Corrective Action Plans

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Finding 1176705 (2025-001)
Material Weakness 2025
here is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Start Early used a payroll system that, after a pay period was locked for processing, would not allow supervisors who missed timecard approvals to go back and approve after the period was locked...
here is no disagreement with the audit finding. Action taken in response to finding: In fiscal year 2025, Start Early used a payroll system that, after a pay period was locked for processing, would not allow supervisors who missed timecard approvals to go back and approve after the period was locked. As a result, Start Early used a manual, time-consuming process to receive these approvals outside of the payroll system. While all approvals were received via this process, due to the manual nature, not all approvals were received timely. In early fiscal year 2026, Start Early changed to a new payroll system which allows for supervisors to go back to prior periods for their sign offs. Start Early will implement a process to, no less than monthly, remind supervisors that had previously missed their timecard approvals to go back and approve to ensure timeliness. Name(s) of the contact person(s) responsible for corrective action: David Paul, Controller Planned completion date for corrective action plan: The corrective action plan detailed above is being implemented by June 30, 2026.
Management acknowledges the cash management finding and the corrective action needed to ensure compliance with drawdown submissions, specifically the need to ensure that the timing of monthly drawdowns is supported by expenditures that have been incurred and paid prior to request for funds. To corre...
Management acknowledges the cash management finding and the corrective action needed to ensure compliance with drawdown submissions, specifically the need to ensure that the timing of monthly drawdowns is supported by expenditures that have been incurred and paid prior to request for funds. To correct this, we have created an updated schedule to ensure allocated expenditures have already been incurred and adjusted the timing of drawdown request submissions to occur during the first week of the following month to ensure all allocated expenses have been incurred and paid. All parties involved in the cash management process for the Base grant funding have been notified. These changes are in effect as of January 2026. Sherri Edwards, Director of Grants, will update timing of the preparation of drawdowns as noted. Brandon Cannon, Accounting Manager, will update the new monthly schedule to ensure that reimbursement status is maintained. Sam Lammers, CFO, will review the prepared monthly drawdown request to ensure updated procedures are properly applied.
Due to lack of personnel and an incomplete fiscal year 2024 audit by March 31, 2025, NRVCS did not file timely with the Federal Audit Clearinghouse. The fiscal year 2025 financial audit was completed on December 3, 2025, and the Single Audit portion was completed on February 26, 2026. NRVCS manageme...
Due to lack of personnel and an incomplete fiscal year 2024 audit by March 31, 2025, NRVCS did not file timely with the Federal Audit Clearinghouse. The fiscal year 2025 financial audit was completed on December 3, 2025, and the Single Audit portion was completed on February 26, 2026. NRVCS management will collaborate with Brown Edwards to ensure proper steps are taken in submitting the filing with the Federal Audit Clearinghouse on or before March 31, 2026, and current and future staff will be aware of this deadline for subsequent years going forward.
Findings #2025-001 and #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Supporting Effective Instruction State Grants, Assistance Listing #: 84.367A, Contract #’s: S367A230041 and S367A240041. Condition and context: During our tes...
Findings #2025-001 and #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Education, Supporting Effective Instruction State Grants, Assistance Listing #: 84.367A, Contract #’s: S367A230041 and S367A240041. Condition and context: During our testing of GAAP and FASRG coding, we identified 5 of 72 non- payroll transactions coded to the incorrect period, and 5 of 49 non-payroll transactions coded to the incorrect object or function code. Recommendation: Reemphasize current policies and procedures to ensure proper coding of disbursements based on the period and the organization’s chart of accounts and FASRG codes. Planned corrective action: Great Hearts America – Texas concurs with the findings. While the noted errors were immaterial, management recognizes the importance of consistent expense recognition and coding accuracy to ensure compliance with TEA, PEIMS and financial reporting standards. To strengthen controls, management has implemented the following actions: 1) Month-End Cutoff Procedures: The Finance Department will issue enhanced month-end closing guidance emphasizing invoice cutoff dates, accrual requirements, and proper period recognition. 2) AP Supervisor Review: The Accounts Payable Supervisor will conduct a secondary review of all significant invoices processed to confirm proper period recognition. 3) Coding Accuracy Checks: The Accounts Payable Supervisor will perform periodic sampling of expense transactions to verify correct Function, Object, and PIC coding. 4) Training: Refresher training will be provided to campus and department staff responsible for coding transactions to ensure understanding of chart of accounts structure. Responsible officer: Stacey Lawrence, Interim Chief Financial Officer. Estimated completion date: Procedures will be implemented during fiscal year 2026 month-end close and reinforced through staff training in January 2026.
The Assistant Superintendent, along with staff, will review the capital asset schedules as part of the audit preparation process to prepare fully adjusted financial statements prior to audit fieldwork.
The Assistant Superintendent, along with staff, will review the capital asset schedules as part of the audit preparation process to prepare fully adjusted financial statements prior to audit fieldwork.
The District implemented a new capital asset appraisal in order to have accurate historical records of all assets owned by the District. These schedules will be updated on an annual basis to reflect accurate reporting requirements.
The District implemented a new capital asset appraisal in order to have accurate historical records of all assets owned by the District. These schedules will be updated on an annual basis to reflect accurate reporting requirements.
Management has reviewed this finding and indicated it will review and revise its procedures to ensure corrective action is taken.
Management has reviewed this finding and indicated it will review and revise its procedures to ensure corrective action is taken.
Finding 2025-001 - Housing Choice Voucher Tenant Files - Eligibility - Rent Calculations Noncompliance & Material Weakness Section 8 Housing Choice Voucher Program -ALNs #14.871 and #14.EHV Corrective Action Plan: Action Steps: • Separate responsibilities into two functions: eligibility/verification...
Finding 2025-001 - Housing Choice Voucher Tenant Files - Eligibility - Rent Calculations Noncompliance & Material Weakness Section 8 Housing Choice Voucher Program -ALNs #14.871 and #14.EHV Corrective Action Plan: Action Steps: • Separate responsibilities into two functions: eligibility/verification and rent calculation, assigning verification tasks to new staff and rent calculations to experienced staff. • Strengthen monitoring and evaluation of HCVP files to ensure accurate income projections and rent calculations. The Compliance Officer will conduct individual reviews of audit findings and resolve discrepancies. • Engage an external contractor to perform biannual audits on 10% of files. Findings will inform targeted staff training. • Implement monthly peer audits among Program Assistants to identify and correct errors collaboratively, fostering continuous learning. • Conduct monthly training sessions led by the Program Director to address recent discrepancies and promote team development. • Enforce disciplinary measures for underperformance: employees failing to achieve an 80% audit success rate for three consecutive months will enter a 90-day improvement plan. Person(s) Responsible: Shanae Golliday-Anderson, Program Director Pam Jackson, Deputy Director Anticipated Completion Date: June 30, 2026
Finding 2025-002 - Low Rent Public Housing Tenant Files - Eligibility - Rent Calculations Noncompliance & Significant Deficiency Low Rent Public Housing - ALN #14.850 Corrective Action Plan: Action Steps: • SCCHA will hire an industry consultant to evaluate its internal processes related to eligibil...
Finding 2025-002 - Low Rent Public Housing Tenant Files - Eligibility - Rent Calculations Noncompliance & Significant Deficiency Low Rent Public Housing - ALN #14.850 Corrective Action Plan: Action Steps: • SCCHA will hire an industry consultant to evaluate its internal processes related to eligibility and tenant rent calculations, with a focus on improving the accuracy of adjusted annual income computations. • An external contractor will conduct biannual audits on 10% of files, with results guiding targeted staff training initiatives. • The Compliance & Integrity Coordinator will review audited files and hold individual meetings with team members to address errors and clarify relevant procedures and policies. • Monthly peer-to-peer audits will be implemented, along with staff meetings to collectively analyze identify errors, fostering ongoing training and staff engagement. • Enforce disciplinary measures for underperformance: employees failing to achieve an 80% audit success rate for three consecutive months will enter a 90-day improvement plan. Person(s) Responsible: Meisha Kerby, Program Director Pam Jackson, Deputy Director Anticipated Completion Date: June 30, 2026
Management has addressed the issue by recertifying the tenant and does not expect late recertifications or income verification to occur again.
Management has addressed the issue by recertifying the tenant and does not expect late recertifications or income verification to occur again.
Finding 2025-002: Enrollment Reporting Condition: The change in student status for 1 of the 25 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. However, this student was ultimately reported to...
Finding 2025-002: Enrollment Reporting Condition: The change in student status for 1 of the 25 students tested was not reported to the National Student Loan Data Systems (NSLDS) within 30 days or included in a response to a roster file within 60 days. However, this student was ultimately reported to the NSLDS. The sample was not a statistically valid sample but was determined using Chapter 21 - Audit Sampling Considerations of Uniform Guidance Compliance Audits of the Government Auditing Standards and Single Audit Guide Corrective Action Plan: The College will closely review submissions to the National Clearing House to alleviate duplicate submissions that override previously submitted data. The College is committed to complete and accurate enrollment data submissions to the National Student Clearinghouse and ultimately to the National Student Loan Data System. Responsible Persons: Kim Peters, Director of Financial Aid and Debbie Schreiber, Registrar Anticipated Completion Date: Immediately
Corrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Corre...
Corrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: For FY26 procedures have been put in place to maintain a schedule of reporting due dates that are reviewed monthly to ensure timely submissions.
orrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Correc...
orrective Action Planned: Management will enhance internal control processes related to grants to include controls for proper lines of communication with granting agencies to ensure all required reporting requirements are identified and adhered to. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: For FY26 procedures have been put in place to maintain a schedule of reporting due dates that are reviewed monthly to ensure timely submissions.
orrective Action Planned: Management will implement a documentation retention policy to ensure approvals of allocations of time for employees are maintained. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: As of July ...
orrective Action Planned: Management will implement a documentation retention policy to ensure approvals of allocations of time for employees are maintained. Name(s) of Contact Person(s) Responsible for Corrective Action: Veronica Bochain, Director of Finance Anticipated Completion Date: As of July 2025, a process was implemented to record the proper allocations of time for employees; in addition, a form was developed to record any subsequent changes.
Finding 2025-001: Reporting Management’s Response: The Center acknowledges the finding and recognizes that inadequate monitoring of federal financial reporting deadlines resulted in untimely submissions to the granting agencies. We understand that timely reporting is critical to ensure the goals and...
Finding 2025-001: Reporting Management’s Response: The Center acknowledges the finding and recognizes that inadequate monitoring of federal financial reporting deadlines resulted in untimely submissions to the granting agencies. We understand that timely reporting is critical to ensure the goals and purposes of federal grants are achieved and to maintain compliance with federal award requirements. Action: The Center will implement the following corrective actions to address the reporting compliance deficiency: Action 1: Development of Comprehensive Federal Reporting Calendar The Grants Manager and Director of Finance will create and maintain a detailed federal reporting calendar that includes: • All federal award identification numbers and grant periods • Complete listing of all required reports (quarterly, semi-annual, annual, and final) • Report due dates calculated based on grant agreement requirements Action 2: Implementation of Automated Reminder System The Center will establish a digital tracking system with automated reminders: • Utilize calendar management software to set automated email alerts • Configure reminders to be sent 30 days, 15 days, 7 days, and 2 days before each deadline Action 3: Enhanced Document Retention and Verification Process To ensure submission verification, the Center will: • Maintain a centralized electronic filing system for all federal reports • Retain submission confirmation emails and system-generated receipts Responsible Official: Shelley Mayhugh, Director of Finance Date of Completion: 06/30/2026
Corrective Action Plan: While Elkhorn Slough Foundation performs SAM.gov suspension and debarment checks for all contracted vendors, documentation evidencing these checks was not consistently maintained. The Foundation will implement enhanced documentation and record‑retention procedures to ensure v...
Corrective Action Plan: While Elkhorn Slough Foundation performs SAM.gov suspension and debarment checks for all contracted vendors, documentation evidencing these checks was not consistently maintained. The Foundation will implement enhanced documentation and record‑retention procedures to ensure verification records are retained in compliance with the Foundation’s Procurement Policy and 2 CFR § 180.995. Contact Person: Mark Silberstein, Executive Director and Administrative Director with review by outside CPA. Contact: 831‐728‐5939 Anticipated Completion: June 30, 2026
Federal Program: Department of Homeland Security Assistance Listing: 97.036 Federal Agency: COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Entity: State of Tennessee Grant Award Number: All FEMA Projects (Projects 435263,550461, 684580) Award Per...
Federal Program: Department of Homeland Security Assistance Listing: 97.036 Federal Agency: COVID-19 Disaster Grants – Public Assistance (Presidentially Declared Disasters) (FEMA) Pass-Through Entity: State of Tennessee Grant Award Number: All FEMA Projects (Projects 435263,550461, 684580) Award Period: Project 435263: 1/1/2020-7/31/2021 Project 550461: 1/1/2020-7/31/2021 Project 684580: 8/1/2020-6/30/2022 Management understands that additional audit evidence must be retained at a detailed enough level to allow the auditor to meet their reperformance standard. All expenses claimed were eligible and were reviewed by management prior to the submission. The control issue identified is due to the lack of evidence to support approval. Should management have a future FEMA claim we will retain additional audit evidence to enable auditor reperformance of the controls regarding approval of expenditures. Paula Yarbrough, VUMC Director – Grants and Contracts will be responsible for the implementation by fiscal year-end 2026.
Federal Program: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.110 Federal Agency: Maternal and Child Health Federal Consolidated Programs (MCH) Grant Award Number: 5 T73MC30767-09 Award Period: 7/1/2024-6/30/2025 Management ...
Federal Program: U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing: 93.110 Federal Agency: Maternal and Child Health Federal Consolidated Programs (MCH) Grant Award Number: 5 T73MC30767-09 Award Period: 7/1/2024-6/30/2025 Management agrees with the finding and has strengthened our internal controls and procedures to ensure required FFATA reports are submitted timely in compliance with the Federal Transparency Act. Paula Yarbrough, VUMC Director – Grants and Contracts will be responsible for the implementation by fiscal year-end 2026.
The agency concurs with this finding as the documents provided by the agency showed that some contracts that were modified and met the required threshold for FFATA reporting was not done when the modifications were approved. FFATA reporting has been done by the agency but a breakdown in the reportin...
The agency concurs with this finding as the documents provided by the agency showed that some contracts that were modified and met the required threshold for FFATA reporting was not done when the modifications were approved. FFATA reporting has been done by the agency but a breakdown in the reporting process by the agency did not include reporting contracts that has modification. The agency is revising internal policies and procedures to ensure all staff responsible for FFATA reporting understand that all contracts, including contracts that have modifications that increase funding up to the threshold of FFATA reporting, must be included in the FFATA reporting. Continuous training will be done for all financial staff responsible for FFATA training.
The agency concurs with this finding as subrecipient monitoring has increased significantly with increase federal funding award to the agency. Subrecipient monitoring has been in place but with new staff being hired the agency processes were not monitored and followed to ensure subrecipient monitori...
The agency concurs with this finding as subrecipient monitoring has increased significantly with increase federal funding award to the agency. Subrecipient monitoring has been in place but with new staff being hired the agency processes were not monitored and followed to ensure subrecipient monitoring requirements were completed. The agency is in the process of strengthening its policies as they are related to subrecipient monitoring. The agency is in the process of reviewing and strengthening its internal policy related to subrecipient monitoring. The agency is working with the State Controller’s Office to include subrecipient monitoring training which will take place in early 2026. The agency is implementing standardized processes to include subrecipient checklist that will be included in all agreements that will identify if the agreement is a subrecipient or contract. The agency is working to ensure all agreement templates have correct subrecipient language Per 2 CFR §200.332 prior to submission for signatures.
The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added...
The agency has verified and concurs with the finding as the payroll expense was inadvertently posted to the incorrect Chartfield. The agency failed to complete the requested journal entry, which was a communication failure within the ASD division. The ASD division has corrected this issue with added communication levels to ensure that more than one person received communication between ASD and agency divisions. The ASD division has implemented better communication lines between the ASD division and the agency divisions which will resolve this issue. With more than one person receiving the information and additional training on ensuring that all reconciling items are addressed timely the agency general ledger will remain clean and in balance with allowable expended posted to the correct Chatfield’s.
The Agency's management agrees with this finding. During the upcoming fiscal year, the Controller, Kimberly Houghton-Bryan, will work with various departments within the Agency including HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the U...
The Agency's management agrees with this finding. During the upcoming fiscal year, the Controller, Kimberly Houghton-Bryan, will work with various departments within the Agency including HR and ORR program directors to identify items that are direct charges or allocated based on percentages to the Unaccompanied Alien Children (UAC) grant where possible. Allocation methods that are allowable under the funding sources will be reviewed for implementation. Methods, such as quarterly time studies, direct recording of time or other methods will be considered to ensure there is supporting documentation. The approved budget is also monitored on a monthly and/or quarterly basis and compared to the UAC approved budget. The allocation process as well as other accounting processes relating to New Horizons are being reviewed and the Accounting which had been outsourced is being brought internally. The Agency will be performing reviews of the internal allocation methodology, at least every other quarter-end. This enhancement will be implemented by March 31,2026. Note: Implementation of corrective action is taking place under the new Financial Controller, Kimberly Houghton-Bryan who recently acquired the role January 2026. Under her leadership, the changes she is making will be complete for Fiscal year 2026-2027 and will be a work in progress for fiscal year 2025-2026.
The Agency's management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency under the oversight of newly hired Financial Controller Kimberly Houghton-Bryan will develop monthly and quarterly...
The Agency's management agrees with this finding and is committed to the development of a solid internal control system that will enable timely reports to government sources. The Agency under the oversight of newly hired Financial Controller Kimberly Houghton-Bryan will develop monthly and quarterly closing procedures to aid in the timely closing and filing of reports required by Assistance Listing No. 93.676. Financial Controller, Kimberly Houghton-Bryan, is to implement the checklist by March 31, 2026, to ensure that regulatory reporting is prepared in timely manner.
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assist...
On November 4, 2025, UK HealthCare (UKHC) Information Technology implemented a system configuration change within Epic related to the NFV Sliding Scale settings. This change restricts the application of Federal Poverty Level (FPL) discounts to accounts with a status of “Approved for Financial Assistance,” thereby preventing discounts from being applied to accounts that have not been formally approved. In addition, on December 8, 2025, a new status option— “Did Not Apply for FA”—was added to the status field within the FPL table in Epic. This option is to be selected when patients do not apply for financial assistance, ensuring that status fields are never left incomplete or blank. NFVCHC staff were notified of this update and instructed to consistently complete this step. Planned Process Improvements:NFVCH leadership will conduct a comprehensive review of the NFV and JB clinic policies and procedures related to Financial Assistance Program (FAP) eligibility determination and reevaluation. This review will ensure that: FAP documentation does not include overlapping coverage periods Effective and termination dates are properly validated Internal processes align with system requirements and safeguard against data inconsistencies Ongoing Monitoring / Sustainability Plan: To strengthen oversight and ensure longterm control effectiveness, UKHC Enterprise Revenue Cycle will incorporate into its monthly audit procedures the following reviews: A report identifying accounts with blank or incomplete status entries on the Federal Poverty Level table A review of overlapping FPL coverage dates Monitoring for patients who have both UK and NFV Charity Care, ensuring the correct NFV FPL table is applied for NFVCH accounts This continuous monitoring will ensure system controls operate as designed and that corrective actions remain effective over time. Responsible Party: Larry Quillen – Executive Director, NFVCH Anne Wray - ERC Revenue Assurance Director/UKHC Target Completion Date: Completed on November 4, 2025, with additional enhancements on December 9, 2025
The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required t...
The untimely filing occurred due to the transition to a new staff member responsible for report submission. Management has since provided additional training, clarified filing responsibilities, and implemented supervisory review and deadline tracking to ensure reports are submitted within required timeframes going forward.
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