2025 Audit Finding # 2025-0001 – Cash Management The Housing Authority of the City of Prichard acknowledges the audit finding regarding interfund balances and accepts responsibility for implementing corrective actions to strengthen internal controls and ensure long-te...
Corrective Action Plan FYE 6/30/2025 Audit Finding # 2025-0001 – Cash Management The Housing Authority of the City of Prichard acknowledges the audit finding regarding interfund balances and accepts responsibility for implementing corrective actions to strengthen internal controls and ensure long-term financial sustainability. At the onset of the fiscal year, management recognized the need to reduce expenses and thus implemented an expense reduction strategy. In reviewing the overall operating expenses for the agency, comparing FYE 2025 to FYE 2024, overall operating expenses declined by approximately $1M, supporting management's goal to reaching a more sustainable long term financial strategy. To further this initiative and continue improving the cash flow position, management will pursue ongoing expense reductions and financial planning strategies to ensure long-term financial sustainability for the agency. This will be accomplished by implementing the following strategies: 1. Engage site management, maintenance, finance, and executive leadership in comprehensive reviews of approved budgets and financial statements to strengthen fiscal oversight and identify additional cost-reduction opportunities. 2. Executive management will review and approve specific categories of expenses to promote accountability, fiscal responsibility, and effective cost control. 3. Continue with enhancement of the agency's home ownership program, providing increased cash flows for operations and improved financial sustainability. 4. Evaluation measures will continue in which intercompany account balances will be reviewed on a monthly basis, determining which entities can support an intercompany reimbursement to the lending property. Upon determining entities with available cash flows, reimbursements will be processed. 5. Continue the agency's initiatives to increase revenues through transition of properties to other revenue streams that would provide more flexibility in establishing an increased rent structure (i.e. PBVs, market rate rents, etc.) As cash flow conditions improve, management will develop and implement a repayment plan to address intercompany balances, recognizing this as a long-term initiative critical to the Agency’s financial sustainability.
Because of turnover, the School lacked sufficient oversight to ensure that allocations of Title I Part A funding by campus was in compliance with rank-and-serve methodologies. The Director of Special Revenue will work with the finance team to ensure that allocations by campus as in compliance and re...
Because of turnover, the School lacked sufficient oversight to ensure that allocations of Title I Part A funding by campus was in compliance with rank-and-serve methodologies. The Director of Special Revenue will work with the finance team to ensure that allocations by campus as in compliance and review those regularly. Responsible Official: Director of Special Revenue Anticipated Completion Date: February 27, 2026
Finding: 2025-004 Name of Contact Person: Renae Miller, Public Housing Director Corrective Action/Management’s Response: The Housing Choice Voucher (HCV) Program repeat findings identified in the audit are acknowledged. As part of the corrective action to address these findings and to strengthen pro...
Finding: 2025-004 Name of Contact Person: Renae Miller, Public Housing Director Corrective Action/Management’s Response: The Housing Choice Voucher (HCV) Program repeat findings identified in the audit are acknowledged. As part of the corrective action to address these findings and to strengthen program compliance and oversight, the City of Albemarle entered into a Memorandum of Agreement (MOA) with the Lexington Housing Authority (LHA) to administer the HCV Program on the City’s behalf. As part of this transition and corrective process, LHA conducted a comprehensive review and audit of the HCV Program covering the previous five (5) years, allowing for the identification of compliance gaps, operational deficiencies, and areas requiring corrective action. This review has informed the implementation of improved controls, processes, and reporting mechanisms. Moving forward, I, as the Director of Housing, will maintain direct and ongoing oversight of the HCV Program by working closely with LHA leadership to ensure the program is administered in full compliance with HUD regulations and applicable requirements. This oversight will include: • Receipt and review of monthly HCV performance and compliance reports • Regular briefings and status meetings with the Executive Director of the Lexington Housing Authority • Ongoing monitoring of corrective actions and compliance benchmarks • Prompt resolution of identified issues to prevent recurrence of findings These measures have been implemented to strengthen accountability, improve internal controls, and ensure sustained compliance of the HCV Program moving forward. Proposed Completion Date: Immediately and Ongoing
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