Corrective Action Plans

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Name of Contact Person: Daniel Nolan, Finance Officer Corrective Action Plan: Management will implement controls and procedures to ensure that consultation with private school officials takes place in a timely manner each year and that documentation is maintained on file to evidence these consultati...
Name of Contact Person: Daniel Nolan, Finance Officer Corrective Action Plan: Management will implement controls and procedures to ensure that consultation with private school officials takes place in a timely manner each year and that documentation is maintained on file to evidence these consultations. Proposed Completion Date: Immediately
Name of Contact Person: Daniel Nolan, Finance Officer Corrective Action Plan: The Board of Education will implement controls to ensure that federal budget amendments are completed in accordance with program requirements. Proposed Completion Date: Immediately
Name of Contact Person: Daniel Nolan, Finance Officer Corrective Action Plan: The Board of Education will implement controls to ensure that federal budget amendments are completed in accordance with program requirements. Proposed Completion Date: Immediately
The City will (1) submit the required FFATA subaward reports for the five unreported tier one subawards, (2) implement a formal FFATA compliance checklist to be completed at the time of subaward execution, (3) designate responsible personnel for FSRS reporting with a documented secondary review, and...
The City will (1) submit the required FFATA subaward reports for the five unreported tier one subawards, (2) implement a formal FFATA compliance checklist to be completed at the time of subaward execution, (3) designate responsible personnel for FSRS reporting with a documented secondary review, and (4) provide training to applicable staff on FFATA reporting requirements and deadlines.
1) Draft policy issued to engineers from Deputy Director of Public Works, 2)finalize policy, and 3)follow procedure established to ensure certified payrolls are received and maintained on file.
1) Draft policy issued to engineers from Deputy Director of Public Works, 2)finalize policy, and 3)follow procedure established to ensure certified payrolls are received and maintained on file.
Finding 2025-002 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for approving timecards which includ...
Finding 2025-002 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for approving timecards which include program codes for allocation to awards. The controls in place did not operate as designed and failed to fully correct an error in five timecards of an employee’s pay to the grant. Corrective Action Plan: The time and attendance software used during this audit’s timeframe required a manual process for access to those who split their time between grants. This process required additional steps after notifying finance when a grant is added or has ended. Since the audit timeframe, GESMN has implemented a new time and attendance system which does not require this manual process, removing the potential for human error. Responsible Individuals: Milissa Orchard, Director of HR Operations Anticipated Completion Date: Completed
Finding 2025-001 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for allocating employee wages based ...
Finding 2025-001 Federal Agency Name: Department of Health and Human Services Pass-Through Entity: Ramsey County Assistance Listing Number: 93.558 Program Name: Temporary Assistance for Needy Families Finding Summary: Goodwill-Easter Seals Minnesota has a process for allocating employee wages based on hours worked. The controls in place did not operate as designed and failed to fully correct an error in the allocation of employee pay to the grant. Corrective Action Plan: Since the audit, the payroll team has spot-checked records to ensure employees are paid accurately (regular or overtime) when retroactive corrections are made to time submissions. In addition, the payroll supervisor will provide training during the week of January 5, 2025, to ensure future retroactive corrections are accurate and the team is auditing regularly for accuracy. Responsible Individuals: Milissa Orchard, Director of HR Operations Anticipated Completion Date: Completed
Condition: The County did not perform required on-site inspections of four out of six HOME-assisted properties evaluated during FY 2025, as mandated by 24 CFR §§ 92.209(i), 92.251(f), and 92.504(d). These inspections are required every one to three years, depending on the number of units per project...
Condition: The County did not perform required on-site inspections of four out of six HOME-assisted properties evaluated during FY 2025, as mandated by 24 CFR §§ 92.209(i), 92.251(f), and 92.504(d). These inspections are required every one to three years, depending on the number of units per project. Recommendation: Establish and maintain a formal inspection schedule with assigned accountability to ensure timely completion of all required HOME inspections. Implement tracking tools and cross-training to mitigate delays caused by staff turnover. Explanation of Disagreement with Audit Finding: There is no disagreement with the audit finding. Action Planned in Response to Finding The County agrees with the finding and is implementing the following corrective actions to strengthen internal controls over HOME inspection compliance and ensure inspections are conducted in accordance with federal requirements. 1. Cross-Training of Inspection Staff Housing & Grants staff will conduct formal cross-training with inspectors from Environmental Health and/or the Marin Housing Authority by June 30, 2026. This training will cover HOME inspection requirements, including property standards, documentation expectations, and inspection frequency requirements. Cross-training will ensure sufficient technical expertise and backup coverage to perform and review HOME inspections in compliance with federal regulations and to maintain continuity during staffing changes.2. Implementation of Inspection Tracking Software The Community Development Agency will implement and utilize inspection tracking software by June 30, 2026 to track, schedule, and document HOME program inspections. The system will maintain inspection dates, inspection type (desk audit or physical), findings, corrective actions, and follow-up status. This tool will strengthen monitoring controls, provide management visibility, and help ensure inspections are conducted timely and consistently. 3. Conducting HOME Inspections in Accordance with HOME Regulations Housing & Grants staff will conduct HOME inspections in accordance with HOME program regulations by June 30, 2026, including both desk audits and physical inspections, as follows: • Desk Audits: Staff will review program documentation, tenant eligibility, income certifications, rent limits, and other compliance documentation using standardized desk audit procedures. • Physical Inspections: Physical property inspections will be performed in accordance with HOME property standards to assess health and safety compliance. • Monitoring and Documentation through JotForm Desk Audits: Desk audits will be documented using JotForm inspection and monitoring tools to ensure consistent documentation, clear audit trails, and management oversight of HOME compliance activities. 4. Formal Inspection Schedule and Ongoing Oversight The Community Development Agency has initiated development of a comprehensive HOME on-site inspection schedule that identifies all HOME-assisted properties, applicable inspection frequencies, and assigned staff responsibilities. The schedule will be maintained and reviewed at least quarterly by program management to ensure inspections are completed timely and any overdue inspections are promptly addressed. Responsible Officials • Leelee Thomas, Deputy Director, Community Development Agency Leelee.Thomas@marincounty.gov • Chris Miranda, Senior Program Coordinator, Community Development Agency Chris.Miranda@marincounty.gov Planned Completion Date All corrective actions described above are expected to be fully implemented by June 30, 2026.
The Organization incorrectly charged intern wages to the grant, which were intended for a different grant. Additionally, for another summer intern, wages were charged in excess of the amount authorized in the approved budget. The Finance Team meets monthly with the Director of the Community Preventi...
The Organization incorrectly charged intern wages to the grant, which were intended for a different grant. Additionally, for another summer intern, wages were charged in excess of the amount authorized in the approved budget. The Finance Team meets monthly with the Director of the Community Prevention Program to ensure that all budget modifications and expenditures are alligned with the approved budget prior to the submission of invoices. Approved budget modifications are shared by the Director of the Community Prevention Program promptly upon receipt. The Organization has established a shared repository for each program, providing access to both program staff and the Finance Team to store and share all approved budget modifications and program expenditure documentation. Addionally, the Organization is transitioning from a manual payroll process to an automated payroll system to reduce errors in payroll allocations accross all programs.
NACAA has received and reviewed the draft audit report for fiscal year 2025 conducted November 25, 2025. We have provided our auditors DeLeon & Stang with a Management Response to include with the audit. This document will outline NACAA’s course of corrective action for those findings. Finding 1: Th...
NACAA has received and reviewed the draft audit report for fiscal year 2025 conducted November 25, 2025. We have provided our auditors DeLeon & Stang with a Management Response to include with the audit. This document will outline NACAA’s course of corrective action for those findings. Finding 1: The Organization charged indirect costs to the major federal program in excess of the amount permitted under its approved NICRA for the fiscal year ended September 20, 2020. In addition, amounts reported on the annual Federal Financial Report (FFR) to the federal funder were incorrect, reporting the wrong base and charged amounts. The amounts reported on the FFR did not match the actual indirect cost base and charges for fiscal year 2025. Background As noted in the audit finding, NACAA’s NICRA has historically been based on a salary and fringe benefits allocation base. During fiscal year 2025, NACAA experienced significant turnover of longtenured employees, resulting in a substantial decrease in salaries and wages and, accordingly, a reduction in the approved indirect cost rate. As a result, indirect costs were overcharged to the federal program by $96,196. The annual Federal Financial Report (FFR) submitted on November 6, 2025, was based on internal year-end reports not NACAA’s audited final numbers. The information reported as the indirect cost rates and amounts were taken from the NICRA applications for the FY24 final and FY25 provisional negotiated rates. Remediation In order to address these findings, NACAA has contacted its EPA Project Officer and Grant Specialist to discuss appropriate corrective action. We explained that NACAA is having trouble paying its overhead expenses using the current negotiated indirect cost rate of 16.84% due to the substantial changes in our staff since the rate was negotiated. NACAA’s 2025 provisional indirect costs rate was calculated based on a SWF amount of $1,306,688. At year end because of staff changes, NACAA’s 2025 SWF amount is only $950,264, which makes our base for calculating indirect costs $356,424 less than when the rate was set. The indirect cost limit based on the old SWF was $220,046, while it’s $160,024 based on the new. NACAA’s indirect costs for 2025 were $256,919. After speaking with EPA, NACAA met with its auditors and accountant to discuss corrective action. It was recommended that some of NACAA’s overhead costs that have traditionally been added to the indirect cost pool (professional fees, rent, office insurance, etc.) be charged as direct costs using NACAA’s grant-related salaries and fringe benefits to allocate expenses between direct and indirect costs. To correct the other issue related to the Federal Financial Report (FFR) errors, NACAA will work with its accountant to complete the required FFRs and other grant reports to ensure that all figures being reported at correct. Reclassifying Indirect Charges to Direct Cost Categories NACAA has contacted the EPA Grants Management team to determine if our anticipated corrective course of action would be acceptable to EPA. We have received concurrence by email that the suggestion made by NACAA’s Auditors that pro-rating costs using salary as a basis for allocating overhead charges as direct costs is reasonable. This method should be used to allocate all expenses that are “traditionally” allocated as indirect costs. NACAA is currently drafting a request to re-budget its 2026 expenses, allocating many of the expenses traditionally part of the indirect cost pool as direct expenses, pro-rating costs using salary as a basis for allocating overhead charges as direct costs. NACAA’s Project Officer needs to approve that request so an amendment can be made for the current year of NACAA’s two-year cooperative agreement. Accountability Once NACAA’s re-budgeting request has been approved, NACAA’s Operations Manager and Accountant will be responsible for ensuring that expenses are correctly allocated every month using salary as a basis for allocating overhead charges as direct costs. Please see a description of NACAA’s Time and Attendance System and Method of Fringe Benefit allocation. These will be used to determine the percentage of expenses that will be allocated as direct costs: Salaries and Wages: Time & Attendance System: NACAA’s staff complete detailed timesheets on the 15th and last day of each month. Personnel Time Allocation Policy: Traditionally, activities of the NACAA headquarters office fall into three categories: federal grant-related activities; non-grant related activities; and indirect functions. Fringe benefits are allocated into these three categories based on the number of hours worked in each. Non-grant related activities are funded by the NACAA treasury. A very modest amount of time is allocated as Indirect Salaries, Wages and Fringes. Indirect salaries are included in NACAA’s indirect cost pool. Fringe Benefits: Fringe Benefits for NACAA’s staff members include employer-paid share of payroll taxes, health, life and disability insurance and a retirement plan. NACAA allocates fringe benefits based on a fringe benefit rate and distributes them based on salaries and wages.
SEE REPONSE AND CORRECTIVE ACTION PLAN AT 2025-001.
SEE REPONSE AND CORRECTIVE ACTION PLAN AT 2025-001.
Condition The amount reported in the June 30, 2025 project and expenditure report for total expenditures was not able to be reconciled to the amounts expended in the Town’s general ledger. Corrective Action Plan The Town will implement procedures to ensure reports are based upon the Town’s general l...
Condition The amount reported in the June 30, 2025 project and expenditure report for total expenditures was not able to be reconciled to the amounts expended in the Town’s general ledger. Corrective Action Plan The Town will implement procedures to ensure reports are based upon the Town’s general ledger and properly reconciled and in compliance with U.S. Treasury guidelines. This is expected to be completed by June 30, 2026. The implementation process for the finding will be monitored by the Town’s Finance Director Adam Lawrence.
Finding 2025.002 Procurement, Suspension and Debarment Recommendation Kalihi-Palama Health should establish a system of internal controls to review employees in accordance with the Uniform Guidance requirements for suspension and debarment. These procedures should be reviewed with the appropriate st...
Finding 2025.002 Procurement, Suspension and Debarment Recommendation Kalihi-Palama Health should establish a system of internal controls to review employees in accordance with the Uniform Guidance requirements for suspension and debarment. These procedures should be reviewed with the appropriate staff to ensure compliance with requirements. Action Taken: Effective Februaty 9, 2026, we will implement the following changes to ensure employees are reviewed for suspension and debarment and the approval is documented. -Review and update the suspension and debarment internal process -Ensure all applicable employees are trained in the suspension and debarment process and understand their role and responsibilities -Implement a formal and documented monthly review and approval process by the Human Resources Supervisor/Director. -Ensure all source documents and approvals are properly stored and available for future reference as needed Emmanuel Kintu CEO/ Executive Director Kalihi-Palama Health Center
Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken: Effective February 9,...
Finding 2025.001 Special Tests and Provisions - Sliding Fee Discounts Recommendation Kalihi-Palama Health should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken: Effective February 9, 2026, we will implement the following changes to ensure clients are appropriately charged according to the sliding fee scale. -Update the frequency of our sliding fee scale employee training sessions -Implement monthly spot checks to ensure compliance to the sliding fee scale and provide timely feedback
Finding Reference Number: 2025-001 – Noncompliance with Procurement Requirements Planned Corrective Action: Food Service Director will participate in the collaborative purchasing each year and will not utilize vendors that do not appear on the bid award. He will be sure to monitor bid results to ens...
Finding Reference Number: 2025-001 – Noncompliance with Procurement Requirements Planned Corrective Action: Food Service Director will participate in the collaborative purchasing each year and will not utilize vendors that do not appear on the bid award. He will be sure to monitor bid results to ensure the previous year’s vendor was awarded the bid before purchasing and will create individual contracts with the vendors who have been awarded the bid for the school year. If not participating in the collaborative purchasing group, the Food Service Director will be sure to follow proper procurement processes to ensure compliance. Responsible Official Name: Erika Snyder Title: Business Manager Anticipated Completion Date: 9/1/2025
PLANNED CORRECTIVE ACTIONS PLANNED: The Organization acknowledges the finding and agrees with the recommendation. The Organization also notes that the percentage of adults maintaining or increasing income was impacted by several participants exiting the program near the end of the fiscal year. Due t...
PLANNED CORRECTIVE ACTIONS PLANNED: The Organization acknowledges the finding and agrees with the recommendation. The Organization also notes that the percentage of adults maintaining or increasing income was impacted by several participants exiting the program near the end of the fiscal year. Due to their shorter timeframe in the program, these participants had limited opportunity to achieve employment goals or secure increased income. The Organization will review program exit timing and case planning procedures to better ensure participants have adequate time to engage in employment-related services before exit, when possible. To address the finding and improve future performance, the Organization is implementing the following corrective actions: 1. Improved Income-Tracking System: A revised income-tracking process will be integrated into case-management to ensure income information is consistently updated at program entry, during routine case reviews, and at exit. 2. Enhanced Staff Training: Case managers and program staff will receive updated training on income documentation requirements, including timely data entry and verification procedures. 3. Quarterly Internal Monitoring: The Finance Manager will conduct quarterly reviews of participant files to ensure accurate income tracking and identify areas needing corrective attention. 4. Program Exit and Case Planning Adjustments: Program leadership will work with case managers to strengthen exit planning protocols, helping ensure participants have sufficient time to pursue employment goals before program completion whenever possible. 5. Regular Coordination Between Finance and Program Teams: Monthly cross-departmental check-ins will be established to keep financial and program data aligned and identify issues early.
Planned Corrective Action: We removed all unallowable costs from our indirect cost pool to ensure full compliance with applicable cost principles. We implemented an additional layer of review during the preparation of our 2025 indirect cost rate proposal to identify and exclude any unallowable charg...
Planned Corrective Action: We removed all unallowable costs from our indirect cost pool to ensure full compliance with applicable cost principles. We implemented an additional layer of review during the preparation of our 2025 indirect cost rate proposal to identify and exclude any unallowable charges. We added a dedicated step to our monthly close process to review all new charges and determine whether any should be classified as unallowable. Anticipated Completion Date 12/31/2025. Responsible Contact Person: Katherine Page, Director of Finance
Planned Corrective Action: Our payroll system provider corrected the backend setting to prevent employees from adjusting their timecards after they have been approved and locked. We reviewed and confirmed that the system is now functioning as intended to prevent similar issues in the future. We dedu...
Planned Corrective Action: Our payroll system provider corrected the backend setting to prevent employees from adjusting their timecards after they have been approved and locked. We reviewed and confirmed that the system is now functioning as intended to prevent similar issues in the future. We deducted the overage amount from the November 2025 invoice to reimburse the agency in full. Anticipated Completion Date 11/17/2025 & 12/31/2025. Responsible Contact Person: Katherine Page, Director of Finance
The District plans to implement more oversight on grant funding requests.
The District plans to implement more oversight on grant funding requests.
Subject: Corrective Action Plan for finding 2025-001 Utilities Allowance Calculation Please find our response in regards to the utility allowance calculation: Finding No. 2025-001: Utilities Allowance Calculation Marlboro Housing Authority was made aware of this finding during the audit file process...
Subject: Corrective Action Plan for finding 2025-001 Utilities Allowance Calculation Please find our response in regards to the utility allowance calculation: Finding No. 2025-001: Utilities Allowance Calculation Marlboro Housing Authority was made aware of this finding during the audit file process. We discovered that the error has to do with the changing of bedroom sizes within our SACS software. This is a process that staff must manually change when household sizes change, as it will not automatically correct when an interim or recertification is processed. Our staff has been briefed about this matter, and they will make sure that the household size and bedroom size is reflected correctly in our software, each time they review a participant file. This should resolve any error in utility allowance calculation going forward. I hope this plan for corrective action will satisfy this finding. Please feel free to contact me if you have any questions. Sincerely, Pamela Stevens Pamela Stevens Executive Director
Corrective Action Plan: Upon assuming the role of Executive Director in July 2024, it became clear that rent reasonableness studies were not being conducted under the previous administration, as required. Recognizing the importance of compliance with HUD regulations, I initiated the implementation o...
Corrective Action Plan: Upon assuming the role of Executive Director in July 2024, it became clear that rent reasonableness studies were not being conducted under the previous administration, as required. Recognizing the importance of compliance with HUD regulations, I initiated the implementation of a rent reasonableness policy and process. To support this effort, we entered into a contract with MRI to provide us with the rent reasonableness software. Last year we supplied MRI with the necessary property addresses and zip codes to begin the analysis. Due to the complexity of the implementation and the volume of data required, the setup process took time. We are now actively incorporating rent reasonableness determinations into all tenant files during annual recertifications and interims. With nearly 700 families in our program, this is an ongoing process, but significant progress has been made. Our team is fully committed to ensuring full compliance with HUD regulations, and we continue to work diligently toward that goal. In addition, to ensure continued compliance and to maintain the integrity of our files, the HCV Supervisor will be conducting weekly audits. This internal quality control measure helps us identify and address any inconsistencies or issues in a timely manner.
Upon notification of the reporting error, the institution corrected the enrollment status effective date in both the National Student Clearinghouse (NSC) and NSLDS to reflect the student's actual withdrawal date of November 15, 2024. To prevent future reporting errors, the Registrar's Office will im...
Upon notification of the reporting error, the institution corrected the enrollment status effective date in both the National Student Clearinghouse (NSC) and NSLDS to reflect the student's actual withdrawal date of November 15, 2024. To prevent future reporting errors, the Registrar's Office will implement an additional procedural verification step in the enrollment status reporting process. This step will include a review of effective dates prior to submission to NSC and NSLDS. The Registrar will also ensure appropriate staff training and oversight as process documentation is developed and implemented in the new student information system.
Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures for allocating expenses to grants to ensure only allowable expenses are charged to the grant. Completion Date: Immediately
Contact Person: Susie Novak Boelter, Executive Director Corrective Action Plan: The Food Bank will review their procedures for allocating expenses to grants to ensure only allowable expenses are charged to the grant. Completion Date: Immediately
Action Taken: Management agrees with the recommendations and will have the business manager compare the support for the amounts reported to the District’s books and records prior to submission. Further, management will implement a review process to confirm the accuracy of the amounts reported, as we...
Action Taken: Management agrees with the recommendations and will have the business manager compare the support for the amounts reported to the District’s books and records prior to submission. Further, management will implement a review process to confirm the accuracy of the amounts reported, as well as maintain the supporting information. Proposed Completion Date: March 31, 2026
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to...
Action Taken: Management agrees with the recommendations. The management team involved with grants will work to modify and improve the current procedures and will implement the controls surrounding grant compliance, from the application process through final reporting. The team will also continue to work to enhance our grant monitoring, including resuming management team meetings to keep everyone abreast of the status of grants. In addition, we will begin to gradually involve the new business office employee in grant reporting to improve on compliance with grant reporting requirements. Proposed Completion Date: June 30, 2026
Action Taken: Management agrees with the recommendations and will contact the Pennsylvania Department of Education to inquire as to how to resubmit the annual report with correct amounts for 2023-24, agreeing the expenditures to the District’s books and records. In addition, the business manager wil...
Action Taken: Management agrees with the recommendations and will contact the Pennsylvania Department of Education to inquire as to how to resubmit the annual report with correct amounts for 2023-24, agreeing the expenditures to the District’s books and records. In addition, the business manager will ensure the amounts reported for the upcoming annual report for fiscal year 2024-25 contain the correct expenditures and that the expenditures agree with the District’s books and records. Proposed Completion Date: March 31, 2026
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