Corrective Action Plans

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This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.
Finding 2025-003: Subrecipient Monitoring Condition: The Sponsoring Organization did not consistently perform the required initial on-site review for new subrecipients (centers and FCC providers) within the mandatory 28-day timeframe. View of Responsible Officials: 4C agrees with the audit finding. ...
Finding 2025-003: Subrecipient Monitoring Condition: The Sponsoring Organization did not consistently perform the required initial on-site review for new subrecipients (centers and FCC providers) within the mandatory 28-day timeframe. View of Responsible Officials: 4C agrees with the audit finding. Corrective Action Plan: 4C will implement a new process of requiring the first visit for new providers to be conducted by the 20th of the month with notes required in kidcare system related to scheduling and rescheduling of visit. Responsible Party: Pagie Runion, Strategic Director of Business Services Anticipated Completion Date: June 30, 2026
Finding 2025-002: Subrecipient Monitoring Condition: During the review of internal controls related to subrecipient monitoring, it was noted that the monthly meetings required between the Program Manager and the Monitoring Specialist were not consistently performed throughout the fiscal year. Specif...
Finding 2025-002: Subrecipient Monitoring Condition: During the review of internal controls related to subrecipient monitoring, it was noted that the monthly meetings required between the Program Manager and the Monitoring Specialist were not consistently performed throughout the fiscal year. Specifically, for the 12-month period tested, the required monthly reviews were not documented for 3 out of 12 months. View of Responsible Officials: 4C agrees with the audit finding. Corrective Action Plan: 4C will improve their control process to include a mandatory monthly check with the department manager to verify visits are completed timely. Responsible Party: Pagie Runion, Strategic Director of Business Services Anticipated Completion Date: June 30, 2026
Finding 2025-001: Suspension and Debarment Condition: The Sponsoring Organization did not consistently document the verification that new Child and Adult Care Food Program (CACFP) centers or Family Child Care (FCC) providers were not suspended or debarred prior to enrollment. View of Responsible Off...
Finding 2025-001: Suspension and Debarment Condition: The Sponsoring Organization did not consistently document the verification that new Child and Adult Care Food Program (CACFP) centers or Family Child Care (FCC) providers were not suspended or debarred prior to enrollment. View of Responsible Officials: 4C agrees with the audit finding. Corrective Action Plan: 4C will implement a control process within the onboarding process. The onboarding check list will have sign offs for the manager and strategic director over the program. Responsible Party: Pagie Runion, Strategic Director of Business Services Anticipated Completion Date: June 30, 2026
The Workforce Development Department (GuilfordWorks) experienced turnover in program service level staffing during FY 2025 along with certain periods of vacancies. Additional training related to federal grant accounting, particularly the reporting requirements for the Department of Labor, will be co...
The Workforce Development Department (GuilfordWorks) experienced turnover in program service level staffing during FY 2025 along with certain periods of vacancies. Additional training related to federal grant accounting, particularly the reporting requirements for the Department of Labor, will be conducted with program staff. Backup program staff are now in place in case of primary staff absences. Finance Department staff will also hold periodic discussions with GuilfordWorks staff to ensure that reporting deadlines are consistently being met timely.
The District is correcting the eligibility status of student participants and is providing training to those that determine the eligibility status to ensure proper eligibility determination in the future.
The District is correcting the eligibility status of student participants and is providing training to those that determine the eligibility status to ensure proper eligibility determination in the future.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
See table on page 48.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
With the late submission/approval of the grants, these dates just slipped through the cracks. Will be monitored better moving forward to ensure the dates they are asking for are made in a timely manner.
Continued understanding is still needed from prior fiscal years. We have improved but more leanring and improvement is needed. We will continue to review account numbers throughout the year to better understand what journal entries need to be made.
Continued understanding is still needed from prior fiscal years. We have improved but more leanring and improvement is needed. We will continue to review account numbers throughout the year to better understand what journal entries need to be made.
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2025-003 also applies to State award findings. Section IV - State Award Findings and Questioned Costs Section III - Federal Aw...
Corrective Action Plan For the Year Ended June 30, 2025 Finding: 2025-003 Name of contact person: Corrective Action: Proposed Completion Date: Corrective actions for Finding 2025-003 also applies to State award findings. Section IV - State Award Findings and Questioned Costs Section III - Federal Award Findings and Questioned Costs Jessica Wall, Human Services Director and Marcy Mays, Assistant Human Services Director Training to include technical assistance related to all Single County Audit Findings from the most recent audit. This training included a powerpoint presentation that covered income calculations, resources, self-employment and how to document each of these. During this training, we covered toggling into each determination to check for validity and made it a requirement that each caseworker calculate income outside of the system, upload their own calcuations into NCFast and verify that the outside calculation matches that in the system. Operational Support Representative visited the agency to provide training on self-employment, unemployment, passalong, SSI cases and passalong. Internally, we have developed second-party spreadsheets per worker to be able to better track individual performance and training needs. Internal Training completed on 09/17/25. Operational Support Training was provided on 10/22/25. Supervisors will provide at least monthly training on any new policy updates or second-party findings. 131
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Co...
2025-002 – Significant Deficiency and Noncompliance – Federal Policies Corrective Action Plan: The City will develop and adopt a comprehensive Uniform Guidance compliance manual that addresses procurement, allowable costs, cash management, subrecipient monitoring, and internal controls. A Federal Compliance Officer will be designated to oversee policy implementation and annual updates. Standard operating procedures will be issued for relevant departments, and mandatory staff training will be conducted. These actions will be completed by March 31, 2026, with ongoing monitoring through quarterly compliance meetings. Anticipated Completion Date: March 31, 2026
2025-003 – Significant Deficiency and Noncompliance – Federal Equipment Corrective Action Plan: The City will implement a centralized Federal Equipment Register capturing all required data elements under 2 CFR §200.313(d) and assign responsibility to the Logistics Officers of the Fire Department, Po...
2025-003 – Significant Deficiency and Noncompliance – Federal Equipment Corrective Action Plan: The City will implement a centralized Federal Equipment Register capturing all required data elements under 2 CFR §200.313(d) and assign responsibility to the Logistics Officers of the Fire Department, Police Department, and Department of Public Works, with oversight by Finance. A full physical inventory of federally funded equipment will be completed and reconciled by March 31, 2026, and biennial inventory procedures will be established. Staff will be trained on equipment management requirements, and documentation will be retained to ensure compliance. Anticipated Completion Date: March 31, 2026
Policy Clarification: Procedures have been revised to explicitly require the use of calendar days for the 45-day deadline. Process Controls: A standardized checklist and calendar alerts are now in place to track withdrawal dates and refund deadlines. Monitoring: Monthly self-reviews of all R2T4 file...
Policy Clarification: Procedures have been revised to explicitly require the use of calendar days for the 45-day deadline. Process Controls: A standardized checklist and calendar alerts are now in place to track withdrawal dates and refund deadlines. Monitoring: Monthly self-reviews of all R2T4 files will be conducted by the Director of Academic Services to ensure timely processing.
Management concurs with the auditor's finding. The noncompliance resulted from a communication breakdown between the College and its third-party financial aid processing company, FAME, Inc. When William R. Moore College of Technology (the College) was placed under Heightened Cash Monitoring 1 (HCMl)...
Management concurs with the auditor's finding. The noncompliance resulted from a communication breakdown between the College and its third-party financial aid processing company, FAME, Inc. When William R. Moore College of Technology (the College) was placed under Heightened Cash Monitoring 1 (HCMl), staff did not immediately notify FAME of the status change. Had FAME been informed, the company would have updated the system configuration to restrict drawdowns until all credit balances were determined and paid. Although this was a communication lapse, the College did follow through on all U.S. Department of Educationdirectives related to financialresponsibility and provisional certification. Specifically, the College obtained and maintained the required Irrevocable Standby Letter of Credit (LOC) each time it was instructed to do so and amended the LOC amount in subsequent years as required by the Department. To correct this issue and ensure full compliance with federal cash-management regulations, the College has implemented the following actions: Notification Protocol and Financial Protection Requirements Before notifying FAME of any change in payment method (placement under or release from HCMl), the College must verify compliance with the Department of Education's Provisional Certification Alternative requirements under 34 C.F.R. § 668.l?S{f). The institution must submit an Irrevocable Standby Letter of Credit (LOC) or cash surety equal to 10% of the most recently completed fiscal year's Title IV funding. The College has complied with this requirement by obtaining and maintaining the LOC as directed and by amending the LOC amount ea'ch time the Department requested an updated financial protection amount. The LOC ensures funds are available to make refunds, provide teach-out facilities, and meet institutional obligations should the College close or terminate classes prematurely. The CFO confirms acceptance of the LOC by the Department before formally notifying FAME of any payment method change (HCMl, HCM2, or release). System Configuration Controls Once notified, FAME has confirmed that the system includes a compliance flag preventing drawdowns prior to disbursement while the College operates under HCMl. This configuration ensures that all Title IV reimbursements occur only after funds have been properly disbursed to students. Staff Training and Awareness Internal financial aid and accounting staff will participate in refresher training with FAME in Spring 2026. The training will cover: Title IV cash-management rules Communication and notification protocols Credit-balance determination and documentation standards Documentation and Oversight A written Title IV Reimbursement Checklist and Approval Workflow has been incorporated into the College's HCMl reimbursement process. The Financial Aid Counselor verifies completion of all disbursement and documentation steps prior to reimbursement. The CFO provides final authorization for each GS drawdown. 5. Monitoring and Continuous Improvement The College conducts quarterly internal reviews of Title IV drawdowns, reconciliations, and reimbursement documentation to confirm ongoing compliance. All findings are shared with FAME to maintain consistent alignment between systems and audit documentation. Anticipated Completion Date: All corrective actions were implemented by October 31, 2025; additional staff training is scheduled for Spring 2026. Status: As of June 30, 2025, the College is no longer operating under Heightened Cash Monitoring 1 (HCMl) and has returned to the standard payment method. However, corrective actions have been implemented; continued monitoring and staff training are in progress. Views of Responsible Official Management agrees with the finding. The noncompliance occurred due to a communication lapse between the College and its third-party processor, FAME, regarding requirements under the Heightened Cash Monitoring 1 (HCMl) payment method. In response, the College has updated its Title IV cash-management policies and procedures to ensure full compliance with federal regulations and the terms of its Provisional Certification Alternative under 34 C.F.R. § 668.175(f). Corrective actions include the submission and amendment of the Irrevocable Standby Letter of Credit, implementation of enhanced notification and verification procedures before alerting FAME of any payment-method changes, and establishment of quarterly internal reviews to confirm ongoing compliance with cash management and financial protection requirements.
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient ...
REFERENCE: 2025-002 – Eligibility HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: U.S. Department of Health and Human Services Facility: Bailey-Boushay House Finding: The Bailey-Boushay House did not retain evidence of eligibility being reviewed prior to patient services being provided. Corrective Action Plan: Beginning in February 2025, Bailey-Boushay House Administrative staff send out upcoming Eligibility expirations occurring in the next 90 days to the Clinical Supervisor and Director of Outpatient Programs. The Clinical Supervisor forwards a list to each care manager/social worker for clients on their caseload. The Clinical Supervisor discusses the status of these updates during meetings with care manager/social worker. Notes are made on the caseload list to document the discussion of status. The Clinical Supervisor sends a list to the care management team for clients who are within 30 days of their expiration, in order to identify clients who may be out of contact or less engaged in the program. A note is provided with these clients' medications to remind them that they need to complete this eligibility update with a care manager or social worker. Quarterly and monthly emails of eligibility expirations are retained for documentation purposes. Person Responsible: Katie Hara, Director of Outpatient Programs – Bailey Boushay House Completion: February 2025
REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria wi...
REFERENCE: 2025-001 – Allowable Costs/Cost Principles HIV Emergency Relief Project Grants (Assistance Listing No. 93.914) Federal Grantor: Health Resources and Services Administration Facility: Bailey-Boushay House Finding: At Bailey-Boushay House, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year. Corrective Action Plan: At Bailey-Boushay House, each Friday and Monday prior to running payroll, approval reminders are sent to all staff with the time-keeping policy attached. At least two different leaders and/or the scheduling coordinator send these reminders. Staff have been educated on the two-step approval system and it will impact their performance evaluation if there is continued non-compliance. The Finance Manager reviews the timecard allocations and populates the hours charged to the grant per the timecard on to the salary allocation spreadsheet. The salary allocation spreadsheet is utilized in completing the reimbursement request. The timecards and the allocation spreadsheet are included in the reimbursement request. Beginning in January 2026, the salary allocation spreadsheet and timecards will be reviewed and signed off by the Director of Outpatient Programs as part of the reimbursement request approval process. Additionally, timecard approval compliance for prior periods will be reviewed during Bailey-Boushay weekly leadership meetings. Person Responsible: Rob Hays, Executive Director – Bailey-Boushay House Expected Completion: January 2026
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: A Federal Direct Loan exit interview was not completed by, nor were instructions sent t...
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: A Federal Direct Loan exit interview was not completed by, nor were instructions sent to, students on how to complete an exit interview when the students graduated from the College or dropped below a halftime enrollment status. This was applicable for two of the nine students selected for testing that received Federal Direct Loan funds. Corrective Action Plan: Federal Direct Loan exit interview information was sent to one of the students in question in August 2025 and the second student in question in September 2025. Procedures will be improved to ensure Federal Direct Loan exit interviews are completed or information is sent to students when they cease enrollment at the College. Anticipated Completion Date: The corrective action was completed in August 2025 and September 2025. Contact Person: Stephanie Dickerson, Registrar/Financial Aid
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: The incorrect withdrawal date was reported to the National Student Loan Database System...
Program Name: Federal Direct Student Loan Program AL# and Program Expenditure: 84.268 ($797,519) Award Number: P268K257533 Federal Award Year: July 1, 2024 to June 30, 2025 Questioned Costs: $-0- Condition Found: The incorrect withdrawal date was reported to the National Student Loan Database System (“NSLDS”) for four of the nine students selected for testing that received Federal Direct Student Loans. Corrective Action Plan: Management agrees with the auditors’ finding and their recommendation. The Financial Aid Director updated the enrollment status for the students in question in December 2025. Procedures will be improved to ensure that a student’s enrollment status is updated timely and with the correct date of the change. Anticipated Completion Date: The corrective action was completed in December 2025. Contact Person: Stephanie Dickerson, Registrar/Financial Aid 910-323-5614
No. 2025-001 Subject: Allowable Costs and Activities ‐ Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Byron Jones, CFO Phone Number: (480) 270-5438 Anticipated Completion Date: June 30, 2026 Corrective Action: We will strengthen internal co...
No. 2025-001 Subject: Allowable Costs and Activities ‐ Significant deficiency in internal control over compliance and compliance finding. Name of Contact Person: Byron Jones, CFO Phone Number: (480) 270-5438 Anticipated Completion Date: June 30, 2026 Corrective Action: We will strengthen internal controls over employee time coding by implementing enhanced review procedures to ensure only allowable Child Nutrition activities are charged to the grant. Supervisors and the accounting team will review all payroll coding charged to the Child Nutrition Cluster to verify that the employee’s position and duties align with approved grant activities. These improved internal procedures will provide proper compliance over allowable costs. We will also conduct an annual audit of all grant-funded employee positions at the start of each school year, reviewed by the grants team, HR, and accounting, to verify the accuracy of all employee costing allocations to federal grants and to ensure any miscoding errors are identified and corrected in a timely manner.
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