Corrective Action Plans

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U.S. Department of Health and Human Services Maternal, Infant and Early Childhood Home Visiting Grant Program – Assistance Listing No. 93.870 Congressional Directives Grant Program – Assistance Listing No. 93.493 Recommendation: Develop and implement an internal control framework that ensures retent...
U.S. Department of Health and Human Services Maternal, Infant and Early Childhood Home Visiting Grant Program – Assistance Listing No. 93.870 Congressional Directives Grant Program – Assistance Listing No. 93.493 Recommendation: Develop and implement an internal control framework that ensures retention of evidence documenting the procedures performed to verify that vendors are not suspended, debarred, or otherwise excluded from conducting business before The Village for Families & Children, Inc. and Subsidiaries procuring their services. Program management should either obtain certifications from applicable vendors or maintain sufficient documentation of their review of the System for Award Management (SAM) website. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Village will establish a standardized process to retain proof of its suspension and debarment review. Compliance with the debarment regulations will be achieved by one of the following methods: 1.) Capturing a screenshot of the verification performed on the System of Award Management (SAM) Exclusions database at SAM.gov, 2.) Obtaining a certification from the entity, or 3.) Including a clause or condition in the agreement related to the covered transaction. The compliance requirements and procedures will be communicated to both Leadership and Finance teams. All supporting documentation will be retained either within the Finance Department or in the respective program records. Name(s) of the contact person(s) responsible for corrective action: Marjorie Loring Planned completion date for corrective action plan: January 31, 2026
Management should ensure surplus cash is calculated in a timely matter in order to make any required deposit to the residual receipts account
Management should ensure surplus cash is calculated in a timely matter in order to make any required deposit to the residual receipts account
In response, the District agrees and intends to continue to provide supervision and monitor accounting information and operations including obtaining explanations for variances from unexpected results and work to increase segregation of duties. In addition to monthly review and Board approval of the...
In response, the District agrees and intends to continue to provide supervision and monitor accounting information and operations including obtaining explanations for variances from unexpected results and work to increase segregation of duties. In addition to monthly review and Board approval of the voucher list, detailed check register, and itemized revenue and expenditure statements relative to the yearly approved district budget, the Administrator will also review the monthly bank reconciliations, payroll records, and accounting information to determine if expectations are being met, as well as to obtain explanations for any variances.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will verify vendors are not suspended or debarred prior to entering into covered transactions.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will verify vendors are not suspended or debarred prior to entering into covered transactions.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.
Monitoring of federal compliance information by management and the Board of Education will continue at the District. The District will conduct a documented review of monthly claim reports.
Management should insure the required monthly deposits into the reserve for replacement account are made in a timely manner.
Management should insure the required monthly deposits into the reserve for replacement account are made in a timely manner.
Management is in process with the insurance company to obtain a fidelity bond or employee dishonesty coverage policy in order to meet the requirements of the Regulatory Agreement.
Management is in process with the insurance company to obtain a fidelity bond or employee dishonesty coverage policy in order to meet the requirements of the Regulatory Agreement.
2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experi...
2025-005 - Material Weakness and Material Noncompliance - Allowable Costs Condition: Federal revenues and expenses reported on the Schedule of Expenditures of Federal Awards should only include eligible expenses that occurred within the current fiscal year. Corrective Action Plan: The Village experienced some staff turnover in the prior fiscal year. In addition, the Village has not historically been subject to single audits, which created some challenges with the preparation of the Schedule of Expenditures of Federal Awards. Going forward, the Village has a better understanding of the requirements for completing the Schedule.
2025-004 - Significant Deficiency and Noncompliance - Written Federal Policies and Procedures Condition: The Village is required to have in place written federal policies and procedures in compliance with Uniform Guidance 2 CFR 200, which include procurement and suspension/debarment and equipment an...
2025-004 - Significant Deficiency and Noncompliance - Written Federal Policies and Procedures Condition: The Village is required to have in place written federal policies and procedures in compliance with Uniform Guidance 2 CFR 200, which include procurement and suspension/debarment and equipment and real property management. Corrective Action Plan: The Village has drafted a Federal Policy/Procedure document which will be approved by the Village Council in early 2026.
FINDING 2025-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls over Eligibility Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Number...
FINDING 2025-001 Information on the federal program: Subject: Child Nutrition Cluster - Internal Controls over Eligibility Federal Agency: Department of Agriculture Federal Program: School Breakfast Program, National School Lunch Program Assistance Listing Number: 10.553, 10.555 Federal Award Numbers and Years (or Other Identifying Numbers): FY2024, FY2025 Pass-Through Entity: Indiana Department of Education Compliance Requirement: Eligibility Audit Finding: Material Weakness Context: During the testing of internal controls over eligibility determinations for free and reduced meals, we noted there was no formal, documented review control in place. There is no documented, secondary review for the applications entered in the food service software which determines eligibility. Additionally, there was no documented review by School Corporation personnel of the Income Eligibility Guidelines used by the food service software which are updated on annual basis Contact Person Responsible for Corrective Action: Amber Swinehart, Food Services Director Contact Phone Number: 765-759-2592 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: The Food Services Director will provide evidence of review for the eligibility parameters from Titan at least once a year prior to the start of the school year Anticipated Completion Date: 6/30/2026
Recommendation: Management should review and update internal controls over reporting requirements to prevent untimely submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management reviews reporting deadli...
Recommendation: Management should review and update internal controls over reporting requirements to prevent untimely submissions. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management reviews reporting deadlines to ensure timely submissions. Name(s) of the contact person(s) responsible for corrective action: Judy Thomas, CFO Planned completion date for corrective action plan: June 2025
Recommendation: Management should reinforce the requirement for supervisor approval of all timecards prior to payroll processing. This should include training for supervisors and payroll staff on federal timekeeping requirements and implementation of system controls or checklists to ensure approvals...
Recommendation: Management should reinforce the requirement for supervisor approval of all timecards prior to payroll processing. This should include training for supervisors and payroll staff on federal timekeeping requirements and implementation of system controls or checklists to ensure approvals are documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Reinforce supervisor approval of all timecards prior to payroll processing. Name(s) of the contact person(s) responsible for corrective action: Judy Thomas, CFO Planned completion date for corrective action plan: June 2026
District has performed audit/adjustments/journal entries as directed. Additionally, accounting procedures/resources have been updated to avoid need for adjustments on further audits. In particular, the district's annual grant tracking spreadsheets have been updated to summarize the specific amount o...
District has performed audit/adjustments/journal entries as directed. Additionally, accounting procedures/resources have been updated to avoid need for adjustments on further audits. In particular, the district's annual grant tracking spreadsheets have been updated to summarize the specific amount of reimbursement that should be desposited to each accounting fund which will allow the bookkeeper to more easily verify total grant throughout the year and at year end.
Finding 1168633 (2025-001)
Material Weakness 2025
Department of Education Federal Direct Student Loans and Federal Pell Grant Program – Assistance Listing No. 84.268 and 84.063 Recommendation: We recommend that the University continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the thir...
Department of Education Federal Direct Student Loans and Federal Pell Grant Program – Assistance Listing No. 84.268 and 84.063 Recommendation: We recommend that the University continue to enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management respectfully agrees on all findings and recommendations. Management will engage in business process review and implement redesigns as necessary. Management is committed to ensuring consistent application of policies and procedures so that enrollment reporting and oversight of third-party service providers result in accurate and timely reporting by the third-party service provider. Although the third-party service provider holds a national monopoly on enrollment reporting and other institutions of higher education face similar reporting issues by the third-party service provider, Management believes that review of internal processes over enrollment reporting will mitigate accuracy and timeliness errors made by the third-party service provider. These measures will help ensure compliance with U.S. Department of Education requirements. Name(s) of the contact person(s) responsible for corrective action: Ashlie Pence Planned completion date for corrective action plan: February 28, 2026
The District will review the general ledger and compare to expenditure reports to ensure agreement before the reports are submitted.
The District will review the general ledger and compare to expenditure reports to ensure agreement before the reports are submitted.
Adjusting Journal Entries and Required Disclosures to the Financial Statements. Year Ended June 30, 2025. Auditors Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both...
Adjusting Journal Entries and Required Disclosures to the Financial Statements. Year Ended June 30, 2025. Auditors Recommendation: Although auditors may continue to provide such assistance both now and in the future, under the new pronouncement, the District should continue to review and accept both proposed adjusting journal entries and footnote disclosures, along with the draft financial statements. School District's Response: The District has received, reviewed and approved all journal entries, footnote disclosures and draft financial statements proposed for the current year audit and will continue to review similar information in future years. Further, the District believes it has a thorough understanding of these financial statements and the ability to make informed judgements based on these financial statements.
Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend that the District review its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the proc...
Child Nutrition Cluster – Assistance Listing No. 10.553 and 10.555 Recommendation: We recommend that the District review its procedures and controls over procurement to ensure that all procurements are documented such that a third party can clearly see and understand the detailed history of the procurement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The District will work with their departments utilizing federal dollars to ensure the proper procurement method is utilized for all procurements and that documentation of that process is retained so it is clear what considerations were made in the procurement decision. Name of the contact person responsible for corrective action: Bill Holmgren Planned completion date for corrective action plan: June 30, 2026
There material adjustment was due to an issue with the migration to a new accounting software. The issue has been addressed. The district will be more diligent in monitoring transactions to ensure proper posting of transactions occurs.
There material adjustment was due to an issue with the migration to a new accounting software. The issue has been addressed. The district will be more diligent in monitoring transactions to ensure proper posting of transactions occurs.
Views of Responsible Officials and Planned Corrective Actions Clearinghouse reports are from the college’s student information system (SIS). During FY24, the finding stems from a student’s withdrawal, which was promptly processed and entered in the SIS. However, the system categorized the student as...
Views of Responsible Officials and Planned Corrective Actions Clearinghouse reports are from the college’s student information system (SIS). During FY24, the finding stems from a student’s withdrawal, which was promptly processed and entered in the SIS. However, the system categorized the student as "less than half-time” because the student received a passing grade in a course for which the student was exempted after passing a proficiency test. The SIS did not update the student status to 'withdrawn' until the semester ended, which was more than 60 days after the withdrawal date. To remedy this issue, the college’s Business Office now maintains an online spreadsheet listing withdrawn students outside the SIS that is updated whenever a student withdraws from the college. The list has been shared with the personnel responsible for the Clearinghouse reports and the Financial Aid Coordinator. Personnel will monitor the withdrawal listing and verify that all withdrawn students are accurately categorized in the Clearinghouse report from the SIS before completing the submission. After reviewing the FY25 finding, we discovered that the student attended in the spring 2025 semester but withdrew during the college’s drop/add period. By default, the SIS removes students who withdraw during drop/add from the Clearinghouse report.We have confirmed that Welch is unable to modify data or correct errors in the SIS report submitted to the Clearinghouse.Action Taken/Planned To address these problems, which ultimately stemmed from the limitations of Clearinghouse reporting by the college’s SIS, Welch has taken the following steps: 1. Clearinghouse reporting responsibilities have transitioned to a full-time, onsite employee in the Provost’s Office. 2. When preparing Clearinghouse reports and to help with identifying any errors before submitting the report, the employee will continue to monitor the withdrawn students listing maintained by the college’s Business Office, as outlined in the steps taken with the FY24 finding. 3. Welch plans to engage with its SIS and explain the reporting issues and limitations to determine if the SIS can help the college resolve the reporting limitations with its system. 4. To minimize the possibility of students being omitted from any Clearinghouse report, the employee responsible for the Clearinghouse report will submit an initial report to Clearinghouse on the first day of each term (fall, winter, spring, summer), followed by submitting reports on the mandatory reporting dates, as given by Clearinghouse. 5. The employee responsible for Clearinghouse reporting and the college’s Financial Aid Coordinator will collaborate before and after each Clearinghouse submission, and once the submission data is reported to NSLDS by Clearinghouse, the Financial Aid Coordinator will review all withdrawn students to confirm their NSLDS status is correct. If not, she will manually update the student’s NSLDS status to ensure accuracy. Anticipated Completion Date/Date Completed: November 6, 2025
Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Condition Enrollment information, including the effective date of separation from the institution, must be accurately rep...
Special Tests and Provisions: Enrollment Reporting – Federal Direct Student Loan Program, Assistance Listing Number 84.268; June 30, 2025 Award Year; U.S. Department of Education Condition Enrollment information, including the effective date of separation from the institution, must be accurately reported to NSLDS within 30 days whenever attendance changes for a student, unless a roster will be submitted within 60 days. May 2025 graduates were reported to NSLDS outside of the maximum 60-day window. Corrective Actions Ellucian has since released a patch to address the known defect, and it has been successfully deployed by the University. Additionally, the University will continue to monitor subsequent submissions to NSC where errors were initially noted, to ensure status changes have been transmitted by the NSC in a timely manner to NSLDS. Responsible Official: Taylor Horner, University Registrar Completion Date: August 2025
Corrective Action Planned: The Organization has updated its policies and procedures to ensure proper approvals are performed and documented. Anticipated Completion Date: Continuous. Responsible Parties: Management and the Board of Directors.
Corrective Action Planned: The Organization has updated its policies and procedures to ensure proper approvals are performed and documented. Anticipated Completion Date: Continuous. Responsible Parties: Management and the Board of Directors.
MANAGEMENT AGREES WITH THE FINDING. THE EXCESS FUNDS WERE ACCRUED TO OFFSET FUTURE SECTION 8 HAP REQUESTS.
MANAGEMENT AGREES WITH THE FINDING. THE EXCESS FUNDS WERE ACCRUED TO OFFSET FUTURE SECTION 8 HAP REQUESTS.
The Chief School Business Official (CSBO) will pay closer attention to detail to avoid this type of error in the future by double checking his/her entry into the ISBE Expenditure Reporting protram. As a further check, the District Bookkeeper will check over the expenses prior to submission.
The Chief School Business Official (CSBO) will pay closer attention to detail to avoid this type of error in the future by double checking his/her entry into the ISBE Expenditure Reporting protram. As a further check, the District Bookkeeper will check over the expenses prior to submission.
Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the program...
Finding Number: 2025-006 Federal Program, Assistance Listing Number and Name: ALN 10.557, United States Department of Agriculture, WIC Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Condition: Original Finding Description: The City applied indirect costs to the programs in a manner that did not align with the allocation methodology outlined in the 2022–2023 cost allocation plan submitted to MDHHS. Furthermore, the plan lacked explicit certification and contained minor errors and omissions. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Regina Greear Terri Daniels Anticipated completion date: July 2026 Planned Corrective Action: Upon identification, the City worked with the Michigan Department of Health and Human Services (MDHHS) and obtained approval and acceptance of the indirect cost calculation. The City will continue to work with MDHHS to ensure full compliance. The City has initiated a review of its indirect cost allocation methodology to ensure compliance. Management is updating the cost allocation calculation to document the approved allocation method and ensure the method is in accordance with the approved plan. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements. The City will also provide training to staff involved in the preparation, submission, and calculation of the indirect costs to ensure understanding requirements.
Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specif...
Finding Number: 2025-005 Federal Program, Assistance Listing Number and Name: ALN 93.914, Department of Health and Human Services (HHS), HIV Relief Project Grants Condition: Original Finding Description: A lack of effective controls resulted in noncompliance with federal payment requirements, specifically for payments made to subrecipients. Contact Person Responsible for Corrective Action / Anticipated Completion Date: Denise Fair Razo Regina Greear Terri Daniels Anticipated completion date: March 2026 Planned Corrective Action: The three payments made were paid one to two days after the 30 day reimbursement requirement. The City will review its subrecipient payment terms and implement additional processes to help ensure compliance with federal payment requirements.
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