Corrective Action Plans

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2025-004 Inadequate Cash Management Procedures and Noncompliance with Period of Performance Requirements Criteria: Per 2 CFR §200.305(b), non-Federal entities must minimize the time elapsing between the transfer of funds from the U.S. Treasury and the disbursement of those funds for program purposes...
2025-004 Inadequate Cash Management Procedures and Noncompliance with Period of Performance Requirements Criteria: Per 2 CFR §200.305(b), non-Federal entities must minimize the time elapsing between the transfer of funds from the U.S. Treasury and the disbursement of those funds for program purposes under the period of performance. Furthermore, entities must have written procedures that clearly outline the timing and methods for drawing down federal funds in accordance with cash management requirements. These procedures should be documented, reviewed, approved, and periodically revised to ensure ongoing compliance. Client’s Response: The organization will revise its current draw-down procedures to reflect timing and methods for drawing down federal funds that are in compliance with cash management requirements. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
2025-003 Lack of Formal Subrecipient Monitoring Criteria: According to 2 CFR §200.332 (Requirements for Pass-Through Entities), a pass-through entity must monitor the activities of subrecipients as necessary to ensure that federal funds are used for authorized purposes and in compliance with applica...
2025-003 Lack of Formal Subrecipient Monitoring Criteria: According to 2 CFR §200.332 (Requirements for Pass-Through Entities), a pass-through entity must monitor the activities of subrecipients as necessary to ensure that federal funds are used for authorized purposes and in compliance with applicable statutes, regulations, and terms and conditions of the Federal award. Required monitoring includes, but is not limited to, the following: a. Reviewing financial and programmatic reports; b. Performing risk assessments of subrecipients; c. Following up on deficiencies identified through audits or reviews; and d. Ensuring subrecipients have required audits under 2 CFR §200.501. Lack of documented subrecipient monitoring constitutes noncompliance with Uniform Guidance. Client Response: While the organization was in constant contact with subrecipients regarding the progress of their programming, those meetings were not transcribed. In the future, the organization will require mid year and year-end impact reports from each grant subrecipient. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
2025-002 SEFA Presentation Error – Prior Year Criteria: Uniform Guidance (2 CFR §200.510(b)) requires that the Schedule of Expenditures of Federal Awards (SEFA) accurately present all federal awards, including the correct identifying numbers assigned by pass-through entities for each award. Accurate...
2025-002 SEFA Presentation Error – Prior Year Criteria: Uniform Guidance (2 CFR §200.510(b)) requires that the Schedule of Expenditures of Federal Awards (SEFA) accurately present all federal awards, including the correct identifying numbers assigned by pass-through entities for each award. Accurate reporting is essential to ensure compliance with funding requirements and enable proper tracking and monitoring of federal awards. Client’s Response: Last year was the organization’s first time going through a Single Audit. Although the organization accurately tracked expenditures corresponding to the grant award, the transactions were charged to an unrestricted program. The correction was detected and corrected during this fiscal year. We have implemented the necessary internal controls to ensure that our grant reporting accurately reflects the expenditures for each of our respective grants. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurr...
2025-001 Costs Incurred Beyond the Period of Performance Criteria: According to 2 CFR §§200.1, 200.308, 200.309, 200.344, and 200.403(h), a non-Federal entity may only charge allowable costs incurred during the approved budget period of the Federal award’s period of performance, and any costs incurred before the Federal award was made that were authorized by the Federal awarding agency or pass-through entity. All financial obligations incurred under the Federal award must be liquidated within the required time period. Costs incurred outside the approved period of performance are unallowable and constitute questioned costs. Client’s Response: During the grant cycle, the Organization submitted for an extension but did not receive confirmation of said extension. During the current fiscal year, the Organization has implemented additional controls to ensure that all grant funding is expended within the timeframe allotted. Proposed Implementation Date – 12/31/2025 Name of Contact Person – John Edwards, Sr. Email: jledwards@umadaop.org Phone: 419-255-4444
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – Will establish policy to ensure payrolls are submitted a week after the week of work is performed. Completion Date – Ongoing
Contact Person – Superintendent, Dr. Erich Heise Corrective Action Plan – Will establish policy to ensure payrolls are submitted a week after the week of work is performed. Completion Date – Ongoing
HHC was in the process of adding a new site in the Steelton area, due to additional need that had been identified for our services. HHC had been the recipient of a Federal Grant- American Rescue Act- Capital Grant and had identified several options for the use of such funds; however, none of those o...
HHC was in the process of adding a new site in the Steelton area, due to additional need that had been identified for our services. HHC had been the recipient of a Federal Grant- American Rescue Act- Capital Grant and had identified several options for the use of such funds; however, none of those options resulted in a viable use of these funds. It was determined late in the Steelton building project to utilize the American Rescue Act- Capital Grant funds to support this project. Due to the timing and the fact that the General Contractor had already been selected and work had already started on the project, HHC did not proceed with an Exclusion List check to ensure that none of the individuals on the project (contractors and sub-contractors) were not prohibited from being involved in this project. HHC’s Procurement Policy does require review of the Exclusions List for all projects supported by Federal Grant Funds. HHC has reviewed our Procurement Policy and determined that no revisions of the policy are required at this time. HHC has already completed a retroactive review of the Exclusions List of all Contractors and Sub-contractors that were involved in the Steelton Project and found that there were no identified exclusions. This review was completed in September 2025. HHC is committed to future compliance with the review of the Exclusions List for all capital projects whether or not they are supported by Federal Grant funds.
HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collab...
HHC has reviewed our process for reporting appropriate charges for each CPT code on bills to all third-party payors and found that in isolated cases, the EPIC system was reporting the Sliding Fee Discount Fee on the bill and not the charge from our Fee Schedule for selected CPT codes. HC will collaborate with our EPIC partner- UPMC- to identify why the bills are not appropriately reflecting the CPT code fees from our Fee Schedule instead of the Sliding Fee Discount Fee. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed our Sliding Fee Discount Policy and determined that there are areas that require revision. There should not be any patients that are given a sliding fee discount based on their self-declaration of income and then continue to receive care without the provision of income verification. HHC is in the process of a total review of our Sliding Fee Discount Policy/Process/Application and will make appropriate adjustments to ensure compliance with the HRSA Sliding Fee Discount Requirements. HHC will replace our One-Time Sliding Fee process with a more compliant approach that will involve: Self-Declaration of Income, whereby the patient will provide us with the income and family size without the required supporting documentation and the appropriate sliding fee will be applied for that visit only, and all future visits will be considered a full fee patient until the patient provides the appropriate support for income and family size; All patients will be requested to provide their income and family size. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements. HHC has reviewed the claim in question and has no explanation as to why the income reported for a patient was different than the supporting income documents provided by the patient. HHC recognizes that this occurred in only one of forty patient samples. HHC will ensure that all employees that are involved with the Sliding Fee Discount program are re-trained on the importance of accurately reporting the patient’s income based on the supporting documentation provided by the patient. HHC has implemented a quarterly internal review process for compliance with all Sliding Fee Discount program requirements.
HHC recognizes their responsibility to ensure that all required Federal Reports, including FFRs, are filed on a timely basis. HHC recognizes that during the fiscal year ended 3/31/2025, we were deficient in meeting the timely filing requirement for FFR reports. HHC established a new process in Augus...
HHC recognizes their responsibility to ensure that all required Federal Reports, including FFRs, are filed on a timely basis. HHC recognizes that during the fiscal year ended 3/31/2025, we were deficient in meeting the timely filing requirement for FFR reports. HHC established a new process in August 2025, whereby the Controller will review the Payment Management System on a bi-weekly basis, but not less frequently than monthly, to identify the deadline for all required Federal Grant reports, including but not limited to FFR reports. The Controller will notify all appropriate individuals of any reports that require attention to meet the reporting deadlines and will be responsible for the timely completion of all such required reporting.
Finance department will set up the coding process and begin including Departments that match project codes for all federal programs. Corrective Action Owner: Lisa Peacock, Comptroller with assistance from the Senior Accountant, and report to Francesca Rattray, CEO
Finance department will set up the coding process and begin including Departments that match project codes for all federal programs. Corrective Action Owner: Lisa Peacock, Comptroller with assistance from the Senior Accountant, and report to Francesca Rattray, CEO
CONTACT PERSON: Dana Hudgins, Executive Director Upstate Workforce Board 864-596-2028 dana@upstatewb.org CORRECTIVE ACTION: The County will follow its internal control policies and procedures. Effective immediately, all agreements between the County and its consultant for the WIOA program will be up...
CONTACT PERSON: Dana Hudgins, Executive Director Upstate Workforce Board 864-596-2028 dana@upstatewb.org CORRECTIVE ACTION: The County will follow its internal control policies and procedures. Effective immediately, all agreements between the County and its consultant for the WIOA program will be updated and signed. PROPOSED COMPLETION DATE: June 30, 2026
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
The District will implement a secondary review process for the nutrition reimbursement reports and will monitor the monthly financials to ensure revenue is reasonable based on meal counts.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Management will review the claims list for completeness and accuracy before presenting the list to the board for approval.
Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly ...
Condition: The Intermediate School District (ISD) did not have internal controls in place to ensure that all the expenditures included in the quarterly claims for reimbursement were allowable. Planned Corrective Action: The ISD will review the process used by the local districts to report quarterly expenditures for the Administrative Outreach program. We will then create a process that ensures that the local districts provide supporting documentation that allows us to monitor the quarterly submission amounts for accuracy. Contact person responsible for corrective action: Chris Frank, Asst. Superintendent for Business Anticipated Completion Date: 1/31/2026
Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Planned Corrective Action: Federation typically receives vouchers from 15 subre...
Condition: Controls in place did not minimize the time elapsing between the transfer receipt of billing from the subrecipient and disbursement of federal dollars to the subrecipient in accordance with the guidance above. Planned Corrective Action: Federation typically receives vouchers from 15 subrecipient organizations approximately ten to fifteen days after the end of each month. The number of vouchers per agency depends on the number of programs they provide. Staff reviews the vouchers for allowability and accuracy and submits them to the Illinois Department of Human Services (IDHS) within 24 days of month end. During fiscal year 2025, the IDHS remitted payment to Federation anywhere from 20 to 82 days after the month end. Upon receipt of the cash, Federation typically pays subrecipient organizations within two to three business days. In the instances identified by the auditors, the IDHS remitted payment over 30 days after Federation submitted the vouchers for reimbursement. Federation’s longstanding policy has always been to reimburse each subrecipient agency after it has received payment from the IDHS. Prior to fiscal year 2024, the IDHS usually provided payment within 15 days of receipt of our voucher and therefore Federation was able to comply with the 30-day requirement. However, reimbursement delays from IDHS began to occur in fiscal year 2024 and continued throughout fiscal year 2025, resulting in the findings describe herein. IDHS made two advance payments to Federation during fiscal 2025, but the amounts provided were not adequate to fund all payments within the 30 day time period. To ensure compliance with the 30-day reimbursement requirement, Federation will again request advances from the IDHS. Kyu Kim, Director of Finance and Contract Compliance, Refugee Services will be responsible for the oversight of the reimbursement payments. Contact person responsible for corrective action: Kyu Kim Anticipated Completion Date: July 2026
CONTACT PERSON: Ralph E. Guarino Jr., Assistant County Administrator, ralphg@pickenscountysc.gov CORRECTIVE ACTION: The County will ensure all sole source procurement approvals are written and documented as required by the County’s procurement code. PROPOSED COMPLETION DATE: June 30, 2026
CONTACT PERSON: Ralph E. Guarino Jr., Assistant County Administrator, ralphg@pickenscountysc.gov CORRECTIVE ACTION: The County will ensure all sole source procurement approvals are written and documented as required by the County’s procurement code. PROPOSED COMPLETION DATE: June 30, 2026
The Director of Financial Aid will review the dates reported to COD at the end of each semester. The current software is set up where manual adjustments to amounts and dates reported to COD are required, the transition to new software should automate part of this process.
The Director of Financial Aid will review the dates reported to COD at the end of each semester. The current software is set up where manual adjustments to amounts and dates reported to COD are required, the transition to new software should automate part of this process.
RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and...
RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and will be included as a cover sheet for each tenant file. Sea Mar will also provide staff with additional training on eligibility determination for qualifying applicants in alignment with applicable program guidelines. This will be completed by 3/31/2026. Name of Contact Person Responsible for Implementation: John Clerkin, Housing Director Sincerely, John Clerkin Housing Director P: (206) 788-3399 E: johnclerkin@seamarchc.org Proudly serving the community since 1978
MANAGEMENT AGREES WITH THE FINDING. THE SECURITY DEPOSIT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $355. MANAGEMENT WILL ENSURE THAT THE SECURITY DEPOSITS ARE PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE SECURITY DEPOSIT DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $355. MANAGEMENT WILL ENSURE THAT THE SECURITY DEPOSITS ARE PROPERLY FUNDED IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE REPLACEMENT RESERVE DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $4,800. MANAGEMENT WILL ENSURE THAT THE REPLACEMENT RESERVE DEPOSITS ARE MADE ON A TIMELY BASIS IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE REPLACEMENT RESERVE DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $4,800. MANAGEMENT WILL ENSURE THAT THE REPLACEMENT RESERVE DEPOSITS ARE MADE ON A TIMELY BASIS IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE REPLACEMENT RESERVE DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $11,200. MANAGEMENT WILL ENSURE THAT THE REPLACEMENT RESERVE DEPOSITS ARE MADE ON A TIMELY BASIS IN THE FUTURE.
MANAGEMENT AGREES WITH THE FINDING. THE REPLACEMENT RESERVE DEFICIENCY WILL BE FUNDED IN THE AMOUNT OF $11,200. MANAGEMENT WILL ENSURE THAT THE REPLACEMENT RESERVE DEPOSITS ARE MADE ON A TIMELY BASIS IN THE FUTURE.
Response: According to the student sampling conducted as part of the audit, several withdrawal records were reported incorrectly. The source of the inconsistencies was unknown at the time of notification by the auditors. However, progress had been made since the 2023-24 audit when little to no withd...
Response: According to the student sampling conducted as part of the audit, several withdrawal records were reported incorrectly. The source of the inconsistencies was unknown at the time of notification by the auditors. However, progress had been made since the 2023-24 audit when little to no withdrawal records were being reported correctly. The purpose of this report submitted to NSLDS through NSC, is to notify lenders of students who have dropped below half time status and therefore should be entering their six month grace period prior to loan repayment. All students are included in the withdrawal report, regardless of whether they have a loan with Vernon College or any other institution. It is important to note, internal records are accurate and loan processes are in compliance. Vernon College is pleased to report that recently the Registrar’s Office has discovered the source of the withdrawal reporting errors and has implemented a solution. The source and subsequent solution involve entering certain dates in designated areas in our student information system, Colleague. If errors occur in the future, the Registrar’s Office has developed a backup manual review process to use to ensure reporting will remain consistent and correct. The Registrar’s Office will run an “Enrollment Activity Report” to identify all course withdrawals within a designated time period as outlined by the NSC First of Term and Subsequent Term reports. The reporting official will then audit the Colleague produced NSC report against the Enrollment Activity Report to ensure accuracy and update manually as needed. This will occur prior to submission to the NSC/NSLDS. Moving forward, the manual process will only be used if needed.
Management's Response: Management concurs with the finding and has taken corrective action by formalizing the procurement policy in a written document reviewed by the Board of Trustees at their meeting on August 26, 2025.
Management's Response: Management concurs with the finding and has taken corrective action by formalizing the procurement policy in a written document reviewed by the Board of Trustees at their meeting on August 26, 2025.
U.S. Department of Housing and Urban Development Housing Voucher Cluster – Assistance Listing No. 14.871 / 14.879, Section 8 Cluster – Assistance Listing No. 14.249 / 14.856 Recommendation: The Authority should implement processes to ensure that inspection requirements are met timely. Explanation of...
U.S. Department of Housing and Urban Development Housing Voucher Cluster – Assistance Listing No. 14.871 / 14.879, Section 8 Cluster – Assistance Listing No. 14.249 / 14.856 Recommendation: The Authority should implement processes to ensure that inspection requirements are met timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: This finding is an isolated situation which resulted from staff transition and a transition away from annual to biennial inspections. Because of its size, the HCV program is audited every year and this is the first year that scheduling concerns have been raised. Prior to the finding issuance by the Auditors and within the period being audited, the BHA had already taken steps to correct the scheduling issue. During a regular Leased Housing management review in December of 2024, it was determined that the system of record was not populating the appropriate due date after a passed inspection and staff misunderstood the requirement that all inspections must occur in less than 2-years after a passed inspection, regardless of the SEMAP or fiscal year cycles. As a result of this review, the parameters in the Elite system were updated and a retraining of staff occurred. The result was a SEMAP report as of March 31, 2025 where the percentage of units under contract with overdue annual HQS inspections was less than 2%. BHA will continue to match our system of record to PIC to be sure inspection scheduling remains within the two-year period. Name(s) of the contact person(s) responsible for corrective action: Kathlin McGonagle Planned completion date for corrective action plan: Already implemented
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